{"id":4773,"date":"2024-10-30T00:46:51","date_gmt":"2024-10-30T00:46:51","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=4773"},"modified":"2026-03-20T13:50:47","modified_gmt":"2026-03-20T21:50:47","slug":"nclex-question-of-the-day-cranial-nerve-assessment","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/nclex-question-of-the-day-cranial-nerve-assessment","title":{"rendered":"NCLEX-RN\u00ae Question of the Day: Cranial nerve assessment"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/nclex-question-of-the-day-cranial-nerve-assessment\/#The_correct_answer_to_todays_NCLEX-RN%C2%AE_Question_is%E2%80%A6\" >The correct answer to today\u2019s NCLEX-RN\u00ae Question is\u2026<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/nclex-question-of-the-day-cranial-nerve-assessment\/#Ready_to_put_your_nursing_knowledge_to_the_test\" >Ready to put your nursing knowledge to the test?<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/nclex-question-of-the-day-cranial-nerve-assessment\/#Major_Takeaway\" >Major Takeaway<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/nclex-question-of-the-day-cranial-nerve-assessment\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/nclex-question-of-the-day-cranial-nerve-assessment\/#Want_to_learn_more_about_this_topic\" >Want to learn more about this topic?<\/a><\/li><\/ul><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><em><strong>Prepare for the NCLEX\u00ae with a question of the day on cranial nerve assessment for a patient who&#8217;s recently lost consciousness. Test your knowledge and review key concepts.<\/strong><\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The nurse in the <strong>emergency department <\/strong>is conducting a <strong>cranial nerve assessment<\/strong> on a patient who briefly <strong>lost consciousness<\/strong> after hitting their head.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Which <strong>normal clinical finding(s)<\/strong> should the nurse anticipate?&nbsp;<strong><em>Select all that apply.<\/em>&nbsp;&nbsp;&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Consensual response<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Ptosis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Anosmia<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Gag reflex present<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Dysarthria<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down for the correct answers!<\/em><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_NCLEX-RN%C2%AE_Question_is%E2%80%A6\"><\/span>The correct answer to today\u2019s NCLEX-RN\u00ae Question is\u2026<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Consensual response<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">When shining a <strong>penlight <\/strong>into one eye, the nurse should expect to observe a <strong>consensual response,<\/strong> meaning the opposite pupil will also constrict along with the illuminated pupil. This indicates correct <strong>motor functioning<\/strong> of <strong>cranial nerve III<\/strong>, the <strong>oculomotor nerve.<\/strong> &nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Gag reflex present<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A client\u2019s <strong>gag reflex<\/strong> should be elicited when the nurse uses a swab to touch the back of a client\u2019s throat. This expected finding indicates correct <strong>motor functioning of cranial nerve IX<\/strong>, <strong>the glossopharyngeal nerve, and cranial nerve X, the vagus nerve.<\/strong>&nbsp;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Ready_to_put_your_nursing_knowledge_to_the_test\"><\/span><em>Ready to put your nursing knowledge to the test?<\/em> <span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Explore the <strong><a href=\"https:\/\/www.osmosis.org\/blog\/nclex-question-of-the-day-smarter-prep-better-results\" target=\"_blank\" rel=\"noreferrer noopener\">NCLEX\u00ae Question of the Day: Smarter Prep, Better Results<\/a><\/strong> page to practice with NCLEX-style questions and boost your confidence before exam day.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">The nurse should perform a <strong>cranial nerve assessment<\/strong> to detect <strong>normal and abnormal findings<\/strong> on a client who has experienced a <strong>head injury<\/strong>. Assessment of the <strong>twelve pairs of cranial nerves<\/strong> helps determine whether they are performing correctly in both <strong>sensory and motor functions<\/strong>. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\">As noted above, when shining a <strong>penlight <\/strong>into one eye, the nurse should expect to observe a <strong>consensual response,<\/strong> meaning the opposite pupil will also constrict along with the illuminated pupil. This indicates correct <strong>motor functioning<\/strong> of <strong>cranial nerve III, <\/strong>the <strong>oculomotor nerve. <\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Further, a client\u2019s <strong>gag reflex<\/strong> should be elicited when the nurse uses a swab to touch the back of a client\u2019s throat. This expected finding indicates <strong>correct motor functioning<\/strong> <strong>of cranial nerve IX, the glossopharyngeal nerve, and cranial nerve X, the vagus nerve.<\/strong> <strong>Ptosis, dysarthria, and anosmia are not anticipated findings.&nbsp;<\/strong><\/p>\n\n\n\n<figure class=\"wp-block-image\"><img decoding=\"async\" src=\"https:\/\/osmose-it.s3.amazonaws.com\/HY3ymDMXQMqg5o31aeG2Z1BkSC_90G0Y\/_.png\" alt=\"CRANIAL NERVE \/ NORMAL ASSESSMENT FINDINGS\n\nI Olfactory \/ Correct identification of smell is present through each nare.\nII Optic Nerve \/ 20\/20 vision is present, meaning the client can read at 20 feet what the average client can read at 20 feet.\nIII 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.\nIV Trochlear \/ Smooth extraocular movements are present, meaning smooth, symmetrical movements of the eyes while following a moving object.\nV 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.\nVI Abducens \/ Smooth extraocular movements are present and muscle tone over the face is symmetrical and without fasciculation.\nVII Facial \/ Facial expressions are able to be conducted and speech sounds clearly articulated, such as &quot;b&quot;, &quot;m&quot;, or &quot;p.&quot; Sweet and salty tastes on the anterior third of the tongue are able to be identified.\nVIII 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.\nIX 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.\nX Vagus \/ Gag reflex is present with no difficulty swallowing an the uvula rises in the midlilne when saying &quot;ah.&quot;\nXI Accessory \/ Strength in neck and shoulder muscles are equal bilaterally while shrugging and turning head from side to side.\nXII Hypoglossal \/ Tongue is midline with unimpaired and smooth movement, and speech is clearly articulated.\"\/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Ptosis &nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Rationale:<\/strong>&nbsp;Ptosis, or <strong>drooping of an eyelid<\/strong>, is <strong>not an expected finding<\/strong>. It may be due to <strong>neuromuscular weakness<\/strong> from conditions such as <strong>myasthenia gravis<\/strong> or damage to <strong>cranial nerve III<\/strong>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Anosmia<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Rationale:&nbsp;<\/strong>Anosmia, or the <strong>inability to smell, <\/strong>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 <strong>cranial nerve I, the olfactory nerve.<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Dysarthria<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Rationale:<\/strong>&nbsp;Dysarthria, or <strong>unclear verbal articulation<\/strong>, is not an expected finding. This can occur with impaired tongue movement associated with damage to <strong>cranial nerve XII, the hypoglossal nerve.<\/strong><\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Want_to_learn_more_about_this_topic\"><\/span>Want to learn more about this topic?<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Watch the Osmosis video:<\/strong> <strong><a href=\"https:\/\/www.osmosis.org\/learn\/Physical_assessment_-_Cranial_nerves:_Nursing\">Physical assessment &#8211; Cranial nerves: Nursing<\/a><\/strong><\/p>\n\n\n\n<figure class=\"wp-block-image\"><a href=\"https:\/\/osmosis.org\/create\" target=\"_blank\" rel=\"noreferrer noopener\"><img decoding=\"async\" src=\"https:\/\/osmose-it.s3.amazonaws.com\/4-yMeaWiQESt45-pPEJqkdZ0RFCUAA03\/_.png\" alt=\"\"\/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Want more NCLEX\u00ae-style practice questions? Try Osmosis by Elsevier today! Access your free trial and discover why millions of current and future clinicians and caregivers love learning with us.<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Practice identifying expected cranial nerve findings during assessment of a patient with recent head trauma, focusing on key neurological functions.<\/p>\n","protected":false},"author":279,"featured_media":4774,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[29,1367,1366,32],"tags":[1729,1726,1087,369,1728,1730,995,1727,154,279],"class_list":["post-4773","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-nclex","category-nclex-rn","category-questions","category-nursing","tag-consensual-response","tag-cranial-nerve-assessment","tag-cranial-nerves","tag-emergency-nursing","tag-gag-reflex","tag-head-injury","tag-nclex-prep","tag-neurological-exam","tag-nursing-skills","tag-patient-assessment"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - 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