When performing a head-to-toe assessment, during which part would the nurse evaluate cranial nerve (CN) IX, X, and XII?

Ears

Mouth and throat

Head and face

Mental status examination

Answer and Explanation

The Correct Answer is B

A. Ears: Evaluation of the ears is primarily concerned with hearing and balance, which involve cranial nerves such as VIII (Vestibulocochlear), not IX, X, and XII.

B. Mouth and throat: Cranial nerves IX (Glossopharyngeal), X (Vagus), and XII (Hypoglossal) are assessed through the examination of the mouth and throat. CN IX and X are evaluated by checking the gag reflex and the ability to swallow, while CN XII is assessed by examining tongue movements.

C. Head and face: The assessment of the head and face generally involves cranial nerves V (Trigeminal) and VII (Facial), which control facial sensation and movement, rather than IX, X, and XII.

D. Mental status examination: While mental status is crucial for overall health assessment, it does not specifically target cranial nerves IX, X, and XII.

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Correct Answer is A

Explanation

A. T wave: The T wave represents ventricular repolarization (relaxation), indicating the end of the ventricular contraction phase.

B. QRS complex: The QRS complex represents ventricular depolarization (contraction), not repolarization.

C. P wave: The P wave represents atrial depolarization, not ventricular repolarization.

D. ST segment: The ST segment represents the time between ventricular depolarization and repolarization, but it is not the waveform indicating repolarization itself.

A. Wheezes B. Rhonchi C. Coarse crackles (rales) D. No sound

Correct Answer is C

Explanation

A. Wheezes: Wheezes are high-pitched sounds usually associated with airway constriction, such as in asthma, not specifically lobar pneumonia.

B. Rhonchi: Rhonchi are low-pitched, snoring sounds associated with secretions in the airways and may be present in pneumonia but are not the most characteristic finding.

C. Coarse crackles (rales): Coarse crackles or rales are bubbling, crackling sounds heard when air moves through fluid in the airways, which is typical in pneumonia due to the presence of alveolar fluid.

D. No sound: Absence of sound is not expected in pneumonia; adventitious sounds like crackles are usually present.

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When performing a head-to-toe assessment, during which part would the nurse evaluate cranial nerve (CN) IX, X, and XII?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

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