A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure the client to ensure client safety?
A. Speak loudly to the client.
B. Test the temperature of the shower water.
C. Check the temperature of the food on the delivery tray.
D. Provide a clear path for ambulation without obstacles.
Correct Answer: D. Provide a clear path for ambulation without obstacles.
Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Compromise of the optic nerve results in visual field defects and/or visual loss. The type of visual field defect depends on which region of the optic pathway is disrupted.
Option A: Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). CN VIII injuries are the result of pathological processes or injuries that commonly involve the cerebellopontine angle (CPA), the internal auditory canal (IAC), or the inner ear. In such cases, symptoms such as vertigo, nystagmus, tinnitus, and sensorineural hearing loss may occur.
Option B: Testing the shower water temperature would be useful if there were an impairment of peripheral nerves. Peripheral nerve injury can cause sensory deficits, loss of motor function, or a combination of both. Recovery from peripheral nerve injury is often incomplete and patients may experience chronic pain.
Option C: Cranial nerve VII (facial) and IX (glossopharyngeal) control taste from the anterior two-thirds and posterior third of the tongue, respectively. The facial nerve provides motor innervation of facial muscles that are responsible for facial expression, parasympathetic innervation of the glands of the oral cavity and the lacrimal gland, and sensory innervation of the anterior two-thirds of the tongue.
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