The nurse performs that technique shown when assessing the client. What cranial nerve is the nurse assessing?

XII

VII

Answer and Explanation

The Correct Answer is C

A. XII: Cranial nerve XII (hypoglossal) controls tongue movements, but is not typically assessed by the technique described.

B. V: Cranial nerve V (trigeminal) is assessed for facial sensation and mastication, not the technique in question.

C. VII: Cranial nerve VII (facial) is responsible for facial expressions and is assessed by asking the client to perform various facial movements.

D. XI: Cranial nerve XI (accessory) is involved in shoulder and neck movements, not facial expressions.

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Correct Answer is C

Explanation

A. Moist nasal mucosa: This is generally a normal finding and does not usually require immediate follow-up unless there are other symptoms suggesting infection or other issues.

B. Cerumen in the ear: While cerumen can impact hearing, it is typically not an urgent issue and can be managed with appropriate ear care.

C. Enlarged lymph node in the neck: Enlarged lymph nodes can indicate an underlying infection or malignancy, especially if persistent or accompanied by other symptoms, thus requiring immediate follow-up.

D. Acne lesions on the face and upper chest: Acne is common and usually not an urgent concern unless it is severe or causing significant distress.

A. Wound infection B. Bacteremia C. Aspiration pneumonia D. Urinary tract infection E. Urinary tract infection

Correct Answer is C

Explanation

A. Wound infection: While important to address, a wound infection does not directly impact airway, breathing, or circulation unless it leads to severe complications.

B. Bacteremia: This condition is serious and can lead to sepsis, which affects circulation, but immediate airway and breathing issues take precedence.

C. Aspiration pneumonia: This directly affects breathing by causing respiratory complications, making it a priority when considering airway and breathing issues.

D. Urinary tract infection: Although it requires treatment, it does not immediately impact airway, breathing, or circulation like aspiration pneumonia can.

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The nurse performs that technique shown when assessing the client. What cranial nerve is the nurse assessing?

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