Cranial Nerves
Assess this cranial nerve by checking visual acuity and visual fields
What is CN II (optic)
A patient is having a tonic-clonic seizure. What is the nurse’s priority action?
Turn the patient on their side
Rationale: The priority is airway protection. Side-lying prevents aspiration. Never insert anything into the mouth or restrain.
A patient has dysphagia following a stroke. What is the priority nursing action?
A. Encourage fluids
B. Place the patient in high Fowler’s position during meals
C. Offer a regular diet
D. Give thin liquids
B. Place the patient in high Fowler’s position during meals
Rationale: Prevents aspiration, which is a major complication after stroke.
The nurse should hold metformin before which procedure?
A. Chest X-ray
B. MRI without contrast
C. CT scan with contrast
D. Ultrasound
C. CT scan with contrast
Rationale: Contrast dye can impair kidney function → increases risk of lactic acidosis.
A nurse has four patients. Which patient should be assessed first?
A. A patient with a fever of 100.8°F
B. A patient with chest pain and shortness of breath
C. A patient requesting pain medication
D. A patient with nausea and vomiting
B. Chest pain and shortness of breath
Rationale: Use ABCs (Airway, Breathing, Circulation) → possible cardiac/respiratory emergency.
This cranial nerve helps recognize odors
What is CN I(olfactory)?
Which finding is expected during the postictal phase?
A. Alert and oriented
B. Severe agitation with hallucinations
C. Confusion and drowsiness
D. Immediate return to baseline
C. Confusion and drowsiness
Rationale: The postictal phase commonly includes confusion, fatigue, and decreased level of consciousness.
A patient with an ischemic stroke is prescribed alteplase. Which finding would contraindicate this medication?
A. Blood pressure 150/90
B. Onset of symptoms 2 hours ago
C. Active internal bleeding
D. Blood glucose 110 mg/dL
Active internal bleeding
Rationale: Thrombolytics increase bleeding risk—active bleeding is an absolute contraindication.
Which instructions should the nurse give a patient taking nitrofurantoin? (Select all that apply)
A. Take with food
B. Expect dark urine
C. Stop when symptoms improve
D. Report shortness of breath
E. Avoid alcohol
A, B, D
Rationale:
✔ Take with food → improves absorption
✔ Dark urine is normal
✔ SOB may indicate pulmonary toxicity
✘ Must finish full course
✘ Alcohol restriction not primary concern here
Which electrolyte imbalance is most associated with cardiac dysrhythmias?
A. Sodium
B. Potassium
C. Calcium
D. Magnesium
B. Potassium
Rationale: Potassium plays a key role in cardiac conduction—abnormal levels can be life-threatening.
The nurse notes that a patient’s right eye deviates laterally and the patient cannot move it medially. Which cranial nerve is likely damaged?
Oculomotor (CN III)
Rationale: CN III controls most eye movements, including medial movement. Damage causes a “down and out” eye position.
Which interventions are appropriate during a seizure? (Select all that apply)
A. Loosen tight clothing
B. Place a tongue blade in the mouth
C. Protect the head
D. Restrain the limbs
E. Move objects away
A, C, E
Rationale:
✔ Loosen clothing → improves breathing
✔ Protect head → prevents injury
✔ Remove objects → prevents trauma
✘ No restraints
✘ Nothing in the mouth
A patient suddenly develops a severe headache, vomiting, and decreased level of consciousness. What type of stroke is most likely?
A. Ischemic
B. Hemorrhagic
C. Transient ischemic attack
D. Lacunar infarct
Answer: B. Hemorrhagic
Rationale: Sudden severe headache + neuro decline is classic for hemorrhagic stroke.
Which supplement should be given with isoniazid to prevent neuropathy?
A. Vitamin C
B. Vitamin B6
C. Vitamin D
D. Iron
B. Vitamin B6
Rationale: Isoniazid can cause peripheral neuropathy, prevented with pyridoxine (B6).
Which interventions help prevent hospital-acquired infections? (Select all that apply)
A. Hand hygiene before and after patient contact
B. Use of personal protective equipment (PPE)
C. Reusing gloves if not visibly soiled
D. Proper sterilization of equipment
E. Limiting unnecessary catheter use
A, B, D, E
Rationale: Standard precautions reduce infection risk; gloves are never reused.
A patient is unable to chew food properly. Which cranial nerve should the nurse assess?
Trigeminal (CN V)
Rationale: CN V controls muscles of mastication (chewing).
A patient with seizure disorder is prescribed phenytoin. Which statement indicates need for further teaching?
A. “I will avoid alcohol.”
B. “I will stop the medication once I feel better.”
C. “I will have regular blood tests.”
D. “I will report gum swelling.”
B. “I will stop the medication once I feel better.”
Rationale: Antiepileptic drugs should never be stopped abruptly—this can trigger seizures.
A nurse is caring for a patient with right-sided weakness from a stroke. Which intervention is appropriate?
A. Place objects on the patient’s right side
B. Encourage use of the unaffected side only
C. Perform passive ROM on the affected side
D. Keep the patient on bed rest
C. Perform passive ROM on the affected side
Rationale: Prevents contractures and muscle atrophy. You should also encourage use of the affected side (not ignore it).
A patient taking phenytoin should receive which teaching?
A. Stop medication if seizure-free
B. Perform good oral hygiene
C. Take on an empty stomach only
D. Double dose if one is missed
B. Perform good oral hygiene
Rationale: Phenytoin causes gingival hyperplasia.
Which lab value requires immediate intervention?
A. Sodium 138 mEq/L
B. Potassium 6.2 mEq/L
C. Glucose 110 mg/dL
D. Calcium 9.0 mg/dL
B. Potassium 6.2 mEq/L
Rationale: Hyperkalemia can cause fatal cardiac arrhythmias.
Which cranial nerve is assessed when a nurse asks a patient to smile and raise their eyebrows?
CN VII
Rationale: The facial nerve controls facial expressions.
Which lab value is most important to monitor for a patient taking valproic acid?
A. Potassium
B. Liver function tests
C. Calcium
D. Hemoglobin
B. Liver function tests
Rationale: Valproic acid can cause hepatotoxicity, so liver enzymes must be monitored.
A nurse is educating a patient about stroke prevention. Which statement indicates understanding?
A. “I will stop my blood pressure medication if I feel fine.”
B. “I will reduce salt intake and exercise regularly.”
C. “Smoking does not affect stroke risk.”
D. “I only need to monitor my cholesterol.”
B.
Rationale: Lifestyle changes like diet, exercise, and BP control reduce stroke risk.
A patient receiving lorazepam for status epilepticus becomes very drowsy with a respiratory rate of 8/min. What is the priority action?
A. Reassure the patient
B. Administer oxygen
C. Prepare to support airway
D. Document findings
C. Prepare to support airway
Rationale: Benzodiazepines can cause respiratory depression → airway is priority.
Which conditions can cause metabolic acidosis? (Select all that apply)
A. Diarrhea
B. Renal failure
C. Diabetic ketoacidosis
D. Vomiting
E. Hyperventilation
A, B, C
Rationale:
✔ Diarrhea → loss of HCO₃
✔ Renal failure → acid retention
✔ DKA → acid buildup
✘ Vomiting → alkalosis
✘ Hyperventilation → respiratory alkalosis