When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart.
The nurse would document this finding as a(n):

Choice A rationale

Asking the client to stick out their tongue and move it from side to side, then up and down, directly assesses the function of the hypoglossal nerve (cranial nerve XII). This nerve innervates the intrinsic and extrinsic muscles of the tongue, controlling its movement, which is essential for speech and swallowing, thereby evaluating its motor integrity.

Choice B rationale

Asking the client to stick out their tongue primarily assesses general tongue protrusion, but does not provide as comprehensive an assessment of hypoglossal nerve function as evaluating its full range of motion. Unilateral weakness or deviation, which is indicative of nerve damage, is better observed with side-to-side and up-and-down movements.

Choice C rationale

Asking the client to cover one eye and read a note card assesses visual acuity and the function of the optic nerve (cranial nerve II). This technique evaluates the eye's ability to perceive details and is unrelated to the motor function of the tongue or the hypoglossal nerve.

Choice D rationale

Having the patient smile, frown, and puff their cheeks primarily assesses the facial nerve (cranial nerve VII). This nerve controls the muscles of facial expression, including those involved in smiling, frowning, and puffing out the cheeks, and is distinct from the hypoglossal nerve's role in tongue movement.

Choice A rationale

Inspection is the systematic observation of the patient using the senses of sight, smell, and hearing. It is always the first technique used in a physical assessment because it provides a foundational understanding of the patient's general appearance, symmetry, posture, skin condition, and any visible abnormalities before physical contact is made.

Choice B rationale

Auscultation involves listening to sounds produced by the body, such as heart sounds, lung sounds, and bowel sounds, using a stethoscope. While crucial for assessing various body systems, it typically follows inspection and palpation to avoid altering natural body sounds.

Choice C rationale

Percussion involves tapping on body surfaces to elicit sounds that indicate the density of underlying tissues and organs. This technique helps in assessing organ size, shape, and consistency, but it is performed after inspection and palpation, as it involves direct contact and manipulation.

Choice D rationale

Palpation involves using the sense of touch to assess characteristics such as texture, temperature, moisture, organ size and location, and tenderness. While a vital component of the physical assessment, it follows inspection to avoid introducing discomfort or altering initial observations.