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","B","D"]

Explanation

A. Rovsing sign: This sign is positive when palpation of the left lower quadrant causes pain in the right lower quadrant, indicating possible appendicitis.

B. Psoas sign: This sign is positive when pain occurs upon extending the right thigh or flexing the hip against resistance, suggesting irritation of the psoas muscle due to appendicitis.

C. Murphy sign: This sign is associated with gallbladder inflammation (cholecystitis), not appendicitis.

D. Obturator sign: This sign is positive when pain occurs upon flexing and internally rotating the right thigh, which can indicate irritation of the obturator muscle due to appendicitis.

A. Head and face B. Mouth and throat C. Mental status examination D. Ears

Correct Answer is A

Explanation

A. Head and face: Cranial nerve VII (facial nerve) controls the muscles of facial expression, so its motor function is assessed by examining the movement of the face, such as smiling, frowning, or raising eyebrows.

B. Mouth and throat: While cranial nerve VII does innervate some muscles involved in facial expressions that might affect the mouth, a more comprehensive assessment of its motor function occurs in the head and face region.

C. Mental status examination: This assesses cognitive functions rather than specific motor functions of cranial nerves.

D. Ears: The assessment of cranial nerve VII does not typically involve the ears.

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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

When assessing for appendicitis, what signs might the nurse look for? (Select all that apply.)

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

Explanation

When performing a head-to-toe assessment, during which part would the nurse assess the motor function of cranial nerve VII?

Correct Answer is A

Explanation

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