Neuro Exam

The client has paralysis of the muscles on one side of the face. Which cranial nerve is involved? a. Cranial nerve IV b. Cranial nerve V c. Cranial nerve VI d. Cranial nerve VII

d. Cranial nerve VII (facial nerve)

The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the client's peripheral response to pain? a. Sternal rub b. Nail bed pressure c. Pressure on the orbital rim d. Squeezing of the sternocleidomastoid muscle

Answer B. Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

During a routine physical examination to assess a male client's deep tendon reflexes, the nurse should make sure to: a. use the pointed end of the reflex hammer when striking the Achilles tendon. b. support the joint where the tendon is being tested. c. tap the tendon slowly and softly d. hold the reflex hammer tightly.

Answer B. To prevent the attached muscle from contracting, the nurse should support the joint where the tendon is being tested. The nurse should use the flat, not pointed, end of the reflex hammer when striking the Achilles tendon. (The pointed end is used to strike over small areas, such as the thumb placed over the biceps tendon.) Tapping the tendon slowly and softly wouldn't provoke a deep tendon reflex response. The nurse should hold the reflex hammer loosely, not tightly, between the thumb and fingers so it can swing in an arc.

A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client to ensure client safety? a. Speak loudly to the client b. Test the temperature of the shower water c. Check the temperature of the food on the delivery tray. d. Provide a clear path for ambulation without obstacles

Answer D. Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Testing the shower water temperature would be useful if there were an impairment of peripheral nerves. Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). Cranial nerve VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior third of the tongue, respectively.

During recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once each shift. This assessment evaluates: a. cranial nerves I and II. b. cranial nerves III and V. c. cranial nerves VI and VIII. d. cranial nerves IX and X.

Answer D. Swallowing is a motor function of cranial nerves IX and X. Cranial nerves I, II, and VIII don't possess motor functions. The motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.

Which ophthalmic nerves are generally tested together by testing the external ocular movements? (Select all that apply) a. Cranial nerve II b. Cranial nerve III c. Cranial nerve IV d. Cranial nerve V e. Cranial nerve VI f. Cranial nerve VII

B,C,E Cranial nerves III (oculomotor), Cranial nerve IV (trochlear), Cranial nerve VI (abducens) are all tested together

The nurse has the client turn their head against resistance and asks the client to shrug the shoulders against resistance. Which cranial nerve is being assessed? a. Cranial nerve IX b. Cranial nerve X c. Cranial nerve XI d. Cranial nerve XII

c. cranial nerve XI (spinal accessory)

A patient presents with concerns about his vision. He states that he is experiencing double vision. Upon evaluation you conclude that he has lateral rectus palsy. Which cranial nerve is most likely lesioned in this young man? A. Trochlear B. Trigeminal C. Occulomotor D. Abducens

D. abducens The lateral rectus muscle is innervated by CN VI (abducens nerve). Remember "LR6 SO4 the rest 3". (Lateral rectus innervated by CN VI, Superior oblique innervated by CN IV, the rest of the eye muscles are controlled by CN III)

The nurse asks the client to smell two items: coffee and alcohol and the client is able to identify both of them. What cranial nerve is being tested? a. Cranial nerve I b. Cranial nerve II c. Cranial nerve III d. Cranial nerve IV

a. Cranial nerve I (olfactory)

The nurse asks the client to stick out his tongue and observes for symmetry or deviation to one side. Which cranial nerve is being assessed? a. Cranial nerve XII b. Cranial nerve XI c. Cranial nerve X d. Cranial nerve IX

a. Cranial nerve XII (hypoglossal nerve)

A client is asked to read from a Snellen eye chart. What cranial nerve is being assessed? a. Cranial nerve I b. Cranial nerve II c. Cranial nerve III d. Cranial nerve IV

b. Cranial nerve II (optic)

The nurse is asking the client if he can hear a ticking watch. What cranial nerve is being assessed? a. Cranial nerve VII b. Cranial nerve VIII c. Cranial nerve IX d. Cranial nerve X

b. cranial nerve VIII (vestibulocholear)

The cranial nerve tested by assessing sensation to the throat and taste to the posterior one third of the tongue is what nerve? a. Cranial nerve VI b. Cranial nerve VII c. Cranial nerve VIII d. Cranial nerve IX

d. cranial nerve IX (glossopharyngeal)