During an assessment of a patient's cranial nerves, the nurse asks the patient to stick out the tongue. The nurse observes that the tongue deviates markedly to the right side. Which condition is the patient most likely exhibiting?

1. Abnormal hypoglossal nerve response
2. First cranial nerve (CN I) damage
3. Sluggish oculomotor response
4. Absence of Homans' sign


1
Rationale 1: Cranial nerve XII (hypoglossal) is tested by having the patient stick his or her tongue out. An abnormal finding is that the tongue deviates to either side.
Rationale 2: Cranial nerve I is the olfactory nerve and is assessed by having the patient use his or her sense of smell.
Rationale 3: Cranial nerve III is the oculomotor nerve and, along with the trochlear and abducens nerves, helps the eye move.
Rationale 4: Homans' sign is a check for thrombophlebitis in the calves of the legs.

Nursing

You might also like to view...

A female patient with a recent diagnosis of end-stage renal disease (ESRD) is scheduled to soon begin hemodialysis. A nephrology nurse has been conducting extensive patient teaching in anticipation of this treatment

What diet should the nurse recommend to minimize her patient's risk of complications and interdialytic weight gain? A) Low-fat diet with an emphasis on simple carbohydrates B) Small, frequent meals with an emphasis on leafy green vegetables C) Low-potassium, high-calorie diet D) Low-protein, low-sodium diet

Nursing

The nurse lists the age-related changes in the male reproductive tract, which include: (Select all that apply.)

a. pendulous scrotum. b. prostate enlargement. c. decrease in testosterone. d. increase in ejaculate volume. e. shortened arousal time.

Nursing

The nurse is providing client education about anticoagulant therapy prior to the client's discharge. Which of the following statements by the client indicates a need for further teaching?

a. "I will still be able to use my grandfather's straightedge razor if I'm careful." b. "I will have to be careful not to bump into things while I am working." c. "I will use a soft bristle toothbrush from now on." d. "I shouldn't use a power saw to cut wood for heating anymore."

Nursing

The main purpose of intermittent skilled care is to

A) get families involved in patient care. B) save money on health care costs. C) teach clients how to best meet their own needs. D) teach clients a better way of doing daily tasks.

Nursing