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. UV rays from the sun can cause skin damage and contribute to skin cancer, even in the winter months when the sun may seem less intense. Sunscreen is necessary year-round, as UV radiation can still reach the skin through clouds and reflections from surfaces like snow or water.
B. Tanning beds are a significant risk factor for skin cancer, as they emit UVA and UVB radiation, both of which can damage the skin and increase the risk of melanoma and other types of skin cancer. The nurse should educate the client that tanning beds should be avoided.
C. While individuals with darker skin have a lower risk of developing skin cancer compared to those with lighter skin, they are still at risk for certain types of skin cancer, particularly melanoma. It's important for people of all skin tones to practice sun safety and undergo regular skin checks.

D. Skin cancer, particularly melanoma, has a genetic component, meaning those with a family history of melanoma are at a higher risk. A family history of skin cancer increases the risk, and the client should be encouraged to have regular skin exams and protect their skin from the sun.

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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