A nurse is performing a cranial nerve assessment on a school-age child.
Which of the following findings indicates proper functioning of the child's trigeminal nerve?
The child maintains balance when standing with eyes closed.
The child has symmetrical jaw strength when biting down.
The child exhibits a gag reflex when stimulated with a tongue blade.
The child correctly identifies specific scents.
The Correct Answer is B
The trigeminal nerve is responsible for sensation in the face and motor functions such as biting and chewing.
Symmetrical jaw strength when biting down indicates proper functioning of the trigeminal nerve.
Choice A is wrong because it assesses the vestibulocochlear nerve, not the trigeminal nerve.
Choice C is wrong because it assesses the glossopharyngeal and vagus nerves, not the trigeminal nerve.
Choice D is wrong because it assesses the olfactory nerve, not the trigeminal nerve.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Elevate the infant’s head to a 10° angle during feedings.
This position can help prevent milk from coming out of the infant’s nose and reduce the risk of choking.
Choice A is wrong because watery eyes are not an indication to discontinue feeding.
Choice B is wrong because babies with cleft palate should be burped more frequently, but not so often as to interrupt good feeding behaviors.
Choice D is wrong because the amount of formula an infant needs varies and should be determined by a pediatrician.
Correct Answer is D
Explanation
The correct answer is d. Exhibits head lag when pulled to a sitting position.
Choice A: Unable to hold a bottle At around 6 months of age, some babies can hold their own bottle. This is not a concerning finding for a 5-month-old infant. Therefore, this is not the correct answer.
Choice B: Unable to roll from back to abdomen Rolling over often starts around 4-6 months, so it’s not unusual for a 5-month-old to still be developing this skill. Therefore, this is not the correct answer.
Choice C: Absent grasp reflex The grasp reflex is an involuntary movement that your baby starts making in utero and continues doing until around 6 months of age. The grasp reflex lasts until the baby is about 5 to 6 months old. Therefore, this is not the correct answer.
Choice D: Exhibits head lag when pulled to a sitting position By the age of 5 months, most infants have developed enough strength in their neck and upper body to control their head movement. This means they should not exhibit a significant head lag when pulled to a sitting position1. If this is not the case, it could indicate a delay in motor development or a potential neurological issue, which should be reported to the healthcare provider for further evaluation. Therefore, this is the correct answer.
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