Cranial Nerves
When eyes move in a smooth coordinated motion in all directions (the six cardinal fields).
What is the normal findings when testing Cranial Nerves III, IV, and VI. (oculomotor, trochlear, abducens)
Standing erect with minimal swaying when eyes are closed.
What is the normal response for Romberg test.
What is assessing for vibratory sensation.
Knee extension, quadriceps muscle contraction.
What is the normal finding for patellar reflex.
Flexing the neck and watching the hips and knees for pain and flexion.
What is Brudzinski sign
Correctly identifying a scent presented to each nostril.
What is the normal finding for Cranial Nerve I (Olfactory)
Client touches finger to nose with smooth, accurate, movements without hesitation.
What is the normal finding when assessing coordination.
Using a cotton wisp or a sharp object to touch the client.
What is assessing for light touch and pain sensation.
Plantar flexion of the foot.
What is the normal finding for achillies reflex.
When assessing reflexes the "normal, usual response"
What is 2+ reflexes
The movements are symmetric when smiles, frowns, puffs out cheeks, closes eyes.
What is the normal findings when testing Cranial Nerve VIII. (facial)
Having the client rapidly turn palms up and down, or touching the finger to thumb rapidly.
What is assessing for rapid alternating movements (RAM).
Moving the clients finger up or down with their eyes closed and asking them to recognize the direction of the movement.
What is assessing for sensitivity to position.
Reflex finding that is markedly hyperactive and may be seen with lesions of the upper motor neurons.
What is 4+ reflex
Face, Arms, Speech, Time
What is the FAST assessment for Stroke
The gag reflex is intact.
What is the normal finding when testing Cranial Nerve IX and X. (glossopharyngeal and vagus)
No fasciculations, tics, or tremors are noted.
Normal findings when assessing for unusual involuntary movements.
When the nurse draws a number or letter in the clients hand.
What is assessing for graphesthesia.
Rapid contractions or oscillations of the ankle and calf.
What is ankle clonus
Flexing the clients leg at both the hip and the knee, then straightening the knee and assessing for pain.
What is Kernig sign
When the client hears a whisper, vibration heard equally during Weber test, and AC is greater than BC during Rinne test.
What is the normal finding for Cranial Nerve VIII. (acoustic, vestibulocochlear)
Steady, even, arms swing in opposition.
What is the normal finding when assessing gait.
When the client correctly identifies an object in their hand with their eyes closed.
What is the normal finding when assessing for tactile discrimination.
Flexion of the toes.
What is the normal finding for plantar reflex.
Alcohol, lack of physical activity, obesity, stress, high cholesterol levels, unhealthy diet.
What are modifiable risk factors for stroke.