A client recovering from a cerebral vascular accident is having difficulty remembering how to chew food. The nurse realizes that which of the following cranial nerves could be affected in this client?
1. IX
2. X
3. XI
4. V
4
Cranial nerve V or Trigeminal nerve has three branches. The mandibular branch innervates the muscles for chewing. Cranial nerve IX glossopharyngeal innervates the muscles of swallowing. Cranial nerve X innervates the gastrointestinal tract through parasympathetic tracts of the nerve. Cranial nerve XI innervates the muscles of the neck for movement.
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The nurse is applying electrodes to the patient's chest for use in continuous cardiac rhythm monitoring. When applying these electrodes, what placement will the nurse use to ensure maximum accuracy?
A) In the fold beneath the breast tissue B) Directly over the clavicle C) In the intercostal spaces D) Over the clavicle/humerus joint
The nurse is caring for an infant with suspected patent ductus arteriosus. Which of the following assessment findings would the nurse expect?
A) Thrill at the base of the heart B) Harsh, continuous, machine-like murmur C) Faint pulses D) Systolic murmur along the left sternal border
Maternal risks of occiput posterior (OP) malposition include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Blood loss greater than 1000 mL 2. Postpartum infection 3. Anal sphincter injury 4. Higher rates of vaginal birth 5. Instrument delivery
A child weighing 18.2 kg with a history of diabetes insipidus has been admitted to the hospital. Which of the following physician's orders would the nurse question?
1. Stat electrolytes 2. Restrict oral fluids to 500 mL every 24 hours. 3. Urine specific gravity with each void 4. DDAVP (desmopressin) p.o.