The nurse should ask the client to do which of the following when testing the function of the spinal accessory nerve (CN XI)?
1. Swallow a sip of water.
2. Elevate the shoulders.
3. Open the mouth and say "ah."
4. Vocalize the sounds "la-la," "mi-mi," and "kuh-kuh."
2
Rationale: The spinal accessory nerve has only a motor component. This cranial nerve is assessed by asking the client to elevate the shoulders, which may be done with or without resistance. It can also be assessed by asking the client to turn the head from one side to the other, resist attempts to pull the chin toward midline, and push the head forward against resistance. The incorrect options are assessed as part of glossopharyngeal nerve (CN IX) and vagus nerve (CN X) testing, which are done together.
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