A patient is admitted to the hospital with a head injury. The nurse is performing a neurologic assessment. Which of the following findings would indicate a potential neurological deficit?

Cranial nerve XI, the spinal accessory nerve, is a motor nerve that innervates the sternocleidomastoid and trapezius muscles. Assessment of this nerve is essential to evaluate the integrity of the cervical spinal cord and the neuromuscular pathway. Deficits may indicate central nervous system lesions or localized trauma to the neck and upper back.

A. The ability to follow an object with the eyes involves the coordinated function of cranial nerves III (oculomotor), IV (trochlear), and VI (abducens). These nerves control the extraocular muscles. While essential for a neurological exam, eye movement is not related to the function of the spinal accessory nerve.

B. To assess the accessory nerve (CN XI), the nurse asks the client to shrug their shoulders against the resistance of the nurse's hands and to turn their head side-to-side against resistance. Strong, symmetrical movement of the trapezius and sternocleidomastoid muscles confirms that the spinal accessory nerve is intact and functioning correctly.

C. Symmetrical smiling and facial expressions are controlled by cranial nerve VII, the facial nerve. This nerve innervates the muscles of facial expression and is tested by asking the client to frown, puff out their cheeks, or show their teeth. It does not provide information about the eleventh cranial nerve.

D. Identifying a familiar scent with the eyes closed is the standard test for cranial nerve I, the olfactory nerve. This is a purely sensory nerve responsible for the sense of smell. It is anatomically and functionally distinct from the motor pathways assessed during the spinal accessory nerve examination.

Normal adult vital signs reflect homeostatic stability across cardiac and pulmonary systems. Deviations such as tachypnea or hypoxemia indicate potential respiratory distress or metabolic derangements. Accurate monitoring is essential for identifying early signs of systemic deterioration and initiating appropriate supplemental oxygen or pharmacological interventions.

A. An SpO2 of 91% is below the normal reference range of 95% to 100% for a healthy adult. This indicates hypoxemia, which may be caused by impaired gas exchange or ventilation-perfusion mismatch. It requires immediate assessment of the respiratory system and may necessitate the administration of supplemental oxygen.

B. A respiratory rate of 28/min is classified as tachypnea, as the normal adult range is 12 to 20 breaths per minute. This elevated rate suggests that the body is attempting to compensate for low oxygen levels or metabolic acidosis. It is a significant clinical indicator of underlying pulmonary or systemic stress.

C. A blood pressure of 111/76 mm Hg is within the normal reference range for an adult. It indicates adequate perfusion without the presence of hypertension or hypotension. This finding does not suggest any immediate cardiovascular instability and is considered a healthy reading for most adult patients.

D. A temperature of 37.1°C (98.8°F) is within the normal physiological range for an adult, which typically centers around 37°C (98.6°F). It does not indicate a febrile state or hypothermia. This temperature reading reflects normal thermoregulation and is not a cause for clinical concern in this context.

E. A pulse of 69 beats/min is well within the normal adult heart rate range of 60 to 100 beats per minute. It indicates a stable cardiac rhythm and adequate stroke volume. This finding is considered normal and does not signify bradycardia or tachycardia in a resting adult.