A nurse is performing a physical examination on a patient. When the patient is asked to protrude his tongue, the nurse noticed a deviation from the midline to the right side. This is related to a lesion of:

CN V

CN XII

CN VII

CN I

Answer and Explanation

The Correct Answer is B

A.   The trigeminal nerve (CN V) primarily controls sensation in the face and the muscles of mastication (chewing). While it is crucial for sensory input and motor control related to chewing, it does not directly control the movement of the tongue.
B.   The hypoglossal nerve (CN XII) is responsible for controlling the movements of the tongue. A lesion of CN XII can cause the tongue to deviate towards the side of the weakness or damage. This is because the hypoglossal nerve innervates the muscles of the tongue, and damage to it results in weakness of the muscles on the affected side, causing the tongue to deviate towards that side when protruded.
C.   The facial nerve (CN VII) controls the muscles of facial expression. While it affects facial movements and expressions, it does not control the movements of the tongue. A lesion in CN VII would typically result in facial asymmetry or weakness rather than tongue deviation.
D.   The olfactory nerve (CN I) is responsible for the sense of smell. It does not have any role in controlling tongue movement. Therefore, a lesion in CN I would not cause deviation of the tongue.

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Correct Answer is A

Explanation

A. A hallucination is a sensory experience that occurs without any external stimulus. It involves perceiving things that are not present in the environment, such as hearing voices or seeing things that are not there. The young man hearing his deceased sister talking to him in his head is an example of an auditory hallucination, which is a common symptom in schizophrenia.
B. Perseveration is the repetitive and persistent repetition of a particular response, such as a word or action, despite the absence of a stimulus or the problem being resolved. It is not related to abnormal sensory perceptions but rather to repetitive behaviors or speech. The young man's experience of hearing voices does not fit this description.
C. A fugue state is a type of dissociative disorder where a person suddenly and unexpectedly travels away from home or customary work locations and cannot recall their past. It often involves amnesia for personal history. The scenario described does not involve such travel or amnesia but rather auditory experiences, making this term irrelevant.
D. An illusion is a misperception of an actual external stimulus. It involves incorrectly interpreting a real sensory input, such as mistaking a shadow for a person. Since the young man is not misinterpreting a real external stimulus but rather hearing something that is not present at all, an illusion does not accurately describe his experience.

A. Assess dilatation of pupils with direct light. B. Ask the client to differentiate between sharp and dull sensations on the client's face. C. Palpates temporal and masseter muscles while client clenches teeth. D. Have the client smile, frown, and wrinkle the forehead.

Correct Answer is C

Explanation

A. This test assesses the function of the oculomotor nerve (CN III), not the trigeminal nerve. The oculomotor nerve controls the constriction and dilation of the pupils, as well as some eye movements. Therefore, this choice is not appropriate for assessing the trigeminal nerve.
B. This test assesses the sensory function of the trigeminal nerve (CN V). The trigeminal nerve provides sensation to the face, and testing the ability to differentiate between sharp and dull sensations evaluates

the sensory component of this nerve. However, this test does not assess the motor function of the trigeminal nerve.
C. This test evaluates the motor function of the trigeminal nerve. The trigeminal nerve controls the muscles involved in chewing, including the temporal and masseter muscles. By palpating these muscles while the client clenches their teeth, the nurse assesses the strength and function of these muscles, which are innervated by the trigeminal nerve. This is a direct test of motor function for CN V.
D. This test assesses the function of the facial nerve (CN VII), which controls the muscles of facial expression. It is not relevant for assessing the trigeminal nerve, which is involved in both sensory functions of the face and motor functions related to chewing.

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A nurse is performing a physical examination on a patient. When the patient is asked to protrude his tongue, the nurse noticed a deviation from the midline to the right side. This is related to a lesion of:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve?

Correct Answer is C

Explanation

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