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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Palm: The palm of the hand is not ideal for palpating lymph nodes because it does not provide the fine sensitivity needed to detect subtle differences in size, texture, and tenderness.

B. Pads of fingers: The pads of the fingers are the best part of the hand to use when examining lymph nodes. This part allows for precise and gentle palpation, helping the nurse assess the size, consistency, and mobility of the lymph nodes effectively.

C. Base of hand: The base of the hand is less sensitive and not suitable for palpating lymph nodes as it provides less sensitivity compared to the pads of the fingers. The base of the hand is better suited for applying pressure during broader palpation techniques It does not provide the necessary tactile feedback for a thorough examination.

D. Ulnar surface: The ulnar surface of the hand is not typically used for palpation of lymph nodes. It is less sensitive compared to the pads of the fingers and is not appropriate for this examination.

A. ethmoid B. maxillary C. mastoid D. sphenoid

Correct Answer is B

Explanation

A. Ethmoid: The ethmoid sinuses are located between the eyes and are not typically accessible for palpation during a physical examination. Instead, tenderness in this area is assessed through inspection and indirect methods rather than direct palpation.

B. Maxillary: The maxillary sinuses are located in the cheeks and are accessible for palpation. The nurse can assess for tenderness or swelling in this area, which can indicate sinusitis or infection. Palpating the maxillary sinuses is a standard part of the examination for patients with cold and sinus pain.

C. Mastoid: The mastoid process is located behind the ear and contains air cells, but it is not directly involved in sinus pain associated with cold symptoms. While mastoid tenderness may indicate a different type of infection (such as mastoiditis), it is not part of the sinus assessment.

D. Sphenoid: The sphenoid sinuses are located deep within the skull, behind the nasal cavity, and are not accessible for palpation during a physical examination. Any issues with the sphenoid sinuses would typically be assessed through imaging studies rather than physical palpation.

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