Author Question: The nurse should ask the client to do which of the following when testing the function of the spinal ... (Read 14 times)

kshipps · **on:** Jul 22, 2018

The nurse should ask the client to do which of the following when testing the function of the spinal accessory nerve (CN XI)?

1. Swallow a sip of water.
2. Elevate the shoulders.
3. Open the mouth and say ah.
4. Vocalize the sounds la-la, mi-mi, and kuh-kuh.

Question 2

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. The initial nursing action would be which of the following?

1. Turn the client on her back, and administer oxygen by nasal cannula at 2 to 4 L/min.
2. Turn the client on her side, and administer oxygen by face mask at 8 to 10 L/min.
3. Turn the client on her back, and administer oxygen by face mask at 8 to 10 L/min.
4. Turn the client on her side, and administer oxygen by nasal cannula at 2 to 4 L/min.

kiamars2010 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

2

Rationale: The spinal accessory nerve has only a motor component. This cranial nerve is assessed by asking the client to elevate the shoulders, which may be done with or without resistance. It can also be assessed by asking the client to turn the head from one side to the other, resist attempts to pull the chin toward midline, and push the head forward against resistance. The incorrect options are assessed as part of glossopharyngeal nerve (CN IX) and vagus nerve (CN X) testing, which are done together.

Answer to Question 2

2

Rationale: If a fetal heart rate begins to slow or a loss of variability is observed, this could indi-cate fetal distress. To facilitate oxygen to the mother and her fetus, the mother is turned to her side, which reduces the pressure of the uterus on the ascending vena cava and descending aorta. Oxygen at 8 to 10 L/min is applied to the mother by face mask.