During an eye assessment, the nurse observes that the patient's pupils constrict when focusing on a near object. What is this response called?

Correct Answer: A

Rationale: Accommodation is the correct answer because it refers to the ability of the eye to adjust its focus when moving between objects at different distances. When the pupils constrict while focusing on a near object, it indicates the eye is accommodating to improve clarity for close-up vision. Convergence (B) is the coordinated movement of both eyes towards a near object, not pupil constriction. Refraction (C) is the bending of light as it passes through the eye, not the pupil's response. Visual acuity (D) is the sharpness of vision, not related to pupil constriction during accommodation.

Correct Answer: B

Rationale: The presence of stridor indicates upper airway obstruction. Stridor is a high-pitched, inspiratory sound that occurs when there is partial obstruction in the upper airway, typically in the larynx or trachea. This sound is produced as air passes through a narrowed or partially blocked airway during inhalation. Lower airway obstruction (Choice A) typically presents with wheezing, not stridor. Pleural effusion (Choice C) is the accumulation of fluid in the pleural space, which would not cause stridor. Pulmonary edema (Choice D) is the accumulation of fluid in the lungs, leading to crackles on auscultation, not stridor.

Correct Answer: B

Rationale: The correct answer is B: Loss of balance and hearing. Damage to cranial nerve VIII (vestibulocochlear nerve) affects balance and hearing as it is responsible for transmitting sensory information related to equilibrium and sound perception. Loss of balance indicates dysfunction in the vestibular component of the nerve, while hearing loss is related to the cochlear component. Difficulty swallowing (choice A) is associated with cranial nerves IX and X. Impaired eye movement (choice C) is linked to cranial nerves III, IV, and VI. Weakness in shoulder shrugging (choice D) is typically attributed to cranial nerve XI.

Correct Answer: D

Rationale: The correct answer is D, Cranial nerve XII (hypoglossal nerve). This nerve innervates the muscles responsible for tongue movement. When the nurse asks the patient to stick out their tongue, they are testing the function of the hypoglossal nerve. The hypoglossal nerve controls the intrinsic and extrinsic muscles of the tongue, allowing for movements such as protrusion, retraction, and side-to-side movements. Choices A, B, and C are incorrect because they do not directly relate to tongue movement. Cranial nerve IX (glossopharyngeal nerve) is involved in taste perception and swallowing, cranial nerve X (vagus nerve) is involved in various autonomic functions and cranial nerve XI (spinal accessory nerve) controls certain neck muscles.

Correct Answer: A

Rationale: The correct answer is A: Ask the patient to shrug their shoulders against resistance. This is the most appropriate action for assessing cranial nerve XI (spinal accessory nerve) because this nerve innervates the trapezius and sternocleidomastoid muscles, which are responsible for shoulder shrugging and head rotation, respectively. By asking the patient to shrug their shoulders against resistance, the nurse can assess the strength and function of the trapezius muscle, which is controlled by the spinal accessory nerve. Choices B, C, and D are incorrect: B: Having the patient stick out their tongue is used to assess cranial nerve XII (hypoglossal nerve), not cranial nerve XI. C: Testing the patient's ability to chew is used to assess cranial nerve V (trigeminal nerve), not cranial nerve XI. D: Evaluating the patient's sense of smell is used to assess cranial nerve I (olfactory nerve),