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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Asymmetry of the scrotum is often normal; one side may hang lower than the other without indicating pathology.
B. Marked tenderness on palpation could suggest inflammation or infection but doesn’t necessarily indicate abnormality in all cases.
C. Easy sliding of scrotal contents is a normal finding; the testes should move easily within the scrotum.
D. The presence of small, firm, non-tender, yellowish nodules could indicate an abnormal finding such as sebaceous cysts or other nodules that may require further evaluation.
Correct Answer is D
Explanation
A. Ability to swallow pureed foods suggests some functional capacity and is not an immediate concern requiring immediate reporting.
B. A mild headache reported by the client might not indicate a critical issue requiring immediate reporting.
C. Weakness can be a concerning symptom, but the severity or extent of weakness needs further clarification before urgent reporting.
D. A Glasgow Coma Scale (GCS) score of 5 is indicative of severe impairment of consciousness, requiring immediate attention and further evaluation by the healthcare provider.
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