You are the nurse performing a nose and mouth assessment.
Which of the following assessment techniques stimulates cranial nerve XII (hypoglossal)?

Ask the client to stick out their tongue and move it from side to side, then up and down.

Ask the client to stick out their tongue.

Ask the client to cover one eye and read a note card.

Have the patient smile, frown, and puff their cheeks.

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is C

Explanation

Choice A rationale

Dullness upon percussion indicates increased tissue density, such as in consolidation (e.g., pneumonia), pleural effusion, or a tumor. This occurs because the sound waves are attenuated and dampened by the solid or fluid-filled structures, resulting in a short, high-pitched, thudding sound.

Choice B rationale

Tympany is a drum-like, high-pitched, loud sound typically heard over air-filled organs like the stomach or intestines. When percussing the lungs, tympany suggests a large pneumothorax or a distended abdomen impinging on the thoracic cavity, indicating abnormal air accumulation.

Choice C rationale

Resonance is the expected percussive sound over healthy, air-filled lung tissue. It is a low-pitched, clear, hollow sound produced by the vibration of air within the alveoli and bronchi. This sound indicates normal lung aeration and the absence of significant pathology.

Choice D rationale

Hyperresonance is a louder, lower-pitched sound than normal resonance and suggests an increased amount of air in the lung or pleural cavity, such as in emphysema or pneumothorax. This hyperinflation causes greater vibration and a more boomy quality to the sound.

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.

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You are the nurse performing a nose and mouth assessment. Which of the following assessment techniques stimulates cranial nerve XII (hypoglossal)?

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You are the nurse performing a nose and mouth assessment.
Which of the following assessment techniques stimulates cranial nerve XII (hypoglossal)?