During an assessment of a patient's cranial nerves, the nurse asks the patient to stick out the tongue. The nurse observes that the tongue deviates markedly to the right side. Which condition is the patient most likely exhibiting?
1. Abnormal hypoglossal nerve response
2. First cranial nerve (CN I) damage
3. Sluggish oculomotor response
4. Absence of Homans' sign
1
Rationale 1: Cranial nerve XII (hypoglossal) is tested by having the patient stick his or her tongue out. An abnormal finding is that the tongue deviates to either side.
Rationale 2: Cranial nerve I is the olfactory nerve and is assessed by having the patient use his or her sense of smell.
Rationale 3: Cranial nerve III is the oculomotor nerve and, along with the trochlear and abducens nerves, helps the eye move.
Rationale 4: Homans' sign is a check for thrombophlebitis in the calves of the legs.
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