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.
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.
Nursing Test Bank
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Related Questions
Correct Answer is B
Explanation
A. Reassurance is important, but it should be given after a thorough assessment and appropriate actions have been taken.
B. Completing an assessment and promptly informing the physician allows for timely intervention in case of testicular torsion or other serious conditions causing severe testicular pain.
C. Performing a focused assessment is crucial but shouldn't delay immediate notification of the physician in such a critical situation.
D. Documenting pain assessment is important but not the priority when a client presents with severe, acute pain in a sensitive area like the testicles.
Correct Answer is D
Explanation
A. The vas deferens is a duct that transports sperm from the epididymis to the ejaculatory duct.
B. The epididymis is where sperm is stored and matures but not produced.
C. The prostate gland produces a fluid that contributes to semen but not sperm production.
D. The testes are responsible for producing sperm through the process of spermatogenesis.
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