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 C

Explanation

Choice A Reason:
Listening while the client reads items listed on the menu is inappropriate. This approach involves assessing the client's speech while they read items listed on the menu. While reading aloud can provide some insight into speech patterns, it may not fully capture spontaneous speech or natural conversation. Additionally, reading may not necessarily assess other aspects of speech such as articulation, fluency, or coherence. Therefore, while this approach can offer some information, it may not be as comprehensive as observing speech during a natural conversation or interview.
Choice B Reason:
Asking the client to complete a common proverb or saying is inappropriate. Asking the client to complete a common proverb or saying is a task that assesses language comprehension and expression. While this approach may provide some insight into the client's ability to formulate and articulate speech, it may not fully capture spontaneous speech patterns or natural conversation. Additionally, completing proverbs or sayings may require specific cultural knowledge or cognitive abilities that could influence the assessment. Therefore, while this approach can be useful in certain contexts, it may not be as comprehensive as observing speech during a natural conversation or interview.
Choice C Reason:
Noting the client's responses during the initial interview is appropriate. Option C involves observing the client's speech patterns during the initial interview, which provides the nurse with an opportunity to assess spontaneous speech, articulation, fluency, and coherence. During the initial interview, the nurse can assess the client's ability to express thoughts, respond to questions, and engage in conversation, which can reveal any abnormalities or difficulties in speech patterns. This approach allows for a comprehensive assessment of speech without requiring specific tasks or prompts that may be more challenging or unfamiliar to the client.
Choice D Reason:
Having the client repeat a phrase containing alliteration is inappropriate. Asking the client to repeat a phrase containing alliteration is a task that assesses speech articulation and phonological skills. While this approach may provide some information about the client's ability to produce specific sounds or syllables, it may not fully capture spontaneous speech patterns or natural conversation. Additionally, repeating phrases with alliteration may not necessarily assess other aspects of speech such as fluency, coherence, or language comprehension. Therefore, while this approach can be useful for assessing specific speech skills, it may not be as comprehensive as observing speech during a natural conversation or interview.

A. Pupils equal, round, reacts to light, and accommodation (PERLA). B. Glasgow Coma Scale (GCS) of 15. C. Pupils equal, round, reacts to light (PERRL). D. Neurological status intact.

Correct Answer is C

Explanation

Choice A Reason:
Pupils equal, round, reacts to light, and accommodation (PERLA) is inappropriate. While PERLA includes accommodation, which involves constriction of the pupils when focusing on a near object, accommodation was not specifically assessed or mentioned in the scenario. Therefore, it would be inaccurate to include it in the documentation based solely on the information provided.
Choice B Reason:
Glasgow Coma Scale (GCS) of 15 is inappropriate. The Glasgow Coma Scale (GCS) assesses the level of consciousness based on eye, verbal, and motor responses. However, the scenario does not provide information about the client's verbal or motor responses, so using the GCS score of 15 would not accurately reflect the findings described in the assessment of the pupils.
Choice C Reason:
Pupils equal, round, reacts to light (PERRL) is appropriate. This notation describes the key observations made during the assessment of the client's pupils. "PERRL" stands for Pupils Equal, Round, and Reactive to Light. In the given scenario, both pupils are equal in size, round, and demonstrate a brisk response to light, indicating normal pupillary function.
Choice D Reason:
Neurological status intact is inappropriate. While the assessment findings suggest normal pupillary function, documenting "neurological status intact" is a broader statement that encompasses various aspects of neurological function beyond just pupillary assessment. It may be accurate to describe the pupillary findings within the context of a broader neurological assessment, but it does not specifically address the pupil findings as described in the scenario. Therefore, option C is the most appropriate notation for documenting the assessment findings of the pupils.

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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

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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