When performing a head-to-toe assessment, during which part would the nurse evaluate cranial nerve (CN) IX, X, and XII?

Ears

Mouth and throat

Head and face

Mental status examination

Answer and Explanation

The Correct Answer is B

A. Ears: Evaluation of the ears is primarily concerned with hearing and balance, which involve cranial nerves such as VIII (Vestibulocochlear), not IX, X, and XII.

B. Mouth and throat: Cranial nerves IX (Glossopharyngeal), X (Vagus), and XII (Hypoglossal) are assessed through the examination of the mouth and throat. CN IX and X are evaluated by checking the gag reflex and the ability to swallow, while CN XII is assessed by examining tongue movements.

C. Head and face: The assessment of the head and face generally involves cranial nerves V (Trigeminal) and VII (Facial), which control facial sensation and movement, rather than IX, X, and XII.

D. Mental status examination: While mental status is crucial for overall health assessment, it does not specifically target cranial nerves IX, X, and XII.

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Correct Answer is A

Explanation

A. Mental: The client's disorientation and altered perception suggest a need for a mental health assessment to evaluate cognitive function, potential delirium, or other psychiatric conditions.

B. Physical: While the client's shaking is noted, the primary concern in this scenario is the client's altered mental state, rather than physical health alone.

C. Spiritual: The client's behavior does not directly indicate a need for a spiritual assessment.

D. Interpersonal: Although the client’s behavior may impact interpersonal interactions, the immediate need is to assess the mental status due to the confusion and altered perception.

A. Facial, Trigeminal, Vestibulocochlear B. Oculomotor, Trochlear, and Abducens C. Spinal Accessory, Facial, Trigeminal D. Glossopharyngeal, Vagus, Hypoglossal

Correct Answer is B

Explanation

A. Facial, Trigeminal, Vestibulocochlear: The Facial nerve (VII) controls facial expressions, the Trigeminal nerve (V) is involved in facial sensation, and the Vestibulocochlear nerve (VIII) handles hearing and balance, none of which are directly related to eye movements.

B. Oculomotor, Trochlear, and Abducens: The Oculomotor nerve (III) controls most eye movements, the Trochlear nerve (IV) controls the superior oblique muscle for downward and outward movements, and the Abducens nerve (VI) controls the lateral rectus muscle for lateral eye movement.

C. Spinal Accessory, Facial, Trigeminal: The Spinal Accessory nerve (XI) controls neck and shoulder movements, while the Facial nerve (VII) and Trigeminal nerve (V) are not involved in eye movements.

D. Glossopharyngeal, Vagus, Hypoglossal: The Glossopharyngeal nerve (IX) is involved in taste and salivation, the Vagus nerve (X) affects parasympathetic functions, and the Hypoglossal nerve (XII) controls tongue movements, none of which are related to eye movements.

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When performing a head-to-toe assessment, during which part would the nurse evaluate cranial nerve (CN) IX, X, and XII?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Cranial nerves involved in eye movements are:

Correct Answer is B

Explanation

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