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","C"]
Explanation
Choice A rationale
Mottling of the skin, especially in the lower extremities, is a common sign of impending death. This is due to decreased blood flow and can be a sign that the body is starting to shut down.
Choice B rationale
This statement is incorrect. As a person nears death, their blood pressure typically decreases, not increases.
Choice C rationale
Cheyne-Stokes breathing, which is characterized by a pattern of increasing and decreasing respiration with periods of apnea, is a common symptom in the final stages of life.
Choice D rationale
This statement is incorrect. As a person nears death, their skin may become cool to the touch and may appear pale or mottled.
Choice E rationale
Regular respiration is not typically a sign of impending death. In fact, changes in breathing patterns, such as Cheyne-Stokes breathing, are more common.
Correct Answer is B
Explanation
Choice A rationale
Experiencing poverty can indeed be a source of chronic stress due to the ongoing hardships and struggles associated with financial instability. However, it is not typically classified as an example of acute stress, which is usually associated with a specific event or situation that causes a sudden and intense reaction.
Choice B rationale
Being a victim of a crime is a prime example of an acute stressor. This is because it is a specific event that can cause immediate emotional and physiological reactions. The individual may experience intense feelings of fear, shock, or distress, and these reactions typically occur immediately after the event.
Choice C rationale
Being part of a dysfunctional family can lead to chronic stress due to ongoing family conflicts, communication problems, or other issues. While specific incidents within the family context (like a heated argument) could potentially trigger acute stress responses, the overall experience of living in a dysfunctional family is more commonly associated with chronic stress.
Choice D rationale
Experiencing racism can lead to both acute and chronic stress. Acute stress might occur in response to a specific incident of racial discrimination, while chronic stress could result from living in a society where racism is pervasive. However, without a specific incident mentioned, it is less likely to be considered an example of acute stress compared to being a victim of a crime.
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