how to assess optic nerve (CN2) - Using ophthalmoscope, examine ocular fundus to determine color,
size, and shape of optic disc
how to assess oculomotor nerve (CN3) - watch eye movement- upward, medial, downward, up and in
check pupils for size, regularity, equality, direct and consensual light reaction, and accommodation
how to assess trochlear nerve (CN4) - watch eye movement- down and in
check pupils for size, regularity, equality, direct and consensual light reaction, and accommodation
how to assess abducens nerve (CN6) - have client look side to side
check pupils for size, regularity, equality, direct and consensual light reaction, and accommodation
, how to assess facial nerve (CN7) - Motor: corneal reflex (with client looking forward, bring cotton in
from side and lightly touch cornea-not routinely tested); request to smile, frown, close eyes tightly, lift
eyebrows, show teeth
Sensory: test taste by covering cotton in solution (not routinely tested)
how to assess vestibulocochlear (acoustic) nerve (CN8) - ability to hear normal conversation and
whispered voice test; may also use tuning fork
how to assess accessory nerve (CN11) - ask client to rotate head against resistance, ask client to shrug
shoulders against resistance
balance test - observe as person walks 10-20 feet, turns, and returns to starting point; walk heel-to-toe
romberg test - -ask client to stand with feet at comfortable distance apart, arms at sides, and eyes
closed
-expected finding: client should be able to stand with minimal swaying for at least 5 seconds
+ swaying
- no swaying
Rapid Alternating Movements - Assess coordination by asking person to pat the knees with both hands,
lift up, turn hands over and pat knees with the backs of the hands. Then ask them to do it faster.
Normal Finding: Done with a equal turning and quick rhythmic pace
normal/abnormal findings for olfactory nerve - -normal: ID smell on each side of nose, dec smell with
age
-abnormal: asymmetry in sense of smell (anosmia)
normal/abnormal findings for optic nerve - -Normal: normal vision, declined vision if 65+
-Abnormal: defect or absent central vision, defect in peripheral vision, absent light reflex
normal/abnormal findings for oculomotor nerve - -Normal: equal width of palpebral fissures
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