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. Dysfunction of the motor component of CN X (vagus nerve) and sensory component of CN VII (facial nerve) would present with different symptoms, such as difficulty swallowing and impaired taste sensation, not the observed facial asymmetry and puffing of cheeks.
B. CN XI (accessory nerve) dysfunction primarily affects the sternocleidomastoid and trapezius muscles and wouldn't cause the observed facial asymmetry.
C. Dysfunction of CN IV (trochlear nerve) leads to issues with downward and inward eye movement, not the facial asymmetry described.
D. Dysfunction of the motor component of CN VII (facial nerve) leads to facial asymmetry during expressions and difficulty controlling facial muscles, which matches the observed findings.

A. salpingitis. B. adnexa C. menarche. D. menopause

Correct Answer is D

Explanation

A. Salpingitis refers to inflammation of the fallopian tubes and doesn’t relate to cessation of menses.
B. Adnexa refers to the accessory structures of the uterus, such as the ovaries and fallopian tubes, but doesn’t describe the cessation of menses.
C. Menarche refers to the onset of menstruation, which is the opposite of cessation of menses.
D. Menopause is the natural cessation of menstruation that occurs typically around the age of 45-55 years in women.

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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?

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Correct Answer is D

Explanation

The nurse is assessing a client who reports cessation of menses. The nurse should document the cessation of menses in the client's record as:

Correct Answer is D

Explanation

A client drove himself to the urgent care center for, "Legs that look like balloons and difficulty walking." The nurse assesses 4+ edema of both legs based upon which finding?

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