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 B
Explanation
Choice A rationale
Academic pressure is a psychological stressor, not a physiological one. It involves mental or emotional strain or tension resulting from adverse or demanding circumstances, in this case, related to academic performance.
Choice B rationale
A burn injury is an example of a physiological stressor. Physiological stressors are related to physical or biological factors that strain the body’s resources. A burn injury places physical stress on the body as it tries to heal and recover.
Choice C rationale
Financial difficulties are a type of environmental stressor, not a physiological one. They involve external factors in a person’s environment that cause stress, such as financial problems or jobrelated stress.
Choice D rationale
A change in marital status is a type of psychosocial stressor, not a physiological one. It involves both psychological factors (such as emotions and behavior) and social factors (such as relationships and social interactions).
Correct Answer is A
Explanation
Choice A rationale
This response shows empathy and understanding towards the patient’s situation. It acknowledges the patient’s craving for strawberry ice cream and offers a compromise that aligns with the patient’s dietary restrictions.
Choice B rationale
This response may come across as insensitive and dismissive of the patient’s feelings. It’s important to show empathy and understanding when dealing with patients, especially those in hospice care.
Choice C rationale
This response may not be appropriate as it does not consider the patient’s dietary restrictions. While it shows empathy, it’s important to respect and adhere to the patient’s dietary needs.
Choice D rationale
This response may not be appropriate as it does not address the patient’s statement. It’s important to acknowledge and respond to the patient’s feelings and concerns.
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