The nurse is teaching a patient to prevent heart disease. Which information should the nurse include? Select all that apply

The cranial nerves (CN I–XII) emerge directly from the brain and brainstem and control various motor, sensory, and parasympathetic functions of the head, neck, and some thoracic organs. During a comprehensive neurological assessment, the nurse must test these nerves to identify signs of neurologic dysfunction.

Rationale for correct answers:

1.XII Hypoglossal -e. Position of the tongue

The hypoglossal nerve controls the motor movement of the tongue. During assessment, the client is asked to stick out the tongue, and deviation or weakness indicates impairment of CN XII.

2. V Trigeminal -a. Motor innervation to the jaw

The trigeminal nerve has both motor and sensory components. Motor function includes muscles of mastication (chewing). The nurse assesses jaw movement and strength.

3. VI Abducens -b. Lateral movement of the eyeballs

The abducens nerve controls the lateral rectus muscle, which moves the eye laterally (abduction). Inability to look outward may suggest CN VI palsy.

4. IV Trochlear -d. Downward, inward eye movements

The trochlear nerve controls the superior oblique muscle, responsible for downward and inward eye movement. Difficulty with this motion may lead to vertical diplopia (double vision).

5. X Vagus -c. Sensation of the pharynx

The vagus nerve provides sensory innervation to the pharynx and larynx, and also has motor and parasympathetic functions. It plays a role in swallowing, speech, and the gag reflex.

Take home points

Each cranial nerve has specific motor, sensory, or both functions, and testing them individually helps identify the location and extent of neurological impairment.

• Cranial nerves IV (Trochlear), VI (Abducens), and III (Oculomotor) are especially important for eye movement coordination.
• CN V (Trigeminal) and XII (Hypoglossal) focus on facial sensation/mastication and tongue movement, respectively.

Lung assessment is a key component of a comprehensive physical examination. Nurses and healthcare providers use percussion and auscultation to evaluate lung structure and function.

Rationale for correct answer:

2. Resonance over the left upper lobe: Resonance is the expected normal percussion sound over healthy lung tissue, including the left upper lobe. It indicates the presence of air within the alveoli and suggests that the lung is well-aerated.

Rationale for incorrect answers:

1. Tympany over the right upper lobe: Tympany is a high-pitched, drum-like sound typically heard over air-filled organs like the stomach or in cases of a large pneumothorax. It is not normal over lung tissue, including the right upper lobe.

3. Hyperresonance over the left lower lobe: Hyperresonance is louder and lower-pitched than normal resonance and often suggests excess air, as seen in emphysema or a pneumothorax. It is not a normal finding over any lung area and should prompt further evaluation.

4. Dullness above the left 10th intercostal space: Dullness on percussion indicates increased density, such as fluid (pleural effusion) or consolidation (pneumonia). This is not a normal finding and may signal underlying pathology in the lung or pleural space.

Take-home points

• Resonance is the normal percussion sound over healthy, aerated lung fields.
• Any deviation-such as dullness, tympany, or hyperresonance-may indicate underlying pathology.