The nurse continues a neurologic assessment of the cranial nerve XI (Spinal accessory) for a client. Which instruction should the nurse give the client to complete this assessment?

Shrug shoulders against resistance.

Stand up slowly with eyes closed.

Turn head from side to side.

Raise both arms overhead

Answer and Explanation

The Correct Answer is A

Choice A Reason:
Shrug shoulders against resistance is correct because cranial nerve XI, also known as the spinal accessory nerve, innervates the trapezius and sternocleidomastoid muscles. Instructing the client to shrug their shoulders against resistance tests the strength and function of the trapezius muscle, which is primarily innervated by cranial nerve XI. Therefore, this instruction directly assesses the function of the cranial nerve XI.
Choice B Reason:
Stand up slowly with eyes closed is incorrect because standing up slowly with eyes closed primarily assesses proprioception and balance, which involve multiple cranial nerves and the vestibular system. While cranial nerve XI may play a role in maintaining posture and balance, it is not the primary nerve involved in this assessment.
Choice C Reason:
Turn head from side to side is incorrect because turning the head from side to side primarily assesses the function of the sternocleidomastoid muscle, which is also innervated by cranial nerve XI. However, this action alone does not provide resistance against which the muscle can contract, making it less specific for assessing cranial nerve XI compared to the instruction to shrug the shoulders against resistance.
Choice D Reason:
Raise both arms overhead incorrect because raising both arms overhead primarily assesses motor function and strength of the upper extremities, which do not directly involve the muscles innervated by cranial nerve XI. While the trapezius muscle may be indirectly involved in shoulder movement, this action does not specifically target the function of cranial nerve XI.

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Correct Answer is B

Explanation

Choice A Reason:
Observing chest and upper neck for a rash is correct. This assessment is unrelated to tinnitus. Observing the chest and upper neck for a rash may be relevant in the context of other conditions, such as skin disorders or infectious diseases, but it does not provide information about the effects of tinnitus.
Choice B Reason:
Performing a hearing test is correct. Tinnitus is the perception of noise or ringing in the ears when no external sound is present. It can affect a person's hearing and overall quality of life. Therefore, the most appropriate assessment to evaluate the effects of tinnitus is to perform a hearing test. This test can assess the client's auditory function, including their ability to hear different frequencies and intensities of sound. By conducting a hearing test, the nurse can gather objective data on the client's hearing abilities and determine the extent to which tinnitus may be impacting their hearing sensitivity and perception.
Choice C Reason:
Evaluating for a loss of peripheral vision is incorrect. Loss of peripheral vision is not a typical effect of tinnitus. While tinnitus can affect auditory perception, it does not directly impact visual function, particularly peripheral vision. Therefore, evaluating for loss of peripheral vision is not relevant to assessing the effects of tinnitus.
Choice D Reason:
Assessing deep tendon reflexes is incorrect. Assessing deep tendon reflexes is unrelated to evaluating the effects of tinnitus. Deep tendon reflexes are assessed to evaluate the integrity of the neurological system and are typically tested in the context of assessing motor function and nerve responses. This assessment does not provide information about the auditory effects of tinnitus.

A. Normal mental status for age. B. Impaired concentration. C. Impaired memory. D. Impaired thinking.

Correct Answer is D

Explanation

Choice A Reason:
Normal mental status for age is incorrect. This choice would not be the most accurate conclusion based on the client's response. While it's possible that the client's response could be influenced by factors such as cultural background or personal interpretation, the inability to understand the metaphorical meaning of a commonly known proverb might suggest some level of cognitive impairment or difficulty with abstract thinking. Therefore, it would be premature to conclude that the client's response reflects a normal mental status for her age.
Choice B Reason:
Impaired concentration is incorrect. Impaired concentration would manifest as difficulty maintaining focus our attention during the interaction. However, the client's response doesn't suggest a lack of attention or focus. Instead, it indicates a misinterpretation of the proverb, which is more indicative of impaired thinking or difficulty understanding abstract concepts rather than impaired concentration.
Choice C Reason:
Impaired memory is incorrect. Impaired memory would typically involve difficulty recalling information or events from the past. In this scenario, the client is able to recall the phrase "Glass Houses" but demonstrates difficulty understanding its meaning. Therefore, impaired memory is not the most appropriate conclusion based on the client's response. Instead, the response suggests impaired thinking or difficulty with abstract reasoning.
Choice D Reason:
Impaired thinking is correct. The client's response indicates difficulty understanding the metaphorical meaning of the proverb "Glass Houses," which typically implies that those who live in fragile or vulnerable situations should avoid criticizing others, as they themselves are also vulnerable to criticism or judgment. Instead, the client's response focuses on the literal interpretation of the phrase, suggesting impaired thinking or difficulty grasping abstract concepts.

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The nurse continues a neurologic assessment of the cranial nerve XI (Spinal accessory) for a client. Which instruction should the nurse give the client to complete this assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In reading a client's record, the nurse notes that the client is experiencing tinnitus. Which assessment provides the nurse with the information needed to evaluate the effects of this condition?

Correct Answer is B

Explanation

The nurse asks a female client about the proverb "Glass Houses," and she replies, "It will break the windows." Which conclusion should be documented about this client's response?

Correct Answer is D

Explanation

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