A nurse is assessing a school-age child's cranial nerve function.
Which of the following actions should the nurse ask the child to take when assessing the accessory nerve?
Show their teeth while smiling.
Follow a light in the six cardinal positions.
Shrug their shoulders against mild pressure.
Move their tongue in all directions.
The Correct Answer is C
Choice A rationale:
Showing teeth while smiling assesses the facial nerve (cranial nerve VII), not the accessory nerve (cranial nerve XI) The facial nerve controls facial expressions, including smiling.
Choice B rationale:
Following a light in the six cardinal positions assesses extraocular eye movements, which are controlled by the oculomotor nerve (cranial nerve III), trochlear nerve (cranial nerve IV), and abducens nerve (cranial nerve VI) This action does not assess the accessory nerve.
Choice C rationale:
Shrugging the shoulders against mild pressure assesses the function of the accessory nerve (cranial nerve XI) The accessory nerve controls the sternocleidomastoid and trapezius muscles, which are responsible for head rotation and shoulder shrugging. Assessing the strength of these muscles helps evaluate the integrity of the accessory nerve.
Choice D rationale:
Moving the tongue in all directions assesses the hypoglossal nerve (cranial nerve XII), which controls tongue movements. This action does not assess the accessory nerve.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Staying under a beach umbrella during morning hours provides some protection from direct sunlight but does not offer comprehensive coverage, especially when the sun's rays are strong. It is not the best option for protecting a toddler from sun exposure.
Choice B rationale:
SPF (Sun Protection Factor) 10 sunscreen is relatively low and may not provide adequate protection, especially for a toddler. Higher SPF sunscreens are recommended, typically SPF 30 or higher, to effectively block harmful UV rays.
Choice C rationale:
Loose-weave clothing may allow sunlight to penetrate, leading to sunburn. Tight-knit, dark-colored clothing offers better protection. Loose-weave clothing is not the most effective choice for sun protection.
Choice D rationale:
Wearing a wide-brimmed hat provides shade to the face, neck, and ears, offering additional protection from direct sunlight. This choice indicates a good understanding of the need for comprehensive sun protection for the toddler.
Correct Answer is C
Explanation
Choice A rationale:
A blood pressure of 95/56 mm Hg is within the normal range for a 5-year-old child. While assessing vital signs, the nurse should consider the patient's age-specific parameters. In this case, the blood pressure is not indicative of hemorrhage.
Choice B rationale:
Flushing of the face might be a common postoperative finding and is not necessarily indicative of hemorrhage. It can be caused by various factors such as anesthesia or emotional states. Flushing alone is not a reliable sign of hemorrhage and should be assessed in conjunction with other symptoms.
Choice C rationale:
Continuous swallowing, especially with an increased heart rate and signs of restlessness, can be indicative of hemorrhage after a tonsillectomy and adenoidectomy. Frequent swallowing suggests the presence of blood in the mouth or throat, indicating possible bleeding at the surgical site. This finding requires immediate attention and intervention by the nurse.
Choice D rationale:
A heart rate of 54/min is below the normal range for a 5-year-old child, which typically ranges from 70 to 120 beats per minute. While bradycardia can be a concern, the more specific and immediate indication of hemorrhage in this case is continuous swallowing, which signals active bleeding from the surgical site.
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