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When performing a comprehensive neurological exam, examiners may assess the functioning of the cranial nerves. When performing these tests, examiners compare responses of opposite sides of the face and neck. Instructions for assessing each cranial nerve are provided below. Cranial Nerve I – OlfactoryAsk the patient to identify a common odor, such as coffee or peppermint, with their eyes closed. See Figure 6.11[1] for an image of a nurse performing an olfactory assessment. Figure 6.11 Assessing Cranial Nerve I (Olfactory)Cranial Nerve II – OpticBe sure to provide adequate lighting when performing a vision assessment. Far vision is tested using the Snellen chart. See Figure 6.12[2] for an image of a Snellen chart. The numerator of the fractions on the chart indicate what the individual can see at 20 feet, and the denominator indicates the distance at which someone with normal vision could see this line. For example, a result of 20/40 indicates this individual can see this line at 20 feet but someone with normal vision could see this line at 40 feet. Test far vision by asking the patient to stand 20 feet away from a Snellen chart. Ask the patient to cover one eye and read the letters from the lowest line they can see.[3] Record the corresponding result in the furthermost right-hand column, such as 20/30. Repeat with the other eye. If the patient is wearing glasses or contact lens during this assessment, document the results as “corrected vision.” Repeat with each eye, having the patient cover the opposite eye. Alternative charts are available for children or adults who can’t read letters in English. Figure 6.12 Snellen ChartNear vision is assessed by having a patient read from a prepared card from 14 inches away. See Figure 6.13[4] for a card used to assess near vision. Figure 6.13 Assessing Near VisionCranial Nerve III, IV, and VI – Oculomotor, Trochlear, AbducensCranial nerve III, IV, and VI (oculomotor, trochlear, abducens nerves) are tested together.
Video Review for Assessment of the Cardinal Fields of Gaze[7]Read more details about assessing the Pupillary Light Reflex. Cranial Nerve V – Trigeminal
Cranial Nerve VII – Facial Nerve
Cranial Nerve VIII – Vestibulocochlear
Cranial Nerve IX – GlossopharyngealAsk the patient to open their mouth and say “Ah” and note symmetry of the upper palate. The uvula and tongue should be in a midline position and the uvula should rise symmetrically when the patient says “Ah.” (see Figure 6.22[14]). Figure 6.22 Assessing Glossopharyngeal NerveCranial Nerve X – VagusUse a cotton swab or tongue blade to touch the patient’s posterior pharynx and observe for a gag reflex followed by a swallow. The glossopharyngeal and vagus nerves work together for integration of gag and swallowing. See Figure 6.23[15] for an image of assessing the gag reflex. Figure 6.23 Observing the Gag ReflexCranial Nerve XI – Spinal AccessoryTest the right sternocleidomastoid muscle. Face the patient and place your right palm laterally on the patient’s left cheek. Ask the patient to turn their head to the left while resisting the pressure you are exerting in the opposite direction. At the same time, observe and palpate the right sternocleidomastoid with your left hand. Then reverse the procedure to test the left sternocleidomastoid. Continue to test the sternocleidomastoid by placing your hand on the patient’s forehead and pushing backward as the patient pushes forward. Observe and palpate the sternocleidomastoid muscles. Test the trapezius muscle. Ask the patient to face away from you and observe the shoulder contour for hollowing, displacement, or winging of the scapula and observe for drooping of the shoulder. Place your hands on the patient’s shoulders and press down as the patient elevates or shrugs the shoulders and then retracts the shoulders.[16] See Figure 6.24[17] for an image of assessing the trapezius muscle. Figure 6.24 Assessing Cranial Nerve XICranial Nerve XII – HypoglossalAsk the patient to protrude the tongue. If there is unilateral weakness present, the tongue will point to the affected side due to unopposed action of the normal muscle. An alternative technique is to ask the patient to press their tongue against their cheek while providing resistance with a finger placed on the outside of the cheek. See Figure 6.25[18] for an image of assessing the hypoglossal nerve. Figure 6.25 Assessing the Hypoglossal NerveVideo Review of Cranial Nerve Assessment[19]Expected Versus Unexpected FindingsSee Table 6.5 for a comparison of expected versus unexpected findings when assessing the cranial nerves. Table 6.5 Expected Versus Unexpected Findings of an Adult Cranial Nerve Assessment
When assessing the system which body areas should be palpated?When assessing the musculoskeletal system, which body areas should be palpated? Select all that apply. The nurse palpates all bones, joints, and surrounding muscles for tone, temperature, crepitus, resistance to pressure, and tenderness.
What are you assessing for when palpating a joint?Palpate the joints and assess the temperature of the skin and the muscles. Palpate for warmth, tenderness, swelling or masses. If pain or tenderness are noted, further assess to specify the joint or structure involved.
What method does the nurse use to evaluate the movements of the shoulder?What method does the nurse use to evaluate the movements of the shoulder? Circumduction is used to evaluate the movements of the shoulder which involves moving the arm in circles from the shoulder joint.
When assessing the range of joint movement the nurse asks the patient to move the arm away from the body this evaluates which movement?Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body. You just studied 52 terms!
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