During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs?

Motor component of CN IV

Motor component of CN VI

Motor and sensory components of CNX

Motor component of CN VII

Answer and Explanation

The Correct Answer is D

A.   The trochlear nerve controls the superior oblique muscle of the eye and is not related to facial movements.
B.   The abducens nerve controls the lateral rectus muscle of the eye, responsible for eye movement, not facial muscles.
C.   The vagus nerve affects the soft palate, pharynx, and larynx, but does not contribute to facial expression.
D.   Asymmetry in facial movements, like smiling, frowning, and puffing the cheeks, suggests dysfunction of the facial nerve (CN VII).

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Correct Answer is A

Explanation

A. Severe nystagmus is often associated with neurological disorders, particularly those affecting the cerebellum or brainstem.
B. is a sign that the patient is nervous about the examination. Nervousness typically doesn’t cause severe, persistent nystagmus.
C. Indicates a visual problem, and a referral to an ophthalmologist is indicated. While nystagmus affects vision, it is usually neurologically based, requiring a neurological assessment rather than a referral to an ophthalmologist.
D. Nystagmus is not typically normal, especially when it is severe and persistent. It warrants further investigation.

A. Grade 1 B. Grade 2 C. Grade 3 D. Grade 5

Correct Answer is D

Explanation

A. This grade indicates trace contraction but no movement. It is not appropriate in this case, as the patient has full range of motion.
B. Grade 2. This grade reflects full range of motion with gravity eliminated. The patient’s range of motion is against gravity, so this is not the correct grade.
C. Grade 3. This grade indicates full range of motion against gravity but without resistance. The patient is able to resist full force, so this is not the correct grade either.
D. Grade 5. This grade indicates normal strength with full range of motion against gravity and full resistance. This best describes the patient's strength, which is normal.

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During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Severe nystagmus in both eyes:

Correct Answer is A

Explanation

When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What grade of muscle strength should the nurse record using a 0- to 5-point scale?

Correct Answer is D

Explanation

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