A nurse is getting ready to conduct a cranial nerve examination on a patient.
What steps should the nurse take to examine cranial nerve XI (Spinal Accessory)?

Choice A rationale
Initiating life-saving measures such as a rapid response call would not be appropriate in this context. The patient is in a hospice setting, which focuses on providing comfort and quality of life for patients who are nearing the end of life, rather than aggressive life-saving interventions.
Choice B rationale
Calling the provider because these signs and symptoms are abnormal would not be the correct response. In a hospice setting, these symptoms are expected and are indicative of the natural dying process.
Choice C rationale
The statement that rapid respirations that are unusually deep and regular are curative for the patient is incorrect. Cheyne-Stokes respirations, characterized by a pattern of increasing and then decreasing depth of breath followed by a period of apnea, are often seen in patients nearing the end of life. They are not curative but are a sign of the body’s decreasing metabolic demands and changing physiology as death approaches.
Choice D rationale
The nurse understanding that these are impending signs of death and are normal is the correct response. The symptoms described, including loss of appetite, swelling of the limbs, increased sleep, Cheyne-Stokes respirations, and hallucinations, are all common in the final stages of life.
Recognizing these signs can help the nurse provide appropriate care and support to the patient and their family during this time.

Choice A rationale
While the thickness of the tympanic membranes can indeed change with age, it typically increases rather than decreases. Thickening of the tympanic membranes can contribute to hearing loss by reducing the ability of the ear to transmit sound vibrations.
Choice B rationale
Tinnitus, or ringing in the ears, is not typically decreased in older adults. In fact, tinnitus is often more common in older individuals and can be a sign of age-related hearing loss.
Choice C rationale
A decreased ability to hear high-frequency sounds is a common physiological change associated with aging. This is often one of the first signs of age-related hearing loss.
Choice D rationale
Decreased ear wax is not typically associated with aging. In fact, some older adults may produce more ear wax, which can contribute to hearing problems if it becomes impacted.