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","C","D","E"]

Explanation

A. Identify ways to ensure client privacy: Ensuring privacy is essential for a respectful and confidential examination.

B. Turn on relaxing music of the client's choice: While this might improve the client's comfort, it is not a standard or necessary step before conducting a physical examination.

C. Wash hands: Hand hygiene is crucial before any physical examination to prevent infection.

D. Obtain and check needed equipment: Having and checking equipment ensures that all necessary tools are available and in working order for the examination.

E. Dim the lighting to promote comfort: Proper lighting can help in conducting a thorough examination and make the client feel more comfortable.

A. Wait until the end of the physical assessment to reassess the radial pulse. B. Reassess the client's pedal pulse on the other foot. C. Assess the client's 51 and 52 sounds for regularity. D. Assess the client's apical pulse for a full minute.

Correct Answer is ["A","D"]

Explanation

A. Wait until the end of the physical assessment to reassess the radial pulse: If the radial pulse is irregular, it is important to reassess it to confirm irregularity. However, waiting until the end of the assessment is not recommended; it is better to reassess promptly.

B. Reassess the client's pedal pulse on the other foot: This is not related to assessing the regularity of the radial pulse.

C. Assess the client's 51 and 52 sounds for regularity: These terms are not standard in assessing pulse regularity; the focus should be on the apical pulse for an irregular radial pulse.

D. Assess the client's apical pulse for a full minute: The apical pulse should be assessed for a full minute to accurately determine the heart rate and rhythm, especially if the radial pulse is irregular.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.)

Correct Answer is ["A","C","D","E"]

Explanation

During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? (Select all that apply.)

Correct Answer is ["A","D"]

Explanation

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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