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The nurse is testing the function of cranial nerve XI (Spinal accessory nerve). Which finding would the nurse expect if the nerve is intact?

A.

Follows an object with eyes without nystagmus or strabismus

B.

Moves the tongue out midline without tremors or deviation

C.

Moves the head and shoulders against resistance with equal strength

D.

Demonstrates full range of the neck

Answer and Explanation

The Correct Answer is C

A. Follows an object with eyes without nystagmus or strabismus
Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) control eye movement. CN XI does not control eye movement.

B. Moves the tongue out midline without tremors or deviation
Cranial nerve XII (hypoglossal nerve) controls tongue movement.

C. Moves the head and shoulders against resistance with equal strength
Cranial nerve XI (spinal accessory nerve) controls the sternocleidomastoid and trapezius muscles. If intact, the client can shrug shoulders and turn the head against resistance with equal strength.

D. Demonstrates full range of the neck
Full range of motion in the neck involves multiple muscles, not just those innervated by CN XI.


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Related Questions

Correct Answer is D

Explanation

A. Decrease chest pain is important but not the highest priority. Managing pain can help with breathing, but oxygenation is the primary concern.

B. Reduce the client's anxiety is secondary to physiological needs. Anxiety can worsen dyspnea, but addressing oxygenation first is more critical.

C. Maintain adequate circulating volume is a priority if there is hemorrhage, but the question does not indicate bleeding. Oxygenation takes precedence in this case.

D. Maintain adequate oxygenation is the priority. Chest trauma can lead to pneumothorax, pulmonary contusion, or other complications that can impair gas exchange. Ensuring adequate oxygenation prevents hypoxia and respiratory failure, which are life-threatening.

Correct Answer is B

Explanation

A. Provide the daughter and client with nutritional counseling.

While nutrition is important, assessing for abuse is the priority.

B. Interview the client alone and assess for abuse.

The client’s reluctance and daughter’s interruptions suggest potential elder abuse.

C. Take the history from the daughter due to the client’s confusion.

The client should be interviewed alone first.

D. Request a psychiatric evaluation.

Confusion can result from dehydration or trauma, not necessarily a psychiatric disorder.

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