A nurse is preparing to perform a cranial nerve examination for a client. Which of the following actions should the nurse take to check cranial nerve XI?

Have the client identify specific smells.

Check the client's visual acuity using a Snellen chart.

Observe for the ability of the client to turn their head side to sidê.

Whisper in one of the client's ears while occluding the other.

Answer and Explanation

The Correct Answer is C

A.   Identifying specific smells checks cranial nerve I (olfactory).
B.   Checking visual acuity with a Snellen chart assesses cranial nerve II (optic).
C.   Observing for the ability to turn the head side to side tests cranial nerve XI (accessory), which controls the sternocleidomastoid and trapezius muscles responsible for head movement.
D.   Whispering in one ear while occluding the other tests cranial nerve VIII (vestibulocochlear).

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Correct Answer is A

Explanation

A. Skin tenting, where the skin remains pinched after being pulled up, is a classic sign of dehydration due to a lack of adequate fluid in the tissues.
B. Low body temperature is not typically associated with dehydration; instead, a fever or elevated temperature is more commonly seen with infection.
C. High blood pressure (178/90 mm Hg) could indicate hypertension or another condition, but it is not a direct sign of dehydration.
D. Jugular vein distention is more commonly associated with fluid overload, heart failure, or other circulatory issues, rather than dehydration.

A. Assess risk for immediate harm. B. instruct the client on how to leave the relationship. C. Implement a safety plan. D. Refer the client to a community support group.

Correct Answer is A

Explanation

A. Assess risk for immediate harm should be the priority. The nurse needs to evaluate whether the client is in immediate danger and take the necessary steps to ensure their safety.
B. Instructing the client on how to leave the relationship is important, but the priority is to assess if the client is in immediate danger first.
C. Implementing a safety plan is essential, but first, the nurse must assess the immediate risks to the client's safety.
D. Referring the client to a community support group is a supportive action but should follow the priority steps of ensuring safety and assessing immediate harm.

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A nurse is preparing to perform a cranial nerve examination for a client. Which of the following actions should the nurse take to check cranial nerve XI?

Nursing Test Bank

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