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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

The general survey is an overall assessment of a client's physical appearance, behavior, mobility, and neurological status. It provides a comprehensive overview of the client's health and well-being, making it the focus of the nurse's observations in this scenario.

Choice B rationale

Medical history includes past and current health conditions, surgeries, medications, and family health history. While important, it is not the focus of the nurse's immediate observations in this scenario.

Choice C rationale

Biographical data involves personal information such as age, gender, occupation, and marital status. While relevant to the client's health, it is not the primary focus of the nurse's observations in this scenario.

Choice D rationale

Social history includes information about the client's lifestyle, habits, and social environment. While valuable for understanding the client's overall health context, it is not the focus of the nurse's immediate observations in this scenario. .

A. Rhonchi. B. Wheeze. C. Crackles. D. Stridor.

Correct Answer is A

Explanation

Choice A rationale

Rhonchi are low-pitched, continuous breath sounds that are often indicative of secretions in the large airways. These sounds may change or clear with coughing, so the nurse should have the patient cough and then auscultate again to reassess the presence of rhonchi.

Choice B rationale

Wheezes are high-pitched, musical sounds heard primarily during expiration. They are caused by narrowed airways, typically due to asthma or other obstructive lung conditions. Wheezes do not usually clear with coughing and require specific treatments to address airway constriction.

Choice C rationale

Crackles are discontinuous, popping sounds heard during inspiration and are associated with fluid in the alveoli, such as in conditions like pneumonia or heart failure. Crackles are not typically cleared by coughing and may persist despite the patient's efforts to clear their airways.

Choice D rationale

Stridor is a high-pitched, harsh sound heard during inspiration, often indicating upper airway obstruction. Stridor is a medical emergency and requires immediate intervention to secure the airway. It does not clear with coughing and signifies a critical respiratory issue. .

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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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?