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. Bronchophony: Bronchophony is an increase in clarity of spoken sounds when auscultating the lungs, typically indicating lung consolidation or pathology. It is not an adventitious sound associated with airflow through narrowed bronchioles.
B. Wheezes: Wheezes are high-pitched, musical sounds that occur when air passes through narrowed or obstructed airways, such as in cases of severe asthma. They are often heard during expiration and indicate bronchoconstriction or inflammation in the airways. This is the correct answer for the scenario presented.
C. Bronchial sounds: Bronchial sounds are normal breath sounds typically heard over the trachea and major bronchi. They are characterized by a higher pitch and a hollow quality. They are not classified as adventitious sounds and are not indicative of asthma.
D. Whispered pectoriloquy: Whispered pectoriloquy is a clinical finding where whispered sounds are heard more clearly over areas of lung consolidation. Like bronchophony, it does not represent an adventitious sound caused by airflow through narrowed bronchioles and is more indicative of lung pathology.
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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