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. Mitral and pulmonic: The mitral valve closure is best heard at the apex of the heart (the left fifth intercostal space) rather than at the base. The pulmonic valve is indeed located near the base but, combined with the mitral valve, does not represent the sounds best heard at the base of the heart.
B. Aortic and pulmonic: The aortic and pulmonic valves are located at the base of the heart. The aortic valve is located in the right second intercostal space at the sternal border, while the pulmonic valve is located in the left second intercostal space. The closure of these valves (S2) is typically loudest at this area, making this option correct.
C. Mitral and tricuspid: The mitral valve is best heard at the apex, and the tricuspid valve is best heard along the left lower sternal border. Both valves are not located at the base of the heart.
D. Tricuspid and aortic: The tricuspid valve is not located at the base of the heart; it is situated along the left lower sternal border, while the aortic valve is at the base. Therefore, this combination does not represent the best valves to listen for at the base.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.