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 A

Explanation

A. Dullness above the right costal margin could indicate an enlarged liver. Referring the client to a healthcare provider is crucial for further evaluation and diagnosis.
B. Documenting hepatomegaly without further investigation or confirmation by a healthcare provider could be premature.
C. While alcohol intake can be a factor in liver conditions, additional history alone may not confirm the cause of the dullness. Direct evaluation by a healthcare provider is necessary.
D. Finding an area of dullness above the right costal margin, particularly of such magnitude, should prompt further investigation rather than being considered normal.

A. Vertigo B. Seizure activity C. Dizziness D. Syncope

Correct Answer is A

Explanation

A. Vertigo is the sensation of spinning or movement when stationary and is often associated with inner ear problems.
B. Seizure activity involves abnormal electrical activity in the brain and might present with various symptoms but not necessarily the feeling of spinning.
C. Dizziness is a more general term that can include feelings of light-headedness or unsteadiness without a specific spinning sensation.
D. Syncope refers to fainting or loss of consciousness due to decreased blood flow to the brain, not the sensation of spinning.

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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

The nurse is percussing a client's abdomen during a physical assessment. The nurse observes an area of dullness above the right costal margin of approximately 11 cm. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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