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 B
Explanation
A. Once the speculum is in the ear, releasing the traction: Releasing traction too soon can lead to collapse of the ear canal, obstructing the view of the tympanic membrane. Maintaining traction throughout the examination ensures a clear view and prevents discomfort.
B. Pulling the pinna up and back before inserting the speculum: The correct technique for an adult involves pulling the pinna up and back to straighten the external auditory canal, allowing for an unobstructed view of the tympanic membrane. In children under three, the pinna is pulled down and back due to the more horizontal orientation of the ear canal.
C. Tilt the person's head forward during the examination: The head should remain upright or slightly tilted away from the examiner to provide better access to the ear canal. Tilting forward is unnecessary and may not improve visualization.
D. Using the smallest speculum to decrease the amount of discomfort: A speculum that is too small may not provide a sufficient view of the tympanic membrane. The largest speculum that comfortably fits should be used to allow for optimal visualization.
Correct Answer is A
Explanation
A. Thyroid: The thyroid gland produces thyroxine (T4) and triiodothyronine (T3), which are essential hormones that regulate metabolism, growth, and development. An elevated T4 level typically indicates hyperthyroidism or other thyroid disorders, making it necessary to assess the function and health of the thyroid gland.
B. Parathyroid: The parathyroid glands regulate calcium levels in the blood through the secretion of parathyroid hormone (PTH). They do not produce T4 or directly influence thyroid hormone levels, so assessing the parathyroid glands would not be relevant in the context of elevated T4.
C. Adrenal: The adrenal glands produce hormones such as cortisol, aldosterone, and adrenaline. While adrenal function can impact overall hormonal balance in the body, they are not directly involved in the production of thyroxine (T4), making them unrelated to the assessment for elevated T4 levels.
D. Parotid: The parotid glands are major salivary glands that secrete saliva. They do not play a role in thyroid hormone production or regulation, so assessing the parotid glands would not be appropriate when investigating elevated T4 levels.
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