A nurse is performing a neurological examination on a client as part of a complete physical assessment.
The nurse should identify that cranial nerve XI is intact when the client performs which of the following actions?

 

Choice A rationale: Sticking the tongue out assesses cranial nerve XII (hypoglossal nerve). This action is used to evaluate tongue movement and is not related to cranial nerve XI (accessory nerve) function.

Choice B rationale: Frowning symmetrically assesses cranial nerve VII (facial nerve). This action is used to evaluate facial muscle strength and is not related to cranial nerve XI (accessory nerve) function.

Choice C rationale: Identifying a sour taste assesses cranial nerve IX (glossopharyngeal nerve). This action is related to taste sensation on the posterior third of the tongue and is not specific to cranial nerve XI (accessory nerve) function.

Choice D rationale: Correct. Shrugging the shoulders assesses cranial nerve XI (accessory nerve). This nerve controls the sternocleidomastoid and trapezius muscles, which are responsible for shoulder movements. Testing the strength of these muscles helps assess the integrity of cranial nerve XI.

Choice A rationale:

Maintaining eye contact with the newborn during feedings is a general caregiving practice and is not specific to managing neonatal abstinence syndrome. While eye contact and bonding are important for newborns, it does not address the symptoms of neonatal abstinence syndrome.

Choice B rationale:

Swaddling the newborn with his legs extended is not a specific action for managing neonatal abstinence syndrome. However, swaddling can provide comfort to some infants, but the positioning of the legs is not directly related to managing symptoms of withdrawal.

Choice C rationale:

Administering naloxone to the newborn is not a standard practice for managing neonatal abstinence syndrome. Naloxone is an opioid antagonist used to reverse opioid overdose in adults and is not typically used in newborns unless there are specific indications, which are rare.