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. 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.

A. “As a nurse, I am required by law to report suspected child abuse.” B. "I reported the incident to my supervisor who decided to contact the authorities." C. "The provider will be coming to explain the situation." D. ”I am unable to discuss this, but I can contact my supervisor to speak with you."

Correct Answer is A

Explanation

A. The nurse is legally obligated to report suspected child abuse according to mandatory reporting laws. This response directly addresses the nurse’s legal responsibility without providing unnecessary details to the parents.
B. Reporting the incident to a supervisor does not fully address the nurse's legal obligation, which is to report the abuse to the authorities.
C. It is inappropriate to defer to the provider in this case, as the nurse holds the legal responsibility to report the suspicion.
D. The nurse should not avoid the discussion but instead provide a clear, legal explanation for their actions.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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