A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. Which nerve does the nurse suspect is damaged and how should the nurse proceed with the examination?
XI; have patient shrug their shoulders against resistance.
XI; palpate the anterior and posterior triangles.
XII; assess for a positive Romberg sign.
XII; percuss the sternomastoid and submandibular neck muscles.
The Correct Answer is A
A. XI; have patient shrug their shoulders against resistance: Cranial nerve XI, also known as the accessory nerve, is responsible for the innervation of the sternocleidomastoid and trapezius muscles. Damage to this nerve can lead to weakness in shoulder shrugging and difficulty turning the head. Asking the patient to shrug their shoulders against resistance allows the nurse to assess the function of this nerve effectively.
B. XI; palpate the anterior and posterior triangles: While palpating the anterior and posterior triangles of the neck can provide useful anatomical information, it does not specifically assess the function of cranial nerve XI. This action may not directly address the patient's complaints or evaluate nerve function adequately.
C. XII; assess for a positive Romberg sign: Cranial nerve XII, the hypoglossal nerve, is responsible for tongue movement. The Romberg test assesses balance and proprioception, not directly related to neck and shoulder pain or head movement. This option is not appropriate in this context.
D. XII; percuss the sternomastoid and submandibular neck muscles: Percussion is not a standard method for assessing cranial nerve function and would not provide useful information about nerve damage. This option also incorrectly identifies the relevant cranial nerve, as cranial nerve XII is not involved in neck and shoulder movement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Bradypnea: Characterized by a regular but abnormally slow respiratory rate, typically fewer than 12 breaths per minute in adults. While the patient’s respiratory rate is 12, the irregular pattern and shallow depth suggest a different pattern rather than simple bradypnea.
B. Agonal respirations: Marked by gasping, labored breaths often seen in severe hypoxia or nearing death. This pattern is typically irregular and associated with brainstem dysfunction, which is not described in this case.
C. Chronic obstructive breathing: Seen in patients with COPD, involving prolonged expiration due to airway obstruction. The patient’s case does not mention an obstructive pattern but rather shallow and irregular respirations.
D. Hypoventilation: Defined by shallow, irregular breathing that leads to inadequate alveolar ventilation, commonly caused by drug overdose, particularly opioids or sedatives. The patient’s presentation of shallow and irregular respirations fits this pattern.
Correct Answer is B
Explanation
A. Maxillary sinuses reach full size after puberty: While maxillary sinuses continue to grow throughout childhood, they are present at birth and reach adult size during late adolescence. The frontal and sphenoid sinuses, rather than the maxillary, experience more significant postnatal development.
B. Maxillary and ethmoid sinuses are the only sinuses present at birth: At birth, only the maxillary and ethmoid sinuses are developed. The frontal and sphenoid sinuses begin to develop later in infancy and childhood, with full maturation occurring in adolescence.
C. Frontal sinuses are fairly well developed at birth: Frontal sinuses do not develop until around 7 to 8 years of age and continue growing into adolescence. They are absent or rudimentary in newborns.
D. Sphenoid sinuses are full size at birth: The sphenoid sinuses begin developing around 2 to 3 years of age and continue growing into late childhood and adolescence. They are not present at birth.
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