When performing a physical assessment of a client's maxillary the nurse should.

Press above and below the cheek bones.

Apply pressure anteriorly to the tragus.

Ask if the client has a history of headaches.

Ask if the client has a history of sinus infections.

Answer and Explanation

The Correct Answer is A

A.   To assess the maxillary sinuses, the nurse should apply gentle pressure to the area above and below the cheekbones, as this is where the maxillary sinuses are located.
B.   The tragus is part of the ear and not relevant to the assessment of the maxillary sinuses. Pressure in this area would not be helpful for evaluating sinus health.
C.   While a history of headaches may be relevant to sinus issues, it is not a direct physical assessment of the maxillary sinuses.
D.   Ask if the client has a history of sinus infections. While a history of sinus infections is useful, it does not replace the physical assessment of the maxillary sinuses.

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Correct Answer is B

Explanation

A. This tests cranial nerve VIII (vestibulocochlear), not cranial nerve XI.
B. Moves the head and shoulders against resistance with equal strength. Cranial nerve XI (accessory nerve) innervates the sternocleidomastoid and trapezius muscles. The expected response would be equal strength when the patient moves their head and shoulders against resistance.
C. Follows an object with his or her eyes without nystagmus or strabismus. This describes the function of cranial nerve II (optic) or cranial nerve III (oculomotor), not cranial nerve XI.
D. Sticks out the tongue midline without tremors or deviation. This tests cranial nerve XII (hypoglossal), not cranial nerve XI.

A. Constriction of pupils and convergence of eyes bilaterally B. Dilation of pupils and convergence of eyes bilaterally C. Nystagmus when object is moved close to the client's nose D. No change in pupil size and parallel alignment of both eyes

Correct Answer is A

Explanation

A. This is the expected response when assessing accommodation. The pupils should constrict (become smaller) and the eyes should converge (move inward) as a person focuses on a near object.
B. This response is not typical for accommodation. Convergence should occur with pupil constriction when focusing on a near object.
C. Nystagmus (a rhythmic jerking of the eyes) is not a normal finding during accommodation testing. It could indicate neurological or vestibular issues.
D. This is not a typical accommodation response. The pupils should constrict, and the eyes should converge when focusing on a near object.

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When performing a physical assessment of a client's maxillary the nurse should.

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Naxlex Comprehensive Predictor Exams

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient.

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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