Which of these statements best describes how the nurse should assess the function of cranial nerve X?

Ask the patient to say "ahh" & watch for movement of the soft palate & uvula.

Have the patient stick out the tongue and observe for tremors or pulling to one side.

Use a wisp of cotton to brush over the eyelashes and observe for blinking.

With eyes closed, touch various areas on the face with a wisp of cotton and have patient identify where touched.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Cranial nerve X, the vagus nerve, plays a crucial role in innervating the pharynx and larynx, influencing speech and swallowing. Observing the movement of the soft palate and uvula when the patient says "ahh" assesses the motor function of the vagus nerve, as its bilateral innervation is essential for the symmetrical elevation of these structures.

Choice B rationale

Having the patient stick out the tongue and observing for tremors or pulling to one side assesses the function of cranial nerve XII, the hypoglossal nerve. This nerve controls the intrinsic and extrinsic muscles of the tongue, and abnormalities can indicate nerve damage or neurological issues affecting tongue movement.

Choice C rationale

Using a wisp of cotton to brush over the eyelashes and observing for blinking assesses the corneal reflex, which involves both cranial nerve V (trigeminal, sensory) and cranial nerve VII (facial, motor). This test evaluates the integrity of the reflex arc rather than solely cranial nerve X.

Choice D rationale

With eyes closed, touching various areas on the face with a wisp of cotton and having the patient identify where touched assesses the sensory function of cranial nerve V, the trigeminal nerve. This nerve is responsible for transmitting touch, pain, and temperature sensations from the face.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale

An absent pulse (0) indicates no palpable pulsation, often due to an occlusion or severe vasoconstriction. This signifies a complete lack of blood flow through the vessel, requiring immediate medical attention to prevent tissue ischemia and necrosis.

Choice B rationale

A bounding pulse (4+) is characterized by a strong, easily palpable pulsation that is not easily obliterated by pressure. This can indicate conditions like fluid overload, hypertension, or hyperkinetic states, reflecting increased stroke volume or decreased peripheral resistance.

Choice C rationale

A weak pulse (1+) is characterized by a faint, barely palpable pulsation that is easily obliterated by pressure. This can be indicative of decreased stroke volume, hypovolemia, or peripheral artery disease, signifying reduced blood flow and perfusion.

Choice D rationale

A normal pulse (2+) is characterized by a readily palpable pulsation that is easily discernible and not easily obliterated by pressure. This finding indicates adequate cardiac output and peripheral perfusion, signifying healthy cardiovascular function within normal physiological parameters.

A. Changes in the peripheral vision in response to light. B. Pupillary constriction and convergence of the axis when looking at a near object. C. Involuntary blinking in the presence of bright light. D. Dilation of the pupils when looking at a far object.

Correct Answer is B

Explanation

Choice A rationale
Changes in peripheral vision in response to light are not directly related to visual accommodation. Peripheral vision is mediated by rod photoreceptors and is assessed through visual field testing, whereas accommodation involves the crystalline lens and its ability to change shape for focusing.
Choice B rationale
Visual accommodation is the process by which the eye changes its optical power to maintain a clear image or focus on an object as its distance varies. When looking at a near object, the ciliary muscles contract, relaxing the suspensory ligaments, allowing the lens to become more convex (thicker) to increase refractive power. This change in lens shape is accompanied by pupillary constriction (miosis) and convergence of the visual axes (medial movement of the eyeballs) to maintain binocular vision.
Choice C rationale
Involuntary blinking in the presence of bright light is a reflex action called the blink reflex, serving to protect the eye from excessive light and maintain lubrication. It is a protective mechanism and not a component of the physiological process of visual accommodation, which focuses on near objects.
Choice D rationale
Dilation of the pupils (mydriasis) occurs when looking at a far object or in dim light conditions to allow more light to enter the eye. This is regulated by the sympathetic nervous system and is opposite to the pupillary constriction that accompanies accommodation for near vision.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which of these statements best describes how the nurse should assess the function of cranial nerve X?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2+". The nurse recognizes that this reading indicates what type of pulse?

Correct Answer is D

Explanation

The nurse is testing a patient's visual accommodation, which finding would the nurse expect to see?

Correct Answer is B

Explanation

The nurse is preparing to assess the visual acuity of a patient. How should the nurse proceed?

Heparin 10,000 units subcutaneous every 12 hours is ordered for a patient after a stent placement. The heparin is available in a 20,000 units per 1 mL concentration. How many milliliters would the nurse administer with each dose? (ROUND TO TENTHS; LABEL CORRECTLY TO RECEIVE CREDIT)

The physician orders Ticar 800mg IM qoh. The medication is supplied in 1g/2.5 mL. How many milliliters will the nurse administer? (SHADE SYRINGE #1 TO CORRECT DOSE & LABEL CORRECTLY TO RECEIVE CREDIT)

The nurse should give a client half a glass of water after taking a buccal medication.

A medication order requiring a nurse's judgment to determine that the client's condition necessitates the drug's administration is:

What is the drug dosage after reconstitution for IM administration? (Use LABEL #2- CEFTRIAXONE)

A nurse administering medications through a tube must remember which of the following?

The nurse is preparing to examine a patient complaining of right lower quadrant (RLQ) pain. Which technique is correct during the assessment? The nurse should: