The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity.

Which method should help the nurse assess for neck rigidity correctly?

Choice A rationale

Cranial nerve VII (Facial nerve) controls muscles of facial expression and functions in taste sensations from the anterior two-thirds of the tongue, not balance.

Choice B rationale

Cranial nerve VI (Abducens nerve) controls lateral eye movement and has no role in balance or proprioception.

Choice C rationale

Cranial nerve VIII (Vestibulocochlear nerve) is responsible for hearing and balance. A positive Romberg test indicates issues with proprioception or vestibular function, which is directly linked to this nerve.

Choice D rationale

Cranial nerve IX (Glossopharyngeal nerve) involves taste sensation from the posterior third of the tongue and some swallowing functions, not balance.

Choice A rationale

Necrosis is the death of body tissue and can result from various factors, including pressure ulcers, but it is not the direct cause of pressure ulcers.

Choice B rationale

Low capillary pressure is not a direct cause of pressure ulcers. Pressure ulcers are caused by prolonged pressure on the skin, leading to reduced blood flow and tissue damage.

Choice C rationale

Increased mobility is not a cause of pressure ulcers. In fact, decreased mobility or immobility is a significant risk factor for developing pressure ulcers.

Choice D rationale

Extrinsic factors, such as prolonged pressure, friction, and shear, are the primary causes of pressure ulcers. These factors lead to reduced blood flow, tissue ischemia, and ultimately, tissue damage.