The nurse continues a neurologic assessment of the cranial nerve XI (Spinal accessory) for a client. Which instruction should the nurse give the client to complete this assessment?

Shrug shoulders against resistance.

Stand up slowly with eyes closed.

Turn head from side to side.

Raise both arms overhead

Answer and Explanation

The Correct Answer is A

Choice A Reason:
Shrug shoulders against resistance is correct because cranial nerve XI, also known as the spinal accessory nerve, innervates the trapezius and sternocleidomastoid muscles. Instructing the client to shrug their shoulders against resistance tests the strength and function of the trapezius muscle, which is primarily innervated by cranial nerve XI. Therefore, this instruction directly assesses the function of the cranial nerve XI.
Choice B Reason:
Stand up slowly with eyes closed is incorrect because standing up slowly with eyes closed primarily assesses proprioception and balance, which involve multiple cranial nerves and the vestibular system. While cranial nerve XI may play a role in maintaining posture and balance, it is not the primary nerve involved in this assessment.
Choice C Reason:
Turn head from side to side is incorrect because turning the head from side to side primarily assesses the function of the sternocleidomastoid muscle, which is also innervated by cranial nerve XI. However, this action alone does not provide resistance against which the muscle can contract, making it less specific for assessing cranial nerve XI compared to the instruction to shrug the shoulders against resistance.
Choice D Reason:
Raise both arms overhead incorrect because raising both arms overhead primarily assesses motor function and strength of the upper extremities, which do not directly involve the muscles innervated by cranial nerve XI. While the trapezius muscle may be indirectly involved in shoulder movement, this action does not specifically target the function of cranial nerve XI.

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Correct Answer is B

Explanation

Choice A Reason:
Chronic pancreatitis is incorrect. Chronic pancreatitis typically presents with persistent, dull abdominal pain that may radiate to the back, often aggravated by eating rather than relieved by it. The pain associated with chronic pancreatitis is not typically described as gnawing or relieved by eating.
Choice B Reason:
Peptic ulcer disease (PUD) is correct. Peptic ulcer disease involves the development of open sores (ulcers) in the lining of the stomach (gastric ulcers) or the upper part of the small intestine (duodenal ulcers). The pain associated with PUD typically occurs in the epigastric region (upper abdomen) and can be described as gnawing, burning, or dull. The pain tends to worsen when the stomach is empty (hunger pains) and is relieved by eating or taking antacids. These symptoms are due to the increase in gastric acid secretion, which exacerbates the ulcer's irritation when the stomach is empty and is neutralized when food buffers the acid. Therefore, the presentation described is consistent with peptic ulcer disease (PUD).
Choice C Reason:
Esophagitis is incorrect. Esophagitis is inflammation of the esophagus and may present with symptoms such as heartburn, difficulty swallowing, or chest pain behind the breastbone. However, the symptoms described, particularly the worsening of pain when hungry and improvement after eating, are not typical of esophagitis.
Choice D Reason:
Gastroesophageal reflux (GERD) is incorrect. While gastroesophageal reflux disease (GERD) can cause epigastric discomfort or heartburn, the symptoms described in the scenario are more indicative of pain related to hunger and relief after eating, which is more characteristic of peptic ulcer disease (PUD). Additionally, GERD symptoms are typically worsened by eating, lying down, or bending over, rather than improved.

A. Expected finding. B. Cardiac atrophy. C. Benign variation. D. Cardiac enlargement.

Correct Answer is D

Explanation

Choice A Reason:
Expected finding is incorrect. While some degree of dullness is expected during percussion of the heart borders due to the presence of solid cardiac tissue, the specific pattern described in the scenario, extending from the 5th left intercostal space to the 2nd left intercostal space at the sternal border, suggests an abnormality rather than an expected finding.
Choice B Reason:
Cardiac atrophy is incorrect. Cardiac atrophy refers to a decrease in the size or mass of the heart muscle, resulting in a smaller than normal heart. However, the described findings indicate dullness extending upward, suggesting an enlargement rather than atrophy of the heart.
Choice C Reason:
Benign variation is incorrect. Benign variations in cardiac percussion findings are less likely to produce a pattern of dullness extending from the 5th left intercostal space to the 2nd left intercostal space at the sternal border. This pattern is more indicative of cardiac enlargement or pathology rather than a benign variation.
Choice D Reason:
Cardiac enlargement is correct. During percussion of the heart borders, dullness indicates solid tissue, such as the heart. The area of dullness extending from the 5th left intercostal space to the 2nd left intercostal space at the sternal border suggests an enlargement of the cardiac silhouette. This enlargement could be due to various cardiac conditions, such as cardiomegaly (enlarged heart), left ventricular hypertrophy, or other structural abnormalities affecting the heart.

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The nurse continues a neurologic assessment of the cranial nerve XI (Spinal accessory) for a client. Which instruction should the nurse give the client to complete this assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult client presents with gnawing epigastric pain. The pain is worse when the client is hungry and abates after eating something. Which problem do these symptoms suggest?

Correct Answer is B

Explanation

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

Correct Answer is D

Explanation

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