A nurse is evaluating a client who has a suspected stroke.

The nurse asks the client to stick out his tongue and observes that it deviates to the left side.

Which of the following cranial nerves is most likely affected?

Hypoglossal nerve (XII)

Facial nerve (VII)

Glossopharyngeal nerve (IX)

Trigeminal nerve (V)

Answer and Explanation

The Correct Answer is A

The hypoglossal nerve controls the movement of the tongue. If this nerve is damaged, the tongue will deviate to the side of the lesion when protruded.

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Correct Answer is A

Explanation

This is a normal reflex that is present in newborns and disappears by 4 to 6 months of age.It is also known as the fencing reflex because the infant assumes a position similar to a fencer when the head is turned to one side.

A. “The Moro reflex is also called the startle reflex because it occurs when the baby is startled by something.” B. “The Moro reflex helps the baby develop their sense of balance and coordination.” C. “The Moro reflex involves extending and flexing the arms and legs in response to a sudden movement.” D. “The Moro reflex can be used to assess the integrity of the baby’s nervous system.” E. “The Moro reflex can be triggered by changing the baby’s position or temperature.”

Correct Answer is ["A","C","D"]

Explanation

The Moro reflex, or startle reflex, is an involuntary response to a sudden loss of support or a loud noise that involves spreading and curling the arms and legs.

The Moro reflex involves three distinct components: spreading out the arms (abduction), pulling the arms in (adduction), and crying (usually). The baby may also extend and flex their legs.

The Moro reflex can be used to assess the integrity of the baby’s nervous system, as it reflects the development and function of the brain stem. Absence, asymmetry, or persistence of the Moro reflex may indicate neurological problems.

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A nurse is evaluating a client who has a suspected stroke. The nurse asks the client to stick out his tongue and observes that it deviates to the left side. Which of the following cranial nerves is most likely affected?

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Naxlex Comprehensive Predictor Exams

A nurse is observing an infant who is lying on his back. The nurse notices that when the infant’s head is turned to the right, his right arm and leg extend, while his left arm and leg flex. The nurse recognizes this as which of the following reflexes?

Correct Answer is A

Explanation

A nurse is teaching a group of new parents about infant reflexes. Which of the following statements should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

A nurse is teaching a group of parents about infant reflexes. Which of the following statements by a parent indicates an understanding of the teaching?

A nurse is performing a neurological examination on a client who has a history of multiple sclerosis. The nurse notices that the client has difficulty walking and maintaining balance. Which of the following tests should the nurse use to assess the client’s coordination?

A nurse is performing a neurological assessment on a 4-month-old infant. The nurse gently drops the infant’s head backward while supporting the body. The nurse expects to see which of the following responses as part of a normal reflex?

A nurse is evaluating a client who has a suspected stroke. The nurse asks the client to stick out his tongue and observes that it deviates to the left side. Which of the following cranial nerves is most likely affected?

A nurse is caring for a 2-month-old infant who has a positive Moro reflex. Which of the following actions should the nurse take to elicit this reflex? (Select all that apply.)

A nurse is performing a neurological assessment on a newborn. Which of the following reflexes should disappear by 8 months of age? (Select all that apply.)

A nurse is evaluating a client who has a suspected stroke.

The nurse asks the client to stick out his tongue and observes that it deviates to the left side.

Which of the following cranial nerves is most likely affected?