A nurse is assessing a school-age child's cranial nerve function.
Which of the following actions should the nurse ask the child to take when assessing the accessory nerve?
Follow a light in the six cardinal positions.
Move their tongue in all directions.
Show their teeth while smiling.
Shrug their shoulders against mild pressure.
The Correct Answer is D
The accessory nerve is tested by evaluating the function of the trapezius and sternocleidomastoid muscles.
The trapezius muscle is tested by asking the patient to shrug their shoulders with and without resistance.
Choice A is wrong because following a light in the six cardinal positions tests the function of cranial nerves III, IV, and VI.
Choice B is wrong because moving their tongue in all directions tests the function of cranial nerve XII.
Choice C is wrong because showing their teeth while smiling tests the function of cranial nerve VII.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is d. Exhibits head lag when pulled to a sitting position.
Choice A: Unable to hold a bottle At around 6 months of age, some babies can hold their own bottle. This is not a concerning finding for a 5-month-old infant. Therefore, this is not the correct answer.
Choice B: Unable to roll from back to abdomen Rolling over often starts around 4-6 months, so it’s not unusual for a 5-month-old to still be developing this skill. Therefore, this is not the correct answer.
Choice C: Absent grasp reflex The grasp reflex is an involuntary movement that your baby starts making in utero and continues doing until around 6 months of age. The grasp reflex lasts until the baby is about 5 to 6 months old. Therefore, this is not the correct answer.
Choice D: Exhibits head lag when pulled to a sitting position By the age of 5 months, most infants have developed enough strength in their neck and upper body to control their head movement. This means they should not exhibit a significant head lag when pulled to a sitting position1. If this is not the case, it could indicate a delay in motor development or a potential neurological issue, which should be reported to the healthcare provider for further evaluation. Therefore, this is the correct answer.
Correct Answer is C
Explanation
A sausage-shaped abdominal mass is a symptom of intussusception in infants.
Intussusception is a serious condition where part of the intestine slides into an adjacent part of the intestine, often blocking food or fluid from passing through and cutting off the blood supply to the affected part of the intestine.
Choice A is wrong because a board-like abdomen is not a symptom of intussusception.
Choice B is wrong because increased urinary output is not a symptom of intussusception.
Choice D is wrong because constipation is not a symptom of intussusception.
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