The nurse observes signs that a patient may be experiencing dysfunction related to the acoustic nerve (CN VIII)

Question

Which action by the nurse is most appropriate for minimizing the patient's risk for injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Identify the patient's fall risk category.
2. Assess the patient's gag reflex prior to offering food or liquids.
3. Assist the patient with bedside sitting or toileting.
4. Assess the patient's vision using a Snellen chart.
5. Place a red "falls risk" bracelet on the patient's arm.

Answer 1

1,3,5
Rationale 1: Dysfunction of the vestibular branch of the acoustic nerve may result in vertigo or disturbed balance, putting the patient at risk for falls.
Rationale 2: Dysfunction of the glossopharyngeal (CN IX) and vagus (CN X) nerves is likely to result in a poor or absent gag reflex.
Rationale 3: Dysfunction of the vestibular branch of the acoustic nerve may result in vertigo or disturbed balance, putting the patient at risk for falls. Precautions to minimize this risk should be implemented.
Rationale 4: A Snellen chart is an eye chart used to measure visual acuity that may be altered due to dysfunction of the optic nerve (CN II).
Rationale 5: Dysfunction of the vestibular branch of the acoustic nerve may result in vertigo or disturbed balance, putting the patient at risk for falls. Precautions to minimize this risk should be implemented.