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)?

Check the patient’s visual acuity using a Snellen chart.

Whisper in one of the patient’s ears while blocking the other.

Observe the patient’s ability to turn their head from side to side.

Ask the patient to identify specific smells.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Checking the patient’s visual acuity using a Snellen chart is used to assess cranial nerve II (Optic), not cranial nerve XI (Spinal Accessory)3.
Choice B rationale
Whispering in one of the patient’s ears while blocking the other is a method used to assess cranial nerve VIII (Vestibulocochlear), not cranial nerve XI4.
Choice C rationale
Observing the patient’s ability to turn their head from side to side is a correct method to assess cranial nerve XI. This nerve innervates the sternocleidomastoid and trapezius muscles, which are responsible for turning the head and shrugging the shoulders respectively.
Choice D rationale
Asking the patient to identify specific smells is used to assess cranial nerve I (Olfactory), not cranial nerve XI3.

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Correct Answer is B

Explanation

Choice A rationale
Analgesics can be used to manage pain associated with Bell’s palsy. Therefore, this statement does not indicate a need for further education.
Choice B rationale
This is the correct answer. Chewing on the affected side can actually exacerbate swallowing issues. Therefore, this statement indicates a need for further education.
Choice C rationale
Brushing teeth should not be affected by Bell’s palsy. Therefore, this statement does not indicate a need for further education.
Choice D rationale
Applying a protective eye shield before going to bed is a recommended practice for patients with Bell’s palsy. This helps to protect the eye from injury and keep it moist, as Bell’s palsy can cause difficulty in blinking or closing the eye.

A. “Install handrails in your bathroom.”. B. “Use a standard height toilet seat.”. C. “Wear backless shoes.”. D. “Cover extension cords with a throw rug.”. . E. “Cover extension cords with a throw rug.”. .

Correct Answer is A

Explanation

Choice A rationale
Installing handrails in the bathroom is a recommended strategy for reducing the risk of falls. Handrails provide support and stability, particularly in slippery environments like the bathroom.
Choice B rationale
Using a standard height toilet seat is not necessarily a recommended strategy for reducing the risk of falls. A toilet seat at an appropriate height for the individual would be more beneficial.
Choice C rationale
Wearing backless shoes is not a recommended strategy for reducing the risk of falls. Shoes with good support and non-slip soles are typically recommended.
Choice D rationale
Covering extension cords with a throw rug is not a recommended strategy for reducing the risk of falls. This could potentially create a tripping hazard.

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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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In the context of outpatient care for a client diagnosed with Bell’s palsy, which of the following statements, if made by the client, would indicate the need for further education?

Correct Answer is B

Explanation

, a nurse is teaching a patient about reducing the risk for falls. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

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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)?