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
For a client with Parkinson’s disease who has difficulty swallowing or chewing due to muscle rigidity, semi-solid food with thick liquids can be easier to swallow and reduce the risk of choking.
Choice B rationale
Minced foods and fluid restriction may not provide the necessary nutrients and hydration for a client with Parkinson’s disease.
Choice C rationale
A low-residue diet, which is low in fiber, may not be appropriate for a client with Parkinson’s disease, as constipation is a common symptom of the disease and fiber can help alleviate this.
Choice D rationale
Total parenteral nutrition (TPN) is a method of feeding that bypasses the gastrointestinal tract. It is typically reserved for clients who cannot or should not get their nutrition through eating.
Correct Answer is A
Explanation
Choice A rationale
Post-traumatic stress disorder (PTSD) is a stress-related disorder that can occur after a person experiences a traumatic event. Symptoms can include flashbacks of the traumatic event, which the patient reports experiencing.
Choice B rationale
Episodic acute stress is a type of stress that occurs in response to specific situations or events. It does not typically involve flashbacks of a traumatic event.
Choice C rationale
Irritable bowel syndrome (IBS) is a common disorder that affects the large intestine. While stress can exacerbate symptoms of IBS, it is not a stress-related disorder in the sense of being a psychological response to stress.
Choice D rationale
Acute stress disorder (ASD) is a stress-related disorder that can occur in response to a traumatic event. However, ASD symptoms occur immediately after the traumatic event and typically resolve within a month. Since the patient reports experiencing flashbacks of a traumatic event that occurred a year ago, ASD is not the correct answer.
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