The nurse tests the function of Cranial Nerve XI while performing a physical examination on a client. Which statement best describes the response the nurse should expect if Cranial Nerve XI is intact?

When the client sticks out the tongue it is in the midline and without tremors or deviation.

Client follows an object with eyes without nystagmus or strabismus.

Client demonstrates the ability to hear normal conversation.

Client moves the head and shoulders against resistance with equal strength.

Answer and Explanation

The Correct Answer is D

A.   Cranial Nerve XI (Accessory nerve) is not involved in tongue movement; it controls muscles involved in head and shoulder movement.
B.   Eye movement and control relate more to Cranial Nerves III, IV, and VI, which control eye muscles.
C.   Hearing is primarily assessed by Cranial Nerve VIII (Vestibulocochlear nerve).
D.   Cranial Nerve XI innervates the sternocleidomastoid and trapezius muscles, enabling movements like head turning and shoulder shrugging against resistance.

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Correct Answer is D

Explanation

A. A peritoneal friction rub is a grating sound caused by inflamed surfaces of the peritoneum rubbing together.
B. Borborygmi refers to loud, gurgling bowel sounds often heard with increased intestinal motility.
C. Hypoactive bowel sounds are abnormally decreased or absent bowel sounds.
D. Borborygmi describes the normal sounds made by the movement of gas and fluid in the intestines.

A. 1 minute in the center of the abdomen. B. 10 minutes in each quadrant. C. 1 minute in each quadrant. D. 5 minutes in each quadrant. E. None F. None

Correct Answer is D

Explanation

A. One minute may not provide a sufficient duration to declare absent bowel sounds, especially if the client has a slower bowel motility.
B.

Listening for 10 minutes in each quadrant is excessive and not supported by clinical guidelines. It would unnecessarily delay care and increase patient discomfort.

C. One minute in each quadrant might not provide an adequate assessment time.
D. This is the correct answer because clinical guidelines recommend auscultating for at least 5 minutes in each quadrant before concluding that bowel sounds are absent. This ensures sufficient time to detect infrequent bowel sounds and accurately assess the situation.

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The nurse tests the function of Cranial Nerve XI while performing a physical examination on a client. Which statement best describes the response the nurse should expect if Cranial Nerve XI is intact?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The physician comments that the client has abdominal borborygmic. The nurse recognizes that which of the following is the best description of borborygmic?

Correct Answer is D

Explanation

During an abdominal assessment, the nurse is unable to hear bowel sounds in a client's abdomen. How long should the nurse listen before reporting absent bowel sounds?

Correct Answer is D

Explanation

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