The nurse detects an abnormality in CN VIII (facial) during a neurological assessment. Which interventions would the nurse consider? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. Have the patient wear an eye patch during the day.
2. Check visual acuity with the Snellen chart.
3. Assess pupils for equality of size and response to light.
4. Provide the patient with an eye shield to wear at night.
5. Warn the patient about the possibility of choking when drinking fluids.
1,4
Rationale 1: Disruption of CN VII may result in the inability to close the eye. The patient should wear an eye patch to protect the eye from drying out or being injured.
Rationale 2: Visual acuity is provided by CN II and would not be affected by disturbance of CN VII.
Rationale 3: Pupil size and response to light are not controlled by CN VII.
Rationale 4: Disruption of CN VII may result in the inability to close the eye. The patient should wear an eye patch or shield to protect the eye from drying out or being injured at night.
Rationale 5: CN VII dysfunction is not associated with choking.
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