A nurse is assessing cranial nerve XI (11) on a client. What method is appropriate for examining cranial nerve XI (11)?

A. Ask the patient to sit about 4 ft away facing the nurse: The assessment of extraocular movements (EOM) requires close observation of the patient’s eye tracking and alignment. Sitting too far away, such as 4 feet, may make it difficult to accurately detect subtle deviations, nystagmus, or limitations in gaze. Proper assessment distance is usually around 12–24 inches.

B. Use a penlight approximately 1 ft away from the patient's face and move it slowly in all 6 directions: This technique aligns with the standard EOM assessment. The nurse instructs the patient to follow a target (penlight or finger) through the six cardinal positions of gaze: up, down, left, right, and diagonals. Moving the target slowly allows for observation of smooth pursuit, symmetry, and potential deficits in cranial nerves III, IV, and VI.

C. Ask the patient to cover one eye with their hand: Covering one eye is part of the cover-uncover test, which assesses for strabismus or phorias, not general EOM. While it can provide information on ocular alignment, it does not evaluate full extraocular muscle function through the six cardinal positions of gaze.

D. Move a penlight in a circular motion 1 ft away in front of the patient's eyes: Moving the penlight in a circular motion is not appropriate for EOM assessment, as it does not systematically test each extraocular muscle or cranial nerve. Circular motion may obscure deficits in specific directions of gaze and can result in incomplete assessment of ocular motor function.

A. Skin remains red on the coccyx when pressed: Persistent redness that does not blanch under pressure is an early sign of tissue ischemia and potential pressure injury. In older adults, fragile skin and reduced subcutaneous tissue increase susceptibility to breakdown over bony prominences like the coccyx. Immediate intervention is required to relieve pressure, prevent ulceration, and preserve tissue integrity.

B. Dry scaly skin on the lower extremities: Xerosis, or dry, scaly skin, is common in older adults due to decreased sebaceous and sweat gland activity. While it requires routine moisturizing and monitoring, it does not pose an immediate threat to tissue viability or indicate acute injury, and thus is less concerning than non-blanching erythema.

C. Decreased tenting when assessing skin turgor: Decreased tenting suggests normal elasticity and adequate hydration, as opposed to tenting which indicates dehydration. This finding is typical in healthy skin and does not indicate acute risk for pressure injuries or compromised tissue perfusion.

D. Skin tags on neck line: Skin tags (acrochordons) are benign, soft growths associated with aging or friction in skin folds. They are not indicative of acute pathology, tissue ischemia, or imminent risk, making them a low-priority finding in comparison to non-blanching erythema over a bony prominence.