The nurse asks the patient to stick out their tongue while performing an assessment of the mouth and throat. The nurse knows this provides information about what cranial nerve?

XII

VII

Answer and Explanation

The Correct Answer is C

A. XI: Cranial nerve XI, also known as the accessory nerve, is responsible for innervating the sternocleidomastoid and trapezius muscles, which are involved in shoulder and head movement. It does not play a role in tongue movement.

B. V: Cranial nerve V, the trigeminal nerve, is responsible for sensation in the face and motor functions such as biting and chewing. While it is important for overall oral sensation, it does not control tongue movement.

C. XII: Cranial nerve XII, the hypoglossal nerve, is responsible for motor control of the tongue muscles. When the patient sticks out their tongue, the nurse can assess the function of this nerve by observing the tongue's position, movement, and any signs of weakness or atrophy, which can indicate nerve damage.

D. VII: Cranial nerve VII, the facial nerve, is responsible for the muscles of facial expression and taste sensations from the anterior two-thirds of the tongue. Although it contributes to some oral functions, it is not directly involved in the movement of the tongue itself.

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Correct Answer is A

Explanation

A. Macular degeneration: The loss of central vision while maintaining peripheral vision is characteristic of macular degeneration, a common age-related condition that affects the macula, the central part of the retina responsible for sharp and detailed vision. Patients with this condition often struggle with tasks that require fine visual acuity, such as reading or recognizing faces.

B. Increased intraocular pressure or glaucoma: Glaucoma typically causes peripheral vision loss rather than central vision loss. Patients may not notice changes in their vision until the disease has progressed significantly, making this option less likely given the patient's symptoms.

C. Vision that is normal for someone her age: While age-related changes in vision are common, the specific symptoms described—difficulty reading, sewing, and recognizing faces—indicate a significant problem rather than a normal aging process. Conditions like macular degeneration should be considered when central vision loss is present.

D. The beginning stages of cataract formation: Cataracts generally cause blurred vision, glare, and difficulty with night vision. They typically affect overall vision rather than causing specific central vision loss while preserving peripheral vision. Therefore, while cataracts are common in older adults, they do not align with the symptoms described in this case.

A. Perform a complete cardiac assessment because these signs are probably indicative of early heart failure. B. Have the mother attempt to bottle feed the infant. C. Assure the mother that these signs are normal symptoms of a cold. D. Recognize that these are serious signs, and contact the physician.

Correct Answer is D

Explanation

A. Perform a complete cardiac assessment because these signs are probably indicative of early heart failure: While congenital heart disease can present with respiratory distress, the presence of nasal flaring and retractions in an infant with a prolonged upper respiratory infection strongly suggests respiratory distress due to a pulmonary cause, such as bronchiolitis or pneumonia. A cardiac assessment may be necessary, but immediate intervention for respiratory distress is the priority.

B. Have the mother attempt to bottle feed the infant: Infants in respiratory distress often struggle with feeding due to increased work of breathing. Attempting to bottle feed could further compromise oxygenation and increase fatigue, worsening the child's condition.

C. Assure the mother that these signs are normal symptoms of a cold: Nasal flaring and intercostal retractions are signs of increased respiratory effort, indicating significant respiratory distress rather than a mild viral upper respiratory infection. These findings warrant prompt medical evaluation.

D. Recognize that these are serious signs, and contact the physician: Nasal flaring, sternal retractions, and intercostal retractions indicate significant respiratory distress, which can rapidly progress to respiratory failure in infants. Immediate assessment and intervention by a healthcare provider are necessary to ensure appropriate treatment and monitoring.

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The nurse asks the patient to stick out their tongue while performing an assessment of the mouth and throat. The nurse knows this provides information about what cranial nerve?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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