Critical Care Registered Nurse (CCRN) Practice Exam

What should the nurse observe when testing the patient's response to a tongue blade on the posterior pharynx?

1. Symmetrical mouth opening

2. Symmetrical upward movement of the soft palate

3. Clear articulation of sounds

4. Consistent arm strength

The correct answer is: Symmetrical upward movement of the soft palate

When testing the patient's response to a tongue blade on the posterior pharynx, observing the symmetrical upward movement of the soft palate is crucial. This assessment helps to evaluate the function of cranial nerves, particularly the glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). When the soft palate rises symmetrically, it indicates proper nerve function and that the swallowing mechanism is intact, reflecting a healthy neurological response. If there is asymmetry in the soft palate during this assessment, it could suggest a dysfunction related to the aforementioned nerve pathways and potential impairment in airway protection and swallowing. Other options, while important in neurological assessments, do not specifically relate to the response elicited by stimulating the posterior pharynx with a tongue blade. For instance, symmetrical mouth opening and clear articulation of sounds assess different functions, such as motor control in the facial area and language processing, respectively. Consistent arm strength pertains to upper extremity function and does not directly reflect the neurological response expected from the action performed in the question. Thus, observing the movement of the soft palate is the key indicator of assessing the patient's cranial nerve function during this test.