A nurse is collecting data about cranial nerve function from an adult client. Which of the following images depicts the method the nurse should use to check the function of the hypoglossal cranial nerve (XII)?
Image A
 |
B.
C.
Image B
Image C
Image D
Image A
Image B
Image C
Image D
The Correct Answer is A
A. The hypoglossal nerve is tested by checking for tongue deviation.
B. This action tests the facial nerve
C. This action tests the trigeminal nerve
D. This action tests the spinal accessory nerve
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Severe wheezing indicates a potential allergic reaction or anaphylaxis to the IV antibiotics, which requires immediate intervention. It can compromise the client's respiratory function and may lead to respiratory arrest if not promptly addressed.
B. Rhinitis, or inflammation of the nasal passages, is not typically associated with IV antibiotic administration and is not a life-threatening emergency.
C. Small, raised vesicles over the body may indicate a rash or allergic reaction, but unless accompanied by other severe symptoms such as difficulty breathing or systemic signs of anaphylaxis, it does not require immediate reporting.
D. Itching of the skin may indicate a mild allergic reaction, but unless accompanied by more severe symptoms, it does not require immediate reporting.
Correct Answer is C
Explanation
A. Simple face mask: This can deliver oxygen at flow rates of 5-10 liters per minute and typically provides an oxygen concentration of about 35-50%.
B. Nasal prongs: Nasal prongs deliver oxygen at lower flow rates and may not be sufficient to raise the client's oxygen saturation to 90%.
C. Non-rebreather mask: This mask can deliver high concentrations of oxygen (up to 90-100%) at flow rates of 10-15 liters per minute. It has one-way valves to prevent the patient from rebreathing exhaled air, thus maximizing the delivery of oxygen.
D. Nasal cannula: Nasal cannulas deliver oxygen at lower flow rates (typically up to 6 liters per minute) and may not provide the necessary concentration to achieve an oxygen saturation of 90%.
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