A nurse is getting ready to conduct a cranial nerve examination on a patient.
What steps should the nurse take to examine cranial nerve XI (Spinal Accessory)?
Check the patient’s visual acuity using a Snellen chart.
Whisper in one of the patient’s ears while blocking the other.
Observe the patient’s ability to turn their head from side to side.
Ask the patient to identify specific smells.
Ask the patient to identify specific smells.
The Correct Answer is C
Choice A rationale
Checking the patient’s visual acuity using a Snellen chart is used to assess cranial nerve II (Optic), not cranial nerve XI (Spinal Accessory)3.
Choice B rationale
Whispering in one of the patient’s ears while blocking the other is a method used to assess cranial nerve VIII (Vestibulocochlear), not cranial nerve XI4.
Choice C rationale
Observing the patient’s ability to turn their head from side to side is a correct method to assess cranial nerve XI. This nerve innervates the sternocleidomastoid and trapezius muscles, which are responsible for turning the head and shrugging the shoulders respectively.
Choice D rationale
Asking the patient to identify specific smells is used to assess cranial nerve I (Olfactory), not cranial nerve XI3.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The first physiological response that occurs during the General Adaptation Syndrome (GAS) is
the alarm reaction stage. This stage is the body’s initial response to stress, where the sympathetic nervous system is activated by the sudden release of hormones.
Choice B rationale
The body remaining alert while blood pressure and heart rate return to pre-stress levels is part of the resistance stage of GAS, not the first physiological response.
Choice C rationale
Prolonged exposure to stress resulting in illness is associated with the exhaustion stage of GAS, which is the final stage, not the first physiological response.
Choice D rationale
An increase in hormones causing an increase in blood pressure and heart rate is part of the alarm reaction stage, but it is not the first physiological response. The first response is the perception of a stressor that stimulates the central nervous system.
Correct Answer is C
Explanation
Choice A rationale
Regression is a defense mechanism where an individual reverts to an earlier stage of development or a less mature behavior when faced with stress or anxiety. This does not fit the scenario provided. Choice B rationale
Projection involves attributing one’s own unacceptable feelings or thoughts to others. This is not the case in the scenario provided.
Choice C rationale
Rationalization involves creating logical but untrue explanations to justify unacceptable behavior or feelings. In this scenario, the patient is rationalizing their failure to take their medication by blaming their partner’s forgetfulness.
Choice D rationale
Repression involves unconsciously blocking out painful or uncomfortable thoughts or feelings. This does not fit the scenario provided.
Question 14.
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