The nurse continues a neurologic assessment of the cranial nerve XI (Spinal accessory) for a client. Which instruction should the nurse give the client to complete this assessment?
A.
Shrug shoulders against resistance.
B.
Stand up slowly with eyes closed.
C.
Turn head from side to side.
D.
Raise both arms overhead
The Correct Answer and Explanation is:
The correct answer is:
A. Shrug shoulders against resistance.
Explanation:
Cranial nerve XI, also known as the spinal accessory nerve, is primarily responsible for innervating two major muscles: the sternocleidomastoid and the trapezius. This nerve plays a crucial role in neck and shoulder movement.
To assess the function of cranial nerve XI, the focus is on evaluating the strength and function of these two muscles. The standard test involves asking the patient to perform certain movements that engage these muscles, allowing the nurse to evaluate the nerve’s performance.
Instructions and Assessment:
- Shrug Shoulders Against Resistance (Option A): This is the appropriate test for cranial nerve XI. The nurse should ask the client to shrug both shoulders simultaneously while the nurse provides resistance by pushing down on the client’s shoulders. This action primarily tests the strength and function of the trapezius muscle, which is innervated by cranial nerve XI. Adequate strength in the trapezius muscle indicates proper functioning of the nerve. Any weakness or asymmetry in this action may suggest dysfunction or damage to the nerve.
- Stand Up Slowly with Eyes Closed (Option B): This test assesses balance and proprioception, which are related to other cranial nerves (e.g., vestibulocochlear nerve, cranial nerve VIII) and spinal nerves, but not specifically to cranial nerve XI.
- Turn Head from Side to Side (Option C): This action primarily tests the function of the sternocleidomastoid muscle. While the sternocleidomastoid muscle is innervated by cranial nerve XI, the specific test for this muscle typically involves resistance to turning the head, rather than simply turning it.
- Raise Both Arms Overhead (Option D): This movement is not related to the assessment of cranial nerve XI. It assesses overall shoulder mobility and strength, which involves multiple muscles and nerves, not just the trapezius and sternocleidomastoid.
In summary, to accurately assess cranial nerve XI, the nurse should ask the client to shrug their shoulders against resistance. This tests the strength of the trapezius muscle and, by extension, the function of the spinal accessory nerve.