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.
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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