Cranial Nerves
When does the mental status begins?
During the health history
Which of the cranial nerves controls lateral eye movements?
Abducens
What is the function of the cerebellum?
Coordination of voluntary motor movement, balance, equilibrium and muscle tone.
The Cranial sensory nerve that is responsible for carrying visual impulses from the eye to the brain.
The Optic Nerve
What instrument is used when testing for reflexes?
Reflex hammer
Glasgow coma scale is used to to assess perceptual ability?
False
The client should sit in a comfortable position at your eye level when assessing for all cranial nerves.
True or False
True
What is done to test cerebellar activity?
Observe patients gait and balance, finger-to-nose test and heel to shin test.
State two equipment used when doing a sensory function assessment.
Cotton balls, tuning fork.
Additional:
Paper clip, Test tubes containing cold or hot water, objects to feel such as a coin or a key
What segmental levels are used when assessing deep tendon reflexes? Give 3.
C5,6- biceps
C6,7,8- triceps
C5,6- brachioradialis
L2,3,4- patellar
S1,2- ankle (achilles)
Alert, lethargic and stuporous are examples of?
Level of consciousness
When the nurse ask the client to clench the teeth while palpating the temporal and massager muscles what is being assessed?
CN V. Trigeminal
What system of the cerebellar activity is assessed with balance and coordination (eye,head, and body movements)?
Vestibular
How do you assess for pain sensation?
Use the blunt or sharp ends of a safety pin or paperclip to inflict pain on the dorsal area of the palm.
List 4 test for deep tendon reflexes.
Biceps reflex
Brachioradialis reflex
Triceps reflex
Patellar reflex
Achilles reflex
Ankle clonus reflex
What are the oriented 4 used to check for level of consciousness?
Place, time, date and person
Asking client to identify smell of soap bar with eyes closed you are testing for_________.
Cranial nerve I- Olfactory
How does a nurse check a patient's gait?
Ask patient to walk across the room, ask the patient to turn and then come back; walk on toes;walk on heels; walk heel to toe(TANDEM gait)..make sure you are with the patient in case they fall and ask patient to hop in place on each foot if appropriate.
Name the VIII (8th) Cranial Nerve, and state the function of that nerve.
Vestibulocochlear
Contains sensory fibers that is responsible for hearing and balance
There are 5 different grade responses for reflex testing.
Please list and explain all 5
0+ No response
1+ Diminishes, low normal
2+ Average, normal
3+ Brisk
4+ Very brisk