Question

Which direction would the nurse give to a client when assessing function of cranial nerve twelve (hypoglossal)? A. “Holding your head straight, move only your eyes to look first to the right and then to the left.” B. “Clench your jaw as tightly shut as you can.” C. “Stick out your tongue.” D. “Raise your eyebrows.”

Short answer

C. “Stick out your tongue.”

Step-by-step solution

Identify the Function of Cranial Nerve Twelve

Cranial nerve twelve, known as the hypoglossal nerve, is responsible for controlling the movements of the tongue. It controls tongue movements that are needed for speech and swallowing.

Match the Function to the Directions

Since the hypoglossal nerve is responsible for tongue movement, the correct direction to assess its function would involve the nurse asking the client to perform an action with their tongue.

Eliminate Incorrect Options

Options A, B, and D assess functions of different cranial nerves. Option A tests the abducens and oculomotor nerves (cranial nerves VI and III, for eye movement), option B tests the trigeminal nerve (cranial nerve V, for jaw clenching), and option D tests the facial nerve (cranial nerve VII, for eyebrow movement).

Key concepts

Hypoglossal Nerve Function

The hypoglossal nerve, also known as cranial nerve XII, plays a crucial role in many of our daily actions such as speaking and swallowing. Its primary function is controlling the muscles of the tongue.

This nerve's health is vital for coordinated tongue movements that allow for clear articulation of words and the ability to manipulate food while chewing and preparing to swallow. Any abnormalities or damages to the hypoglossal nerve can lead to conditions like dysarthria (difficulty in speaking) or dysphagia (difficulty in swallowing), impacting a person's quality of life. In assessing the hypoglossal nerve, healthcare professionals will typically ask a patient to perform actions that directly involve tongue movement, such as sticking out the tongue or moving it side to side.

Nursing Assessment

Nursing assessments are an integral part of patient care, laying the foundation for diagnosis and subsequent treatment plans. When assessing cranial nerves, a nurse's observation must be meticulous and systematic.

In evaluating the hypoglossal nerve function during a nursing assessment, a nurse will observe the tongue at rest and in motion. They look out for symmetry, involuntary movements, atrophy, and the strength of the tongue upon protrusion. A nurse might ask the patient to 'stick out your tongue' and check for deviation, which could imply muscle weakness or nerve damage. It's crucial to compare the observed outcomes with normal functions and document any abnormalities accordingly.

NCLEX-RN Examination Preparation

The National Council Licensure Examination for Registered Nurses (NCLEX-RN) is a standardized test that all nursing graduates must pass to practice nursing. An important part of preparation involves understanding how to perform and interpret various assessments, including those for cranial nerves.

Prospective nurses must be well-versed in linking symptoms and clinical findings to corresponding cranial nerve functions. Study strategies often include reviewing anatomy and physiology, practicing critical thinking skills with sample questions, and mastering the step-by-step procedures in nursing assessments. Familiarizing oneself with the rationale behind each test helps in making accurate interpretations during the exam and in clinical practice.