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 C
Explanation
Choice A rationale
Reporting the APs to the charge nurse may seem like an appropriate action, but it does not directly address the conflict. It’s important for the nurse to take an active role in conflict resolution, rather than passing the responsibility to someone else.
Choice B rationale
Allowing the APs to resolve their issues might be a good idea in some situations, but it’s not the best choice here. As a nurse, it’s part of your role to ensure that conflicts are resolved in a way that promotes a positive and productive work environment. By simply allowing the APs to resolve their issues, you’re not taking an active role in conflict resolution.
Choice C rationale
Confronting the APs to discuss their argument is the best choice. This action demonstrates conflict resolution because the nurse is taking an active role in addressing the issue. By discussing the argument with the APs, the nurse can help them understand each other’s perspectives and find a solution that works for everyone.
Choice D rationale
Telling the APs they are acting immaturely is not an effective way to resolve conflict. This approach is likely to escalate the conflict rather than resolve it. It’s important to approach conflicts with a goal of understanding and resolution, rather than placing blame or making judgments.
Correct Answer is A
Explanation
Choice A rationale
Increased joint stiffness is a common age-related change in older adults.
Choice B rationale
Increased muscle mass is not typically an age-related change. In fact, older adults often experience a decrease in muscle mass, a condition known as sarcopenia.
Choice C rationale
Increased calcification of bones is not a typical age-related change. Older adults are more likely to experience osteoporosis, a condition characterized by a decrease in bone density.
Choice D rationale
Decreased balance is a common age-related change, but it is not the correct answer for this question.
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