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 B

Explanation

A. Intact skin with localized erythema: This describes a stage 1 pressure injury.
B. Partial-thickness skin loss with red tissue in wound bed: This is characteristic of stage 2 pressure injuries, where there is damage to the epidermis and partial dermis.
C. Full thickness skin loss with visible adipose tissue: This describes a stage 3 pressure injury.
D. Full thickness skin loss with visible bone: This describes a stage 4 pressure injury.

A. Scale B. Pustule C. Macule D. Papule

Correct Answer is B

Explanation

A. Scale refers to flakes of dead skin cells and is not typically used to describe acne lesions.
B. Pustules are small, inflamed, pus-filled lesions, which are characteristic of acne.

C. A macule is a flat, discolored spot on the skin and does not apply to the raised, pus-filled lesions seen in acne.
D. A papule is a small, solid, raised lesion, but it is not filled with pus like a pustule. Acne lesions are often described as pustules when they contain pus.

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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

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

When assessing a client's skin, the nurse finds acne. How would the nurse document the lesions?

Correct Answer is B

Explanation

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