A patient reports hearing noises when alone in a quiet room. What ...

[shofmannx20]

A patient reports hearing noises when alone in a quiet room. What action should the nurse take?
 
  1. make sure the patient is referred to a psychiatrist
  2. document that the patient has a mental illness
  3. ask if the patient experiences any visual disturbances
  4. explain to the patient that this is not unusual

Question 2

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?
 
  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

[swimkari]

Answer to Question 1

Correct Answer: 3
Information about perception difficulties such as visual and/or auditory disturbances is an important part of the health history of the nervous system. The nervous system controls cognition and sensory function, which includes vision and auditory changes. Making a referral to a psychiatrist would not be the appropriate next step, and it is not within the scope of nursing practice to document mental illness. Hearing and vision changes are not usual assessment findings and should be investigated.

Answer to Question 2

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).