The nurse observes signs that a patient may be experiencing dysfunction related to the acoustic nerve (CN VIII). Which actions should the nurse take to minimize the patient's risk for injury?

Question

Select all that apply.
1. identifying the patient's fall risk category
2. assessing the patient's gag reflex prior to offering food or liquids
3. assisting the patient with bedside sitting or toileting
4. assessing the patient's vision using a Snellen chart
5. placing a red "falls risk" bracelet on the patient's arm

Answer 1

Correct Answer: 1, 3, 5
Dysfunction 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, such as assisting with bedside toileting or sitting and placing a falls risk bracelet on the patient's arm. Dysfunction of the glossopharyngeal (CN IX) and vagus (CN X) nerves is likely to result in a poor or absent gag reflex. 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).