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:
Unable to hold a bottle is a developmental milestone expected at around 6 months of age. This is not a concerning finding for a 5-month-old infant.
Choice B rationale:
The grasp reflex is present in infants until about 6 months of age. Its absence is expected at 5 months and is not a cause for concern.
Choice C rationale:
Rolling from back to abdomen is typically achieved by 5 months of age. However, the inability to do so is not necessarily a red flag at this age, as each infant develops at their own pace.
Choice D rationale:
Head lag refers to the infant's head falling backward when pulled to a sitting position, indicating poor head control. This is a significant developmental red flag at 5 months of age and should be reported to the provider. It might indicate possible neuromuscular issues or developmental delays, requiring further evaluation and intervention.
Correct Answer is D
Explanation
The correct answer is Choice D: 5 mL.
Choice A: 8 mL This choice suggests administering 8 mL of amoxicillin per dose. However, based on the child’s weight (10 kg) and the prescribed dosage (80 mg/kg/day divided into two doses), the correct calculation leads to a dosage of 5 mL per dose. Therefore, 8 mL would be more than the recommended dosage.
Choice B: 80 mL Administering 80 mL of amoxicillin per dose would be significantly more than the recommended dosage. This could potentially lead to an overdose, which could cause harmful side effects.
Choice C: 10 mL While 10 mL is close to the correct dosage, it is still double the recommended amount. Administering too much amoxicillin could potentially lead to an overdose and cause harmful side effects.
Choice D:
Step 1: Calculate the total amount of amoxicillin needed per day.
The total amount of amoxicillin needed per day is calculated by multiplying the weight of the child by the dosage per kg. So, 80 mg/kg/day × 10 kg = 800 mg/day.
Step 2: Divide the total amount of amoxicillin needed per day by the number of doses per day.
The total amount of amoxicillin needed per day is divided into two doses. So, 800 mg/day ÷ 2 = 400 mg/dose.
Step 3: Calculate the volume of amoxicillin suspension needed per dose.
The volume of amoxicillin suspension needed per dose is calculated by dividing the amount of amoxicillin needed per dose by the concentration of the suspension. So, 400 mg/dose ÷ (400 mg/5 mL) = 5 mL/dose.
Therefore, the nurse should administer 5 mL of amoxicillin per dose.
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