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 B

Explanation

A. The sternoclavicular joint is where the sternum (breastbone) meets the clavicle (collarbone). It plays a role in the movement of the shoulder girdle but does not involve the jaw. Issues with this joint would typically present as shoulder or chest discomfort rather than problems with the jaw.
B. The temporomandibular joint is the joint where the mandible (lower jaw) meets the temporal bone of the skull, just in front of the ear. It is crucial for jaw movement, including opening, closing, and chewing. If a client feels that their jaws are "stuck," it is likely related to a problem with the TMJ. Common issues include TMJ disorders, which can cause pain, limited movement, or a sensation of the jaw being stuck.
C. The subtalar joint is located in the ankle, between the talus and calcaneus bones. It is involved in the movement of the foot, particularly in inversion and eversion. This joint is unrelated to jaw function, so problems here would affect the foot rather than the jaw.
D. The radioulnar joints are located in the forearm and involve the radius and ulna bones. These joints are responsible for the rotation of the forearm, such as turning the palm up or down. They do not relate to jaw movement or problems, so issues with these joints would affect the forearm or wrist rather than the jaw.

A. Lock the fingers together and pull against each other. B. Squeeze a thigh with the opposite hand. C. Stretch the arms over the head. D. Clench the jaw tightly

Correct Answer is A

Explanation

A. This maneuver is intended to engage other muscle groups and increase overall muscle tone. It can help facilitate the patellar reflex by increasing muscle tension and sensitivity. This technique can enhance the reflex response by engaging the client in a physical action that might make the reflex more pronounced.
B. Squeezing the thigh might create discomfort or involuntary muscle contraction, which could interfere with the reflex response. It is not a recommended technique for eliciting the patellar reflex and may not have a significant effect on reflex assessment.
C. Stretching the arms over the head does not directly influence the patellar reflex. Reflexes are typically assessed in a relaxed state, and this action might not be relevant for improving the patellar reflex response.
D. Clenching the jaw might increase overall muscle tone temporarily, but it does not directly impact the patellar reflex. This technique is less likely to influence the patellar reflex compared to techniques that engage lower body muscle groups.

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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

The client presents to the nurse stating that his jaws feel "stuck". What joint should the nurse assess?

Correct Answer is B

Explanation

A nurse is having difficulty eliciting a patellar reflex. Which of the following would be most appropriate for the nurse to have the client do?

Correct Answer is A

Explanation

The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?

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