A nurse is preparing to perform a cranial nerve examination for a client. Which of the following actions should the nurse take to check cranial nerve XI?

Have the client identify specific smells.

Check the client's visual acuity using a Snellen chart.

Observe for the ability of the client to turn their head side to sidê.

Whisper in one of the client's ears while occluding the other.

Answer and Explanation

The Correct Answer is C

A.   Identifying specific smells checks cranial nerve I (olfactory).
B.   Checking visual acuity with a Snellen chart assesses cranial nerve II (optic).
C.   Observing for the ability to turn the head side to side tests cranial nerve XI (accessory), which controls the sternocleidomastoid and trapezius muscles responsible for head movement.
D.   Whispering in one ear while occluding the other tests cranial nerve VIII (vestibulocochlear).

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Correct Answer is A

Explanation

A. Reposition the client every 2 hr: This is an essential action to prevent pressure ulcers and skin breakdown, especially for bedridden patients. Frequent repositioning helps alleviate pressure on bony prominences.
B. Assess the client's skin for increased coolness: While assessing skin temperature is important, it is not as immediate as repositioning the patient. Increased coolness may suggest poor circulation.
C. Keep the client's skin moist: Keeping the skin moist can lead to skin breakdown and increases the risk for pressure ulcers. Dry skin is typically preferred to avoid moisture-related damage.
D. Massage the client's red bony prominences: Massaging reddened skin can actually damage the tissue and worsen pressure injuries. It is advised to avoid massaging bony prominences that show signs of pressure.

A. The cone of light at 7 o'clock in the right ear and 5 o'clock in the left ear with a pink and moist tympanic membrane. B. The cone of light at 7 o'clock in the right ear and 5 o'clock in the left ear with a pearly gray tympanic membrane. C. The cone of light at 5 o'clock in the right ear and 7 o'clock in the left ear with a pink and moist tympanic membrane. D. The cone of light at 5 o'clock in the right ear and 7 o'clock in the left ear with a pearly gray tympanic membrane.

Correct Answer is B

Explanation

A. The cone of light at 7 o'clock in the right ear and 5 o'clock in the left ear with a pink and moist tympanic membrane is not a typical finding, as the tympanic membrane should be pearly gray.
B. The cone of light at 7 o'clock in the right ear and 5 o'clock in the left ear with a pearly gray tympanic membrane is the expected finding for a normal ear exam, showing the healthy tympanic membrane and the proper positioning of the cone of light.
C. The cone of light at 5 o'clock in the right ear and 7 o'clock in the left ear with a pink and moist tympanic membrane is incorrect, as the tympanic membrane should be pearly gray, not pink and moist.
D. The cone of light at 5 o'clock in the right ear and 7 o'clock in the left ear with a pearly gray tympanic membrane is an incorrect positioning of the cone of light (should be at 7 o'clock for the right ear and 5 o'clock for the left).

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A nurse is preparing to perform a cranial nerve examination for a client. Which of the following actions should the nurse take to check cranial nerve XI?

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