During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve?

VII

VIII

Answer and Explanation

The Correct Answer is D

A.   The trigeminal nerve (CN V) is primarily responsible for sensation in the face and the motor control of the muscles used for chewing. It does not have a role in balance or equilibrium, so it would not be the focus when assessing balance issues.
B.   The facial nerve (CN VII) controls the muscles of facial expression and provides taste sensation to the anterior two-thirds of the tongue. While it plays a significant role in facial movement and taste, it is not involved in balance or equilibrium.
C.   The olfactory nerve (CN I) is responsible for the sense of smell. It does not have any role in balance or equilibrium. Balance issues are not related to the olfactory nerve, so this is not the appropriate focus for balance assessment.
D.   The vestibulocochlear nerve (CN VIII) has two major components: the cochlear nerve, which is responsible for hearing, and the vestibular nerve, which is responsible for balance and equilibrium. The vestibular component of CN VIII is crucial for maintaining balance and spatial orientation. When a client reports spontaneous loss of balance, this nerve should be the focus of additional assessment.

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Correct Answer is C

Explanation

A. This test assesses the function of the oculomotor nerve (CN III), not the trigeminal nerve. The oculomotor nerve controls the constriction and dilation of the pupils, as well as some eye movements. Therefore, this choice is not appropriate for assessing the trigeminal nerve.
B. This test assesses the sensory function of the trigeminal nerve (CN V). The trigeminal nerve provides sensation to the face, and testing the ability to differentiate between sharp and dull sensations evaluates

the sensory component of this nerve. However, this test does not assess the motor function of the trigeminal nerve.
C. This test evaluates the motor function of the trigeminal nerve. The trigeminal nerve controls the muscles involved in chewing, including the temporal and masseter muscles. By palpating these muscles while the client clenches their teeth, the nurse assesses the strength and function of these muscles, which are innervated by the trigeminal nerve. This is a direct test of motor function for CN V.
D. This test assesses the function of the facial nerve (CN VII), which controls the muscles of facial expression. It is not relevant for assessing the trigeminal nerve, which is involved in both sensory functions of the face and motor functions related to chewing.

A. 2+ B. 3+ C. 1+ D. 4+

Correct Answer is B

Explanation

A. A reflex grade of 2+ is considered normal. It indicates that the reflex is present and of normal intensity, with a typical response.
B. A reflex grade of 3+ is considered brisk. It indicates that the reflex is more pronounced than normal
but not necessarily pathological. It’s often described as "brisk" or "exaggerated."
C. A reflex grade of 1+ is considered diminished or hypoactive. It indicates that the reflex is present but less intense than normal.
D. A reflex grade of 4+ is considered very brisk or hyperactive. It indicates a reflex response that is exaggerated and may suggest an upper motor neuron lesion or other neurological abnormalities.

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During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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