Today’s NCLEX-RN® question of the day focuses on a client who has experienced a stroke.
When assessing cranial nerve XII in a client who has experienced a stroke, which task should the nurse ask the client to perform?
A. Focus on a distant object
B. Stand with eyes closed
C. Turn the head to one side
D. Stick out the tongueScroll down for the correct answer!
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The correct answer to today’s NCLEX-RN® Question is…
D. Stick out the tongue
Rationale: Cranial nerve XII is the hypoglossal nerve, which means “under the tongue.” One way to assess this nerve is to ask the client to stick out the tongue.
Main takeaway
Following a stroke or another condition that may result in cranial nerve dysfunction, it is important for the nurse to do a thorough neuro assessment including an assessment of the cranial nerves. To assess cranial nerve XII, the hypoglossal nerve, ask the client to stick out their tongue and check for deviation away from the midline.
Incorrect answer explanations
A. Focus on a distant object
Rationale: This tests cranial nerve III, the oculomotor nerve.
B. Stand with eyes closed
Rationale: This tests cranial nerve VIII, the vestibulocochlear nerve.
C. Turn the head to one side
Rationale: This tests cranial nerve XI, the spinal accessory nerve.
References
Jarvis, C. (2016). Physical examination and health assessment (7th ed.). St. Louis, MO: Elsevier.
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