Exam (elaborations)
NURS 5220: Advanced Health Assessment Test 2 Prep
NURS 5220: Advanced Health Assessment Test 2 Prep
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By: Victorious23 • 1 month ago
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NURS 5220: Advanced HealthAssessment Test 2 Prep
Cranial Nerve I (one) - -Olfactory
Sense of smell
Sensory
Test for odor identification (rule out nasal obstruction)
-Cranial Nerve II (two) - -Optic
Sensory and visual acuity
Test for visual acuity
Test visual fields
Perform ophthalmologic exam
-Cranial Nerve III (three) - -Oculomotor
Motor
Evaluated with IV and VI
Eye movement, pupil size, eyelid opening
Inspect eyelid for drooping
Inspect pupil size and equality
Test consensual response and accommodation
Test extra-ocular eye movement
So tested thru PERLA and six cardinal fields
Eyelid dooping/palsy is cranial nerve III
-Cranial Nerve IV (four) - -Trochlear
Motor
Evaluated with III and VI
Eye movement, pupil size, eyelid opening
Inspect eyelid for drooping
Inspect pupil size and equality
Test consensual response and accommodation
Test extra-ocular eye movement
So tested thru PERLA and six cardinal fields
-Cranial Nerve V (five) - -Trigeminal
Mixed (both sensory and motor)
Jaw strength, ask to clench teeth
Inspect face for atrophy or tremors
Palpate jaw for tone and strength
Test for pain and sensation
Test corneal reflex
-Cranial Nerve VI (six) - -Abducens
, Motor
Evaluated with III and IV
Eye movement, pupil size, eyelid opening
Inspect eyelid for drooping
Inspect pupil size and equality
Test consensual response and accommodation
Test extra-ocular eye movement
So tested thru PERLA and six cardinal fields
-Cranial Nerve VII (seven) - -Facial
Mixed (both sensory and motor)
Facial expressions and taste
Inspect facial symmetry
Test tongue for salt and sweet
Assess smile, frown, puff out cheeks
-Cranial Nerve VIII (eight) - -Acoustic
Sensory
Hearing and balance
Test hearing (whisper test)
Compare bone and air conduction
Test for sound lateralization
-Cranial Nerve IX (nine) - -Glossopharyngeal
Mixed (both sensory and motor)
Taste and swallowing
Test tongue for sour and bitter
Test gag reflex and swallowing
-Cranial Nerve X (ten) - -Vagus
Mixed (both sensory and motor)
Swallowing and speech
Inspect palate and uvula for symmetry
Inspect for swallow difficulty
Evaluate guttural speech sounds
-Cranial Nerve XI (eleven) - -Spinal accessory
Motor
Muscle strength
Test trapezius and sternocleidomastoid muscle strength
Shrug shoulders against resistance
-Cranial Nerve XII (twelve) - -Hypoglossal
Motor
Tongue strength
Inspect tongue for tremors, symmetry, atrophy
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