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?

Sticks his tongue out.

Frowns symmetrically.

Identifies a sour taste.

Shrugs his shoulders.

None

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is D

Explanation

Choice A rationale:

Instructing the client to abstain from sexual intercourse for one month is not necessary for the management of Chlamydia trachomatis. Instead, the client should be advised to abstain from sexual activity until they and their partner(s) have completed the prescribed course of antibiotics and are no longer contagious, which is usually within 7 days.

Choice B rationale:

Administering ceftriaxone via intermittent IV bolus is not the recommended route for treating Chlamydia trachomatis. The standard treatment for Chlamydia trachomatis infection is oral antibiotics, such as azithromycin or doxycycline. Intravenous administration is not typically required for uncomplicated cases.

Choice C rationale:

Scheduling the client for retesting in one week is not necessary if the client has received appropriate treatment and follows the prescribed course of antibiotics. Retesting is generally recommended 3 months after treatment, especially in cases of persistent or recurrent symptoms.

Choice D rationale:

Reporting the infection to the state department of health is a crucial action. Chlamydia trachomatis is a reportable sexually transmitted infection in many jurisdictions. Reporting helps public health authorities track the incidence of the disease, implement preventive measures, and allocate resources effectively to control its spread within the community. It is essential for the nurse to comply with legal and ethical obligations by reporting the infection to the appropriate health authorities.

A. The client has a decreased energy level. B. The client requests a second opinion. C. The client wants to talk about the diagnosis with the nursing staff. D. The client makes funeral arrangements.

Correct Answer is D

Explanation

Explanation: Making funeral arrangements is an indication of hopelessness because it shows that the client has given up on the possibility of recovery or improvement. A decreased energy level, requesting a second opinion, and wanting to talk about the diagnosis are not necessarily signs of hopelessness, but rather normal reactions to a terminal illness.

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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?

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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?