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 A

Explanation

Choice A rationale

Orientation to person, place, and time is a fundamental component of cognitive assessment, indicating intact neurological function. Knowing one's full name demonstrates personal orientation. Recognizing the hospital and its location signifies place orientation. Providing the correct month and year, even without the exact day, suggests a reasonable grasp of temporal orientation, reflecting adequate higher cortical processing.

Choice B rationale

The inability to state one's location and an incorrect year indicate significant deficits in both place and time orientation. This suggests impaired cognitive function, potentially due to delirium, dementia, or other neurological issues affecting memory and executive functions. Such a response would warrant further comprehensive cognitive evaluation.

Choice C rationale

While knowing one's name indicates personal orientation, confusion about the date points to a deficit in time orientation. This partial disorientation suggests some level of cognitive impairment, necessitating further assessment to determine the underlying cause and extent of the confusion.

Choice D rationale

Hesitation regarding location and complete inability to state the date demonstrate significant disorientation to both place and time. This pattern of response is indicative of impaired cognitive function and necessitates a thorough neurological and cognitive workup to identify potential etiologies.

A. Standing order. B. Routine order. C. STAT order. D. PRN order.

Correct Answer is B

Explanation

Choice A rationale

A standing order is a pre-written medication order and protocol that applies to a specific patient population or clinical situation, allowing nurses to initiate treatment without immediate physician consultation. While it provides a framework, a daily medication is more specifically classified by its regular administration schedule, distinguishing it from general standing orders.

Choice B rationale

A routine order signifies a medication order that is carried out as prescribed until a discontinuation order or change is made. The medication is given on a regular, scheduled basis, often daily, multiple times a day, or weekly. This ensures consistent therapeutic levels for chronic conditions. Lasix 40 mg PO daily fits this description, as it is given consistently each day.

Choice C rationale

A STAT order (statim) means "immediately" and indicates that the medication must be administered as soon as possible, typically within 30 minutes of the order. This type of order is reserved for urgent situations where delay could significantly impact patient outcomes. Lasix ordered daily does not fall into this urgent category.

Choice D rationale

A PRN order (pro re nata) means "as needed.”. This type of order allows the nurse to administer medication based on the patient's symptoms or specific criteria rather than on a fixed schedule. Since Lasix is ordered "daily," it implies a fixed schedule, not an "as needed" administration.

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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)?