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.
Ask the patient to identify specific smells.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Slow capillary refill is a sign that the body is not circulating blood as effectively as it should be. This can be a sign that a person is actively dying.
Choice B rationale
Ringing in the ears, also known as tinnitus, is not typically a sign that a person is actively dying. It can be caused by a variety of factors, including exposure to loud noise, certain medications, and some health conditions.
Choice C rationale
Cold hands and feet can be a sign that a person is actively dying. As the body’s systems start to shut down, blood flow to the extremities can decrease, causing them to feel cold.
Choice D rationale
Mottled and blotchy skin, especially on the hands, feet, and knees, can be a sign that a person is actively dying. This is caused by reduced blood flow to the skin.
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