Which component(s) of cranial nerve function should the practical nurse (PN) evaluate during the focused assessment? Select all that apply.

Sticking out and moving the tongue.

Tactile discrimination and fine touch.

A Babinski response.

Distinguishing salty and sweet tastes.

Symmetrically smiling and frowning.

Answer and Explanation

Correct Answer : A,B,D,E

Rationale:

A. Sticking out and moving the tongue: This assesses cranial nerve XII (hypoglossal), which controls tongue movement and coordination. Observing the ability to protrude and move the tongue side to side provides information about motor function and potential neurological impairment.

B. Tactile discrimination and fine touch: Testing tactile discrimination evaluates cranial nerve V (trigeminal) sensory function. Assessing the ability to detect light touch, pressure, and texture helps identify sensory deficits that may indicate nerve damage or central nervous system pathology.

C. A Babinski response: The Babinski reflex assesses corticospinal tract integrity rather than specific cranial nerve function. While important for neurological assessment, it is not a direct measure of cranial nerve performance and is therefore not included in this focused cranial nerve evaluation.

D. Distinguishing salty and sweet tastes: Taste perception on the anterior two-thirds of the tongue involves cranial nerve VII (facial), while the posterior third is innervated by cranial nerve IX (glossopharyngeal). Evaluating the client’s ability to differentiate flavors provides sensory information about these cranial nerves.

E. Symmetrically smiling and frowning: Observing facial expressions assesses cranial nerve VII (facial) motor function. Symmetry in smiling, frowning, and other facial movements helps detect unilateral weakness or paralysis, which may indicate facial nerve dysfunction.

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Correct Answer is A

Explanation

Rationale:

A. Tonsils are observable and covered with a white exudate: White exudate on the tonsils can indicate an acute infection, such as bacterial tonsillitis or streptococcal pharyngitis, which can rapidly progress and cause systemic complications if untreated. Immediate reporting is warranted to ensure timely medical evaluation, potential antibiotic therapy, and prevention of complications

B. Ventral surface of the tongue appears smooth and glistening: A smooth, glistening tongue may reflect nutritional deficiencies, such as vitamin B12 or iron deficiency, but it is generally a chronic finding and not immediately life-threatening. It requires assessment but not urgent intervention.

C. Dorsal surface of the tongue is rough with a white coating: A white coating on the dorsal tongue often represents benign causes, such as oral candidiasis or debris accumulation. While it may require treatment, it is typically not an acute emergency unless accompanied by severe symptoms like dysphagia or systemic infection.

D. Teeth are yellowed and crooked with debris collected in the gaps: Poor dental hygiene and discoloration indicate chronic oral health issues. These findings require preventive education and routine dental care but do not demand immediate medical action.

A. Hematocrit of 44% (0.44 volume fraction). B. Serum potassium 2.5 mEq/L (2.5 mmol/L). C. Hemoglobin 13 grams/dL (130 g/L). D. Serum sodium 125 mEq/L (125 mmol/L). E. White blood cell count 15,000/mm3 (15 x 109/L).

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

Explanation

Rationale:

A. Hematocrit of 44% (0.44 volume fraction): This value falls within the normal reference range of 37%–47% for adult females. It indicates adequate red blood cell volume relative to plasma and does not require reporting to the healthcare provider.

B. Serum potassium 2.5 mEq/L (2.5 mmol/L): This value is below the normal range of 3.5–5.0 mEq/L, indicating hypokalemia. Low potassium levels can cause cardiac arrhythmias, muscle weakness, and respiratory compromise, necessitating immediate notification of the healthcare provider for intervention.

C. Hemoglobin 13 grams/dL (130 g/L): Hemoglobin within the range of 12–16 g/dL reflects adequate oxygen-carrying capacity and red blood cell mass. No abnormality is indicated, so it does not require reporting.

D. Serum sodium 125 mEq/L (125 mmol/L): This value is below the normal sodium range of 136–145 mEq/L, indicating hyponatremia. Hyponatremia can lead to neurological symptoms such as confusion, seizures, or lethargy, making it essential to report to the healthcare provider promptly.

E. White blood cell count 15,000/mm3 (15 x 10⁹/L): A WBC count above the reference range of 5,000–10,000/mm3 suggests leukocytosis, which may indicate infection, inflammation, or stress response. This abnormal finding should be communicated to the healthcare provider for further evaluation and management.

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Which component(s) of cranial nerve function should the practical nurse (PN) evaluate during the focused assessment? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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

Explanation

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