The nurse completes a neurological examination on a client who has suffered a stroke to determine if damage has occurred to any of the cranial nerves. The nurse understands that damage has occurred to cranial nerve IX based on which assessment finding?

Question

The nurse completes a neurological examination on a client who has suffered a stroke to determine if damage has occurred to any of the cranial nerves.  The nurse understands that damage has occurred to cranial nerve IX based on which assessment finding?

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11ecbb05_ca2e_ad8e_b433_35676b8288fb_MD0009_00 Cranial nerves IX (glossopharyngeal) and X (vagus) are related to the movement of the pharynx and tongue. To evaluate cranial nerves IX and X, the nurse assesses for the presence of a gag reflex and symmetrical movements of the uvula and soft palate, and listens to voice quality. A tongue blade can be used to touch the posterior pharyngeal wall to assess for a gag reflex. Asking the client to say "ah" will allow assessment of the uvula and soft palate. Harsh or brassy voice quality indicates dysfunction with the vagus nerve (X) (Option A). (Option B) The facial nerve (VII) is assessed by observing for symmetrical movements during facial expressions (eg, smile, frown, close eyes). (Option C) The trigeminal nerve (V) has both sensory and motor functions. The nurse assesses for equal jaw strength by palpating the masseter muscle while the client clenches the jaw. To assess sensory function, the nurse touches the client's face with the client's eyes closed to determine if sensations are equal. (Option D) The spinal accessory nerve innervates the sternocleidomastoid and part of the trapezius muscles. The nurse applies resistance during shrugging and head turning and assesses for equal strength. Educational objective: Cranial nerves IX and X work together to create movement of the pharynx and tongue. An absent gag reflex, asymmetrical uvular and palate movement, or a change in voice quality indicates damage.

The Nurse Completes a Neurological Examination on a Client Who