Prepare for the NCLEX® with a question of the day on cranial nerve assessment for a patient who’s recently lost consciousness. Test your knowledge and review key concepts.

The nurse in the emergency department is conducting a cranial nerve assessment on a patient who briefly lost consciousness after hitting their head. 

Which normal clinical finding(s) should the nurse anticipate? Select all that apply.   

A. Consensual response

B. Ptosis

C. Anosmia

D. Gag reflex present

E. Dysarthria

Scroll down for the correct answers!

The correct answer to today’s NCLEX-RN® Question is…

A. Consensual response

When shining a penlight into one eye, the nurse should expect to observe a consensual response, meaning the opposite pupil will also constrict along with the illuminated pupil. This indicates correct motor functioning of cranial nerve III, the oculomotor nerve.  

D. Gag reflex present

A client’s gag reflex should be elicited when the nurse uses a swab to touch the back of a client’s throat. This expected finding indicates correct motor functioning of cranial nerve IX, the glossopharyngeal nerve, and cranial nerve X, the vagus nerve. 

Major Takeaway

The nurse should perform a cranial nerve assessment to detect normal and abnormal findings on a client who has experienced a head injury. Assessment of the twelve pairs of cranial nerves helps determine whether they are performing correctly in both sensory and motor functions. When shining a penlight into one eye, the nurse should expect to observe a consensual response, meaning the opposite pupil will also constrict along with the illuminated pupil. This indicates correct motor functioning of cranial nerve III, the oculomotor nerve. Further, a client’s gag reflex should be elicited when the nurse uses a swab to touch the back of a client’s throat. This expected finding indicates correct motor functioning of cranial nerve IX, the glossopharyngeal nerve, and cranial nerve X, the vagus nerve. Ptosis, dysarthria, and anosmia are not anticipated findings. 

CRANIAL NERVE / NORMAL ASSESSMENT FINDINGS

I Olfactory / Correct identification of smell is present through each nare.
II Optic Nerve / 20/20 vision is present, meaning the client can read at 20 feet what the average client can read at 20 feet.
III Oculomotor / Pupil constriction and dilation, consensual response, accommodation, and symmetry of eyelid positions are all present. A gradual lost of accommodation with age, called, presbyopia, is anticipated in older adults.
IV Trochlear / Smooth extraocular movements are present, meaning smooth, symmetrical movements of the eyes while following a moving object.
V Trigeminal / Sensation of a cotton wisp is felt against the anterior scalp, cheek, and jaw. Symmetry and even muscle tone across the face is present at rest and while clenching the jaw.
VI Abducens / Smooth extraocular movements are present and muscle tone over the face is symmetrical and without fasciculation.
VII Facial / Facial expressions are able to be conducted and speech sounds clearly articulated, such as "b", "m", or "p." Sweet and salty tastes on the anterior third of the tongue are able to be identified.
VIII Acoustic / Ability to repeat words whispered in each ear and maintain balance during the Rhomberg test is present. A gradual lost of hearing with age, called, presbycusis, is anticipated in older adults.
IX Glossopharyngeal / Ability to identify bitter and sour tastes applied to the posterior third of the tongue is present, as well as a present gag reflex with no difficultly swallowing.
X Vagus / Gag reflex is present with no difficulty swallowing an the uvula rises in the midlilne when saying "ah."
XI Accessory / Strength in neck and shoulder muscles are equal bilaterally while shrugging and turning head from side to side.
XII Hypoglossal / Tongue is midline with unimpaired and smooth movement, and speech is clearly articulated.

Incorrect Answer Explanations

B. Ptosis  

Rationale: Ptosis, or drooping of an eyelid, is not an expected finding. It may be due to neuromuscular weakness from conditions such as myasthenia gravis or damage to cranial nerve III.

C. Anosmia

Rationale: Anosmia, or the inability to smell, is not an expected finding. Although the ability to smell decreases with age, the client should still be able to correctly identify a smell. Anosmia may be due to damage to cranial nerve I, the olfactory nerve.

E. Dysarthria

Rationale: Dysarthria, or unclear verbal articulation, is not an expected finding. This can occur with impaired tongue movement associated with damage to cranial nerve XII, the hypoglossal nerve.

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