Rationale 2 cranial nerve i is the olfactory nerve

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.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 20-3
Question 10
Type: MCSA
An emergency department (ED) nurse receives a report that an incoming patient has a Glasgow Coma Scale
(GCS) score of 8. Which is the most appropriate action by the nurse?
1. Treat the patient’s pain.
2. Assess the patient’s airway, breathing, and circulation.
3. Obtain a complete history from the patient.
4. Triage the patient with the other ED patients.
Correct Answer: 2
Rationale 1 : Another action is the nurse’s priority.
Rationale 2 : The GCS (Glasgow Coma Scale) is a standardized system for assessing consciousness. A score of 15
indicates full alertness, and a score of 8 or less is usually indicative of coma. A comatose patient receives high

priority, and the nurse will utilize the ABCs of care in this case. Additionally, assessment is the first step of the
nursing process.
Rationale 3 : This patient will not be able to respond to questions.
Rationale 4 : The patient should receive priority care in the ED.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 20-1
Question 11
Type: MCSA
When bringing in the meal tray for a patient with damage to the glossopharyngeal nerve (CN IX), which action by
the nurse is most appropriate?
1. Place the tray on the patient’s right side.
2. Assess the patient’s ability to swallow.
3. Speak loudly and make eye contact with the patient.
4. Assist the patient in identifying where items are on the tray.
Correct Answer: 2
Rationale 1 : The optic nerve (CN II) controls vision. There should be no extinction present in this patient.
Rationale 2 : Gag reflex and swallowing are controlled by CN IX.
Rationale 3 : Auditory function is controlled by the acoustic nerve (CN VIII).
Rationale 4 : The optic nerve (CN II) controls vision.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 20-3
Question 12

Type: MCSA
The nurse has just finished explaining to a patient’s son the function of the Mini-Mental Status Examination
(MMSE). Which statement by the patient’s son indicates his understanding?