The nurse is assessing cranial nerve 5 (the trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of the assessment?

"Clench your teeth together tightly."

"Open your mouth wide and say 'ah.'"

"Look at me while I shine this light in your eye."

"Close your left eye and look at me with your right eye."

Answer and Explanation

The Correct Answer is A

Choice A reason: Clenching teeth tests cranial nerve V’s motor branch, innervating mastication muscles like the masseter. This assesses strength and symmetry, directly evaluating trigeminal function, making it the precise instruction for this nerve’s motor assessment accurately here.
Choice B reason: Opening the mouth and saying “ah” tests cranial nerves IX and X, not V. This assesses gag reflex and palate movement, missing the trigeminal’s role in jaw strength, rendering it irrelevant to this specific nerve exam fully.
Choice C reason: Shining light in the eye tests cranial nerves II and III, not V. This checks pupil response, unrelated to trigeminal sensory or motor functions, excluding it from the assessment of jaw and facial sensation entirely here.
Choice D reason: Closing one eye and looking tests cranial nerves III, IV, and VI, not V. This evaluates eye movement, not trigeminal innervation of facial muscles or sensation, disconnecting it from the intended cranial nerve assessment fully here.

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Correct Answer is B

Explanation

Choice A reason: Loss of tactile sensation ties to parietal lobe damage, not frontal. A frontal contusion affects executive function and speech, not sensory processing, making this finding less likely given the injury’s location in this trauma scenario fully.
Choice B reason: Difficulty speaking, like Broca’s aphasia, is common with frontal lobe contusions, as this area houses speech production centers. Post-accident, this aligns with damage to motor speech pathways, making it the most probable finding here accurately.
Choice C reason: Blurred vision relates to occipital or optic nerve injury, not frontal lobe. A contusion here impacts cognition or speech, not visual processing, rendering this less expected than speech issues in this head injury context entirely.
Choice D reason: Inability to hear high-pitched sounds involves cranial nerve VIII or temporal lobe, not frontal. This contusion affects behavior and speech, not auditory function, excluding this as a primary finding in this frontal damage case fully.

A. Rapid oscillations of the ankle B. Deviation of the heel to one side C. Pain and flexion in the knee D. The client reports paresthesia

Correct Answer is B

Explanation

Choice A reason: Rapid ankle oscillations might suggest tremor, possibly basal ganglia issues, not cerebellar dysfunction. The heel-shin test assesses coordination, where cerebellar damage causes drift, not rhythmic shaking, making this less indicative of the target pathology here.
Choice B reason: Heel deviation to one side in the heel-shin test signals cerebellar dysfunction, impairing coordination. The cerebellum fine-tunes movement; damage causes ataxia, leading to inaccurate sliding, making this the key sign of cerebellar issues accurately.
Choice C reason: Pain and knee flexion suggest joint or nerve issues, not cerebellar dysfunction. This test evaluates smooth motion, not pain response; cerebellar problems show ataxia, not discomfort, disconnecting this from the intended motor assessment fully.
Choice D reason: Paresthesia (tingling) indicates sensory nerve issues, not cerebellar motor control. The cerebellum coordinates movement, not sensation; this response misses the coordination focus of the heel-shin test, excluding it as a cerebellar sign here entirely.

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The nurse is assessing cranial nerve 5 (the trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of the assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the emergency room with a head injury. The client denies a previous history of seizures or head injury. What would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident?

Correct Answer is B

Explanation

The nurse is testing for motor functioning by having the client lie down and slide the heel of the right foot down the left shin and then slide the heel of the left foot down the right shin. Which response by the patient would indicate that there may be cerebellar dysfunction?

Correct Answer is B

Explanation

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