On assessment of the client's tongue, the client is unable to protrude the tongue and has poor strength on testing against resistance.
This would indicate dysfunction of which cranial nerve?
Optic nerve.
Abducens nerve.
Hypoglossal nerve.
Vestibulocochlear nerve.
The Correct Answer is C
Choice A rationale
The optic nerve (CN II) is responsible for vision. It transmits visual information from the retina to the brain. Dysfunction in this nerve typically results in visual disturbances such as loss of vision, visual field defects, or difficulty in distinguishing colors. It does not control the movement or strength of the tongue.
Choice B rationale
The abducens nerve (CN VI) innervates the lateral rectus muscle of the eye, which is responsible for abducting the eye (moving it outward). Dysfunction in this nerve can lead to strabismus (misalignment of the eyes), double vision, or inability to move the eye outward. It does not affect tongue movement or strength.
Choice C rationale
The hypoglossal nerve (CN XII) innervates the muscles of the tongue, controlling its movement and strength. Dysfunction in this nerve can result in difficulty protruding the tongue, poor strength against resistance, and impaired speech or swallowing. Therefore, the symptoms described in the question indicate a dysfunction of the hypoglossal nerve.
Choice D rationale
The vestibulocochlear nerve (CN VIII) is responsible for hearing and balance. It transmits sound and equilibrium information from the inner ear to the brain. Dysfunction in this nerve can lead to hearing loss, tinnitus, vertigo, or balance problems. It does not control tongue movement or strength.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Visual acuity tests assess the clarity of vision and the ability to discern letters or numbers at a set distance. It is used to test the function of cranial nerve II (optic nerve) rather than cranial nerve III (oculomotor nerve). Testing visual acuity involves using eye charts and assessing each eye separately.
Choice B rationale
Peripheral vision tests evaluate the ability to see objects outside the direct line of vision and are used to test the function of cranial nerve II (optic nerve). Peripheral vision assessment helps in diagnosing conditions like glaucoma but does not test the function of cranial nerve III.
Choice C rationale
The presence of the red reflex is assessed by looking into the eye with an ophthalmoscope to check for abnormalities in the eye's posterior segment. It is not related to the function of cranial nerve III but rather indicates healthy eye structures, including the retina and optic nerve (cranial nerve II).
Choice D rationale
Pupillary constriction to light is a direct test of cranial nerve III function. The oculomotor nerve controls the constriction of the pupil in response to light. By shining a light into the eyes and observing the pupils' response, the nurse can assess the integrity of cranial nerve III.
Correct Answer is D
Explanation
Choice A rationale
Scleroderma is a chronic autoimmune disorder characterized by hardening and tightening of the skin and connective tissues. While it affects the skin, it is unrelated to emphysema and bronchitis, making it an unlikely finding in this client.
Choice B rationale
Pedal erythema, or redness of the feet, can result from various causes, including infections, allergies, and circulatory issues. However, it is not commonly associated with emphysema and bronchitis, making it an unlikely finding in this client.
Choice C rationale
Anasarca is generalized body swelling due to fluid retention, often seen in severe heart failure, liver disease, and kidney failure. While this condition involves significant swelling, it is not typically linked to emphysema and bronchitis.
Choice D rationale
Clubbing of the nails is a common finding in chronic respiratory conditions like emphysema and bronchitis. It involves bulbous enlargement of the fingertips and nail curvature, resulting from prolonged low oxygen levels, making it a likely finding in this client.
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