A nurse cares for a client with impairment of cranial nerve VIII. What instructions will the nurse provide the unlicensed assistive personnel prior to delegating interventions related to the client's activities of daily living?

Question

A nurse cares for a client with impairment of cranial nerve VIII.  What instructions will the nurse provide the unlicensed assistive personnel prior to delegating interventions related to the client's activities of daily living?

Quizplus · Accepted Answer

The client has an impairment of cranial nerve (CN) VIII, the vestibulocochlear (or auditory) nerve. Symptoms of impairment may include loss of hearing, dizziness, vertigo, and motion sickness, which place the client at a high risk for falls. Therefore, when instructing the unlicensed assistive personnel (UAP) about helping the client with activities of daily living, the nurse emphasizes the need to keep items at the bedside within the client's reach (Option D). (Option A) Weakness of the shoulder muscle occurs with impairment of CN XI, the spinal accessory nerve. Impairment of CN VIII does not affect shoulder strength. (Option B) Dysphagia may occur with impairment of CN IX (glossopharyngeal) and CN X (vagus), not CN VIII. Instructing the client to tuck the chin while eating is a technique for those who have difficulty swallowing. (Option C) Impairment of visual acuity occurs with disorders affecting CN II (optic). Because impairment of CN VIII does not affect visual acuity, providing a detailed, step-by-step explanation of procedures may be helpful but is not the most appropriate instruction to give the UAP. Educational objective: Impairment of cranial nerve (CN) VIII, the vestibulocochlear or auditory nerve, may cause dizziness, vertigo, loss of hearing, and motion sickness. To assist the client with impairment of CN VIII, needed items should be placed nearby to decrease the risk of the client getting out of bed and falling.

A Nurse Cares for a Client with Impairment of Cranial