The nurse asks the patient to shrug the shoulders against resistance. Which cranial nerve (CN) is being assessed?
1) CN IX
2) CN X
3) CN XI
4) CN XII
ANS: 3
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An older adult patient in the ICU has diabetes. Which intervention could the nurse perform that would best prevent complications related to this disease?
A) Have the patient rise from his bed and bear weight. B) Offer the patient sugar-free candy. C) Bathe the patient's feet daily and apply emollient. D) Reposition the patient often in bed.
The nurse is reviewing documentation for a client from the previous shift. The documentation states, "+1 edema right lower leg." Based on this data, what does the nurse expect when assessing this client?
1. The presence of slight pitting, no obvious distortion. 2. Deep pitting, obvious distortion. 3. Pitting is obvious, extremities are swollen. 4. Moderate amount of edema.
A home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client states he has been vomiting and had diarrhea for the past 36 hours. He also has had no food intake in the same time frame
Which statement by the client indicates a need for further teaching? A) "I need to stop my insulin." B) "I need to increase my fluid intake." C) "I need to monitor my blood glucose every 3 to 4 hours." D) "I need to call the physician because of these symptoms."
The nurse is caring for a patient placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?
A) Assessing the extremity for neurovascular integrity B) Keeping the patient from sliding to the foot of the bed C) Keeping the ropes over the center of the pulley D) Ensuring that the weights hang freely at all times