Complete QueStioNS ANd CoRReCt detAiled ANSweRS
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A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag
reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider
a priority nursing diagnosis? - detAiled ANSweR-risk for aspiration
Which finding is considered a positive finding of the Romberg test? - detAiled ANSweR-loss of
balance
Which structural and motor change is related to aging and may be assessed in geriatric clients
during an examination of neurological function? - detAiled ANSweR-Decreased or absent deep
tendon reflexes
A nurse is evaluating a client's cranial nerves during a routine examination. To assess the
function of cranial nerve XII (hypoglossal), the nurse should assess the client's ability to: -
detAiled ANSweR-stick out the tongue and move it rapidly from side to side and in and out.
In which specific instances should the nurse assess the client's cranial nerves?
Select all that apply. - detAiled ANSweR-In the presence of peripheral nervous system disease
When level of consciousness is decreased
With brain stem pathology
The nurse is providing care for a client who is unconscious. What nursing intervention takes
highest priority? - detAiled ANSweR-Maintaining a patent airway A client the nurse is caring for