The nurse is completing a neurological assessment on a client who suffered from a motor vehicle accident (MVA).

Which of the following findings should the nurse report to the practitioner immediately?

ability to swallow pureed foods

client reports mild headache

Weakness

Glasgow coma scale of 5

Answer and Explanation

The Correct Answer is D

A.   Ability to swallow pureed foods suggests some functional capacity and is not an immediate concern requiring immediate reporting.
B.   A mild headache reported by the client might not indicate a critical issue requiring immediate reporting.
C.   Weakness can be a concerning symptom, but the severity or extent of weakness needs further clarification before urgent reporting.
D.   A Glasgow Coma Scale (GCS) score of 5 is indicative of severe impairment of consciousness, requiring immediate attention and further evaluation by the healthcare provider.

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Correct Answer is D

Explanation

A. Cranial Nerve XI (Accessory nerve) is not involved in tongue movement; it controls muscles involved in head and shoulder movement.
B. Eye movement and control relate more to Cranial Nerves III, IV, and VI, which control eye muscles.
C. Hearing is primarily assessed by Cranial Nerve VIII (Vestibulocochlear nerve).
D. Cranial Nerve XI innervates the sternocleidomastoid and trapezius muscles, enabling movements like head turning and shoulder shrugging against resistance.

A. Bone spur B. Crepitation C. Tendonitis D. Fluid in the knee joint

Correct Answer is B

Explanation

A. A bone spur is a bony projection often caused by joint damage, but it does not typically produce audible crunching or grating sounds.
B. Crepitation refers to a crunching, grating, or popping sound or sensation that occurs with movement of a joint. It's often associated with conditions like osteoarthritis.
C. Tendonitis involves inflammation of a tendon and may cause pain or tenderness, but it does not typically produce audible sounds like crepitation.
D. Fluid in the knee joint might cause swelling and limited movement, but it does not usually produce audible crunching or grating sounds.

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The nurse is completing a neurological assessment on a client who suffered from a motor vehicle accident (MVA). Which of the following findings should the nurse report to the practitioner immediately?

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Naxlex Comprehensive Predictor Exams

The nurse tests the function of Cranial Nerve XI while performing a physical examination on a client. Which statement best describes the response the nurse should expect if Cranial Nerve XI is intact?

Correct Answer is D

Explanation

A client states, "I can hear a crunching or grating sound when I kneel and have difficulty getting out of bed in the morning because of pain and stiffness." Which of the following should the nurse expect as an assessment finding?

Correct Answer is B

Explanation

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The nurse is completing a neurological assessment on a client who suffered from a motor vehicle accident (MVA).

Which of the following findings should the nurse report to the practitioner immediately?