Mental Status & LOC
This portion of the mental status exam includes posture, dress, grooming, and hygiene.
What is Appearance?
This cranial nerve controls sense of smell.
What is CN I – Olfactory?
Touching each finger to the thumb rapidly tests this major neurologic function.
What is cerebellar function?
The Snellen chart should be read from this standardized distance.
What is 20 feet?
Pull the ear up and back when performing an otoscope exam on this age group.
What are adults?
A patient is lethargic but arouses to name, answers slowly, and drifts back to sleep. What LOC is this?
What is lethargic?
You test this cranial nerve by assessing visual acuity using the Snellen chart.
What is CN II – Optic?
A vibrating tuning fork placed on the great toe tests this sensory pathway.
What is the posterior column (vibration sense)?
Accommodation is assessed by having the patient do this with their focus.
What is shift gaze from far to near?
Hearing screening by whispered voice tests this cranial nerve.
What is CN VIII – Acoustic/Vestibulocochlear?
This part of ABCT assesses how logically a patient connects their ideas.
What is Thought process?
Tongue movement side-to-side assesses this cranial nerve.
What is CN XII – Hypoglossal?
A 3-month-old whose toes fan when the lateral foot is stroked is showing this reflex.
What is a normal Babinski reflex?
Strabismus screening is particularly important in this age group.
What are infants and children?
This finding is a classic risk factor for frequent childhood ear infections.
What is daycare attendance or secondhand smoke exposure?
Name the four components used to assess orientation.
What are person, place, time, and situation?
Which cranial nerves are tested together when assessing the gag reflex and swallowing?
What are CN IX & X – Glossopharyngeal and Vagus?
Deep tendon reflexes rated 4+ indicate this abnormal finding.
What is hyperactive reflexes with clonus?
A patient misreads the 20/40 line and misses two letters. How is this documented?
What is 20/40 −2?
Lateralization to the affected ear during the Weber test indicates this type of hearing loss.
What is conductive hearing loss?
A client suddenly appears without a coat on a 30° day, is unshaven, pacing, and speech is mumbled/nonsensical. Which ABCT area shows the biggest change?
What is Behavior?
A patient is unable to raise their shoulders against resistance and has difficulty turning their head side-to-side. Which cranial nerve is impaired?
What is CN XI – Spinal Accessory?
This test is performed when a patient cannot feel sharp vs. dull (analgesia).
What is heat and cold sensation (temperature)?
Arcus senilis and xanthelasma are normal age-related changes found in this population.
What are older adults?
The cone of light appears at 5 o’clock in the right ear. At which position does it appear in the left ear?
What is 7 o’clock?