The nurse notices the client's physical appearance, behavior, mobility, and neurological status when they enter the room.
Which of the following is the nurse assessing?

Choice A rationale

The optic nerve (CN II) is responsible for vision, transmitting visual information from the retina to the brain. Dysfunction of the optic nerve would result in visual disturbances, such as loss of vision or changes in visual acuity, rather than difficulty with tongue movement. This nerve does not control motor functions of the tongue.

Choice B rationale

The abducens nerve (CN VI) controls the lateral rectus muscle of the eye, which is responsible for moving the eye outward, away from the nose. Dysfunction of the abducens nerve would result in issues with eye movement, such as double vision or inability to move the eye laterally, not tongue movement. It does not play a role in tongue motor control.

Choice C rationale

The hypoglossal nerve (CN XII) controls the muscles of the tongue, enabling movements necessary for speech, swallowing, and mastication. Dysfunction of this nerve would result in difficulty protruding the tongue and reduced strength during resistance testing. Symptoms can include atrophy of the tongue muscles, fasciculations, and deviation of the tongue to one side when extended.

Choice D rationale

The vestibulocochlear nerve (CN VIII) is responsible for hearing and balance, transmitting sound and equilibrium information from the inner ear to the brain. Dysfunction of the vestibulocochlear nerve would lead to symptoms such as hearing loss, tinnitus, or balance disorders like vertigo. It does not affect the motor control of the tongue.

Choice A rationale

An elliptical chest configuration is considered a normal shape for the thorax. This configuration allows for optimal lung expansion and function. Deviations from this shape, such as a barrel chest, might indicate underlying pulmonary conditions.

Choice B rationale

Eupnea refers to normal, unlabored breathing, which is an expected finding during a respiratory assessment. It indicates that the individual is not experiencing respiratory distress and that their respiratory rate, rhythm, and effort are within normal limits.

Choice C rationale

Resonance is a normal percussion sound heard over healthy lung tissue. It indicates that the underlying lung areas are filled with air, which is a positive sign of healthy lung function.

Choice D rationale

Inspiratory wheezing, a high-pitched whistling sound during breathing, is typically indicative of narrowed or obstructed airways, often associated with conditions such as asthma or chronic obstructive pulmonary disease, and is not considered a normal finding.