The nurse observes signs that a client may be experiencing dysfunction related to the vestibular branch of his acoustic nerve (CN VIII). In order to minimize the client's risk for injury, the nurse should:
1. Identify the client as a "fall risk.".
2. Assess the client's gag reflex prior to offering food or liquids.
3. Apply an "eye bubble" to the client at bedtime.
4. Assess the client's vision using a Snellen chart.
Identifying the client as a "fall risk.".
Rationale: Dysfunction of the vestibular branch of the acoustic nerve may result in vertigo or disturbed balance, making the client at risk for falls. Precautions to minimize this risk should be implemented. Dysfunction of the glossopharyngeal (CN IX) and vagus (CN X) nerves are likely to result in a poor or absent gag reflex. During sleep, the use of an "eye bubble" is appropriate when damage to the facial nerve (CN VII) results in the inability to keep the eyelid closed. 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)
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