The nurse is performing a neurologic assessment on a patient. Which action should the nurse take to adequately test the effectiveness for the hypoglossal nerve?
Ask the patient to touch the tip of the tongue to each cheek
Check air movement through each nostril separately.
Ask the patient to shrug the shoulders,
Ask the patient to wrinkle the forehead.
The Correct Answer is A
A. The hypoglossal nerve (cranial nerve XII) controls tongue movements, so asking the patient to move the tongue side to side tests its function.
B. Checking air movement through each nostril assesses the olfactory nerve (cranial nerve I).
C. Asking the patient to shrug the shoulders tests the accessory nerve (cranial nerve XI).
D. Asking the patient to wrinkle the forehead tests the facial nerve (cranial nerve VII).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Fingers being pink and cool bilaterally may be expected postoperatively due to anesthesia or positioning and does not indicate an immediate complication.
B. A capillary refill time of 8 seconds is significantly prolonged (normal is ≤2 seconds) and may indicate compromised circulation, possibly due to compartment syndrome or vascular compromise. This requires immediate action to preserve limb function.
C. A pain level of 5/10 is moderate and may be expected after surgery. It does not indicate an urgent issue unless unrelieved by medication or out of proportion to the procedure.
D. Swollen and warm fingers may be part of the normal inflammatory process after surgery but are not immediately life- or limb-threatening.
Correct Answer is D
Explanation
A. The nurse should stay with the child during the seizure and ensure safety before seeking help if needed.
B. Manually restraining the child can cause injury and is not recommended.
C. Inserting a tongue blade is contraindicated and can cause choking or injury.
D. Removing nearby objects prevents injury during the seizure and is the safest immediate action.
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