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. Apparent state of health: This generally reflects overall health rather than specific mental or cognitive status.

B. Facial expression: Facial expression provides insight into mood and emotional state but does not specifically assess consciousness or orientation.

C. Level of consciousness: Being awake, alert, and oriented is directly related to the level of consciousness, which is a key aspect of assessing cognitive and mental function.

D. Posture, gait, motor activity, and speech: These aspects are relevant for physical activity and motor skills, not specifically for consciousness or cognitive orientation.

A. Mental B. Physical C. Spiritual D. Interpersonal

Correct Answer is A

Explanation

A. Mental: The client's disorientation and altered perception suggest a need for a mental health assessment to evaluate cognitive function, potential delirium, or other psychiatric conditions.

B. Physical: While the client's shaking is noted, the primary concern in this scenario is the client's altered mental state, rather than physical health alone.

C. Spiritual: The client's behavior does not directly indicate a need for a spiritual assessment.

D. Interpersonal: Although the client’s behavior may impact interpersonal interactions, the immediate need is to assess the mental status due to the confusion and altered perception.

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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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Naxlex Comprehensive Predictor Exams

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