A nursing student asked the respiratory floor nurse why the adventitious wheezing breath sounds are present in asthmatic patients. The nurse should respond:

A) XI: Cranial nerve XI, the spinal accessory nerve, is primarily responsible for motor function, particularly in the muscles involved in shoulder elevation and head rotation. It does not play a role in balance, so focusing on this nerve would not be relevant to the client’s complaint of balance issues.
B) VIII: Cranial nerve VIII, the vestibulocochlear nerve, is directly involved in hearing and balance. It transmits information from the inner ear to the brain regarding head position and motion, which are essential for maintaining balance. The client’s report of spontaneous loss of balance strongly suggests involvement of this nerve, making it the most appropriate focus for additional assessment.
C) IX: Cranial nerve IX, the glossopharyngeal nerve, is primarily associated with taste and the gag reflex. While it is important for swallowing and certain aspects of speech, it does not influence balance, so it would not be the primary concern in this situation.
D) X: Cranial nerve X, the vagus nerve, has extensive functions related to autonomic control of the heart, lungs, and digestive tract, as well as motor and sensory functions in the throat. Although it plays a significant role in the body, it does not directly influence balance, making it less relevant in this context.

A) Tension headache: Tension headaches are typically characterized by a dull, aching pain that feels like a tight band around the head. They are often associated with muscle tension and stress, and they generally do not involve nausea, vomiting, or sensitivity to light and sound, which are more indicative of migraines.
B) Migraine headache: The symptoms described—severe pain rated 10 out of 10, nausea, vomiting, and sensitivity to light (photophobia) and sound (phonophobia)—are classic signs of a migraine headache. Migraines are often intense and can be accompanied by these additional symptoms, making this the most likely diagnosis.
C) Cluster headache: Cluster headaches are extremely painful and typically occur in cyclical patterns or clusters. They are often unilateral (one-sided) and can cause severe pain, redness of the eye, and nasal congestion. While they can be very painful, they are less commonly associated with nausea, vomiting, and sensitivity to light and sound as described in the scenario.
D) Sinus headache: Sinus headaches are associated with sinusitis and typically involve pain and pressure in the forehead, cheeks, or nose area, often accompanied by nasal congestion. They usually do not present with the intensity of pain, nausea, vomiting, and sensitivity to light and sound seen in migraines.