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. Is impaired in a patient with cataracts: Cataracts primarily cause lens opacity, leading to blurry vision and reduced acuity. They do not directly affect extraocular muscle function, which is controlled by cranial nerves rather than the lens.
B. Is always decreased in the older adult: Aging can cause minor changes in eye movement speed and coordination, but significant impairment is not inevitable. Extraocular muscle function remains intact unless affected by neurological conditions such as cranial nerve palsy.
C. Is stimulated by cranial nerves (CNS) I and II: Cranial nerve I (olfactory) is responsible for smell, and cranial nerve II (optic) transmits visual signals to the brain. Neither nerve controls eye movement, which is instead governed by different cranial nerves.
D. Is stimulated by cranial nerves III, IV, and VI: The oculomotor (III), trochlear (IV), and abducens (VI) nerves control extraocular muscle movement. They coordinate eye positioning, alignment, and smooth tracking, ensuring proper function of the visual system.
Correct Answer is D
Explanation
A. Perform the confrontation test: The confrontation test is used to assess peripheral vision rather than overall visual acuity. It is not the standard method for measuring visual acuity in routine physical examinations.
B. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches: While this can be useful for assessing near vision, it does not provide a complete assessment of visual acuity, which includes both near and distance vision.
C. Ask the patient to read the print on a handheld Jaeger card: The Jaeger card is specifically used for assessing near vision. While it is useful for determining how well the patient can see up close, it does not assess distance visual acuity, which is typically required in routine examinations for teenagers.
D. Use the Snellen chart positioned 20 feet away from the patient: The Snellen chart is the standard tool for measuring distance visual acuity. It is positioned 20 feet away from the patient to evaluate how well they can see letters of various sizes. This method provides a clear assessment of the patient’s visual acuity for routine physical examinations.
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