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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is C
Explanation
Choice A rationale
Minimal assistance implies that the patient needs some help but can do most of the task on their own. In this case, the patient is able to stand up from a seated position using a cane for support, which suggests that they do not need assistance.
Choice B rationale
Moderate assistance implies that the patient needs more help to perform the task. The patient in the scenario is able to perform the task independently with the help of a cane.
Choice C rationale
No assistance means that the patient can perform the task independently. This is the most fitting answer because the patient is able to stand up from a seated position using a cane for support.
Choice D rationale
Maximum assistance implies that the patient is unable to perform the task without substantial help. This does not apply to the patient in the scenario as they are able to stand up independently with the help of a cane.
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