The nurse is speaking to the client and suspects a weakness in eye muscle after observing the eyes cross.
What test should the nurse administer to further assess this problem?

Choice A rationale

The optic nerve (CN II) is responsible for vision. It transmits visual information from the retina to the brain. Dysfunction in this nerve typically results in visual disturbances such as loss of vision, visual field defects, or difficulty in distinguishing colors. It does not control the movement or strength of the tongue.

Choice B rationale

The abducens nerve (CN VI) innervates the lateral rectus muscle of the eye, which is responsible for abducting the eye (moving it outward). Dysfunction in this nerve can lead to strabismus (misalignment of the eyes), double vision, or inability to move the eye outward. It does not affect tongue movement or strength.

Choice C rationale

The hypoglossal nerve (CN XII) innervates the muscles of the tongue, controlling its movement and strength. Dysfunction in this nerve can result in difficulty protruding the tongue, poor strength against resistance, and impaired speech or swallowing. Therefore, the symptoms described in the question indicate a dysfunction of the hypoglossal nerve.

Choice D rationale

The vestibulocochlear nerve (CN VIII) is responsible for hearing and balance. It transmits sound and equilibrium information from the inner ear to the brain. Dysfunction in this nerve can lead to hearing loss, tinnitus, vertigo, or balance problems. It does not control tongue movement or strength.

Choice A rationale

Lordosis refers to an excessive inward curvature of the lumbar spine, often referred to as swayback. This condition causes the lower back to arch more than normal, leading to a prominent abdomen and buttocks. Lordosis does not affect the thoracic spine and does not cause an exaggerated curvature in that region.

Choice B rationale

Scoliosis is a lateral curvature of the spine that results in an S- or C-shaped curve. It can occur in the thoracic, lumbar, or cervical regions of the spine. Scoliosis involves a sideways deviation rather than an exaggerated curvature in the thoracic spine.

Choice C rationale

Spinal dysplasia is a broad term that refers to various congenital abnormalities affecting the development of the spine. It includes conditions such as spina bifida, kyphosis, and scoliosis, each with distinct characteristics. The term itself does not specify an exaggerated thoracic curvature.

Choice D rationale

Kyphosis is an exaggerated outward curvature of the thoracic spine, resulting in a rounded or hunched back appearance. This condition is common in elderly individuals and can be caused by factors such as osteoporosis, vertebral fractures, or degenerative changes. It leads to a noticeable forward bend of the upper back.