2 point discrimination Correct Answers fingertips: 0.3-0.6 cm
hands and feet: 1.5-2. cm
lower leg: 4 cm
A client has a flattened nasolabial fold and drooping of the
mouth on the left side. Which of the following cranial nerves is
most likely to be involved?
1. Cranial nerve V (Trigeminal)
2. Cranial nerve VII (Facial)
3. Cranial nerve XII (Hypoglossal)
4. Cranial nerve XI (Accessory) Correct Answers 2. Cranial
nerve VII (Facial)
-Cranial nerve VII (Facial) is responsible for symmetry of facial
expressions such as smiling, frowning, and puffing of the
cheeks. Cranial nerve V (Trigeminal) is responsible for facial
sensation and temporal and masseter muscle strength. Cranial
nerve XII (Hypoglossal) is responsible for movements of the
tongue and protrusion of the tongue in the midline. Cranial
nerve XI (Accessory) is responsible for sternocleidomastoid and
trapezius muscle strength.
A client has a history of anosmia over the past three months.
The nurse knows that this condition is:
1. Related to swallowing difficulty
2. Associated with ataxia
3. Difficulty with tongue movements
4. Loss of ability to smell or detect odors Correct Answers 4.
Loss of ability to smell or detect odors
,-Anosmia, the absence of the sense of smell, may be due to
cranial nerve dysfunction, colds, rhinitis, or zinc deficiency, or it
may be genetic. Difficulty in swallowing is called dysphagia.
Ataxia is an unsteady gait. Difficulty with tongue movements
may cause problems with swallowing or speech.
A client with a head injury is demonstrating dysphagia and
dysphasia. Which cranial nerve(s) might be involved with this
symptom? Select all that apply.
1. Glossopharyngeal (CN IX)
2. Vagus (CN X)
3. Accessory (CN XI)
4. Facial (CN VII)
5. Trigeminal (CN V) Correct Answers 1. and 2.
-Glossopharyngeal (CN IX) - Produces the gag and swallowing
reflexes and taste on the posterior third of the tongue.
-Vagus (CN X) - Innervates the muscles of the throat and mouth
for swallowing and talking.
-Accessory (CN XI) - Is responsible for movement of the
trapezius and sternocleidomastoid muscles.
-Facial (CN VII) - Is responsible for facial movements such as
smiling, closing of the eyes, frowning; production of tears and
salivary stimulation, as well as taste on the anterior two thirds of
the tongue.
-Trigeminal (CN V) - Is responsible for facial sensation and
muscle strength of the mandible.
A client, seen previously for herpes zoster, comes into the clinic
with ongoing neurologic changes, pain, and sensory/motor
function changes. The nurse realizes that this client might be
experiencing:
, 1. Myasthenia gravis
2. Lyme disease
3. Meningitis
4. Myelitis Correct Answers 4. Myelitis
-Myelitis is an inflammation of the spinal cord. Herpes zoster
infection is a common cause. Myasthenia gravis is a chronic
neuromuscular disorder involving increasing weakness of
voluntary muscles with activity, and some abatement of
symptoms with rest. Lyme disease is an infection caused by a
bite from an infected deer tick. Major symptoms include
arthritis, a flulike syndrome and a rash. Meningitis is caused by
a virus or bacteria that infects the meninges of the brain or spinal
cord. Headache, fever, and altered levels of consciousness can
occur.
Agnosia Correct Answers inability to recognize the forming
nature of an object (personal, smell, taste)
Amyotrophic Lateral Sclerosis ALS Correct Answers -chronic
degenerative disease involving the cerebral cortex and motor
neurons in the spinal cord
-progressive wasting of skeletal muscles
-cause unknown, viral infection?
An elderly client is experiencing an alteration in his equilibrium
and coordinated muscle movements. The nurse realizes that
these functions are controlled by which area of the nervous
system?
1. Cerebrum
2. Hypothalamus
3. Cerebellum