The nurse tests the function of Cranial Nerve XI while performing a physical examination on a client. Which statement best describes the response the nurse should expect if Cranial Nerve XI is intact?

When the client sticks out the tongue it is in the midline and without tremors or deviation.

Client follows an object with eyes without nystagmus or strabismus.

Client demonstrates the ability to hear normal conversation.

Client moves the head and shoulders against resistance with equal strength.

Answer and Explanation

The Correct Answer is D

A.   Cranial Nerve XI (Accessory nerve) is not involved in tongue movement; it controls muscles involved in head and shoulder movement.
B.   Eye movement and control relate more to Cranial Nerves III, IV, and VI, which control eye muscles.
C.   Hearing is primarily assessed by Cranial Nerve VIII (Vestibulocochlear nerve).
D.   Cranial Nerve XI innervates the sternocleidomastoid and trapezius muscles, enabling movements like head turning and shoulder shrugging against resistance.

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Correct Answer is B

Explanation

A. A bone spur is a bony projection often caused by joint damage, but it does not typically produce audible crunching or grating sounds.
B. Crepitation refers to a crunching, grating, or popping sound or sensation that occurs with movement of a joint. It's often associated with conditions like osteoarthritis.
C. Tendonitis involves inflammation of a tendon and may cause pain or tenderness, but it does not typically produce audible sounds like crepitation.
D. Fluid in the knee joint might cause swelling and limited movement, but it does not usually produce audible crunching or grating sounds.

A. Plantarflex the foot B. Dorsiflex the foot C. Hold both hands back to back while flexing the wrists 90 degrees for 60 seconds D. Hyperextend the wrists with the palmar surface of both hands touching, and wait for 60 seconds

Correct Answer is C

Explanation

A. Plantarflexion and dorsiflexion refer to movements of the foot and are unrelated to the Phalen test.
B. Hyperextension of the wrists with the palmar surfaces touching is not the correct maneuver for the Phalen test.
C. The Phalen test involves holding both hands back to back while flexing the wrists at a 90- degree angle for about 60 seconds, which may induce symptoms of carpal tunnel syndrome in those affected.
D. Hyperextending the wrists with the palms together doesn’t simulate the stress on the median nerve in the same way as the Phalen test.

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The nurse tests the function of Cranial Nerve XI while performing a physical examination on a client. Which statement best describes the response the nurse should expect if Cranial Nerve XI is intact?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client states, "I can hear a crunching or grating sound when I kneel and have difficulty getting out of bed in the morning because of pain and stiffness." Which of the following should the nurse expect as an assessment finding?

Correct Answer is B

Explanation

The nurse suspects that a client has carpal tunnel syndrome and prepares to conduct the Phalen test. What instructions should the nurse give the client to perform the Phalen test?

Correct Answer is C

Explanation

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