Cranial Nerves: Assessment and Function

• Client Assessment Exam 2 covers multiple-choice questions from Chapters 10, 11, 15, and 16.
• It takes place on March 11, 2025, at 8:30 a.m.

Cranial Nerves (CN)

CN I: Olfactory Nerve

• Type: Sensory
• Function: Smell reception and interpretation
• Assessment: Have the patient close their eyes, block one nostril, and identify a familiar smell like coffee or soap.

CN II: Optic Nerve

• Type: Sensory
• Function: Visual acuity and visual fields
• Assessment for visual acuity: Have the patient cover one eye, stand 20 feet away, and read a Snellen chart.
• Assessment for visual fields: Have the patient cover one eye, cover your opposite eye, and ask them to look straight ahead while you wiggle your fingers, asking when they see them.
• Assess pupillary responses by shining a light into the pupils and observing for constriction.

CN III: Oculomotor Nerve

• Type: Motor
• Function:
• Motor: Raises eyelids and performs most extraocular movements.
• Parasympathetic: Pupillary constriction and lens shape changes
• Assessment: Have the patient keep their head still and follow a moving target, then look for involuntary eye movements (nystagmus).

CN IV: Trochlear Nerve

• Type: Motor
• Function: Downward, inward eye movement
• Assessment: Have the patient hold their head still while following a pen in an H pattern to check smooth eye movements.

CN V: Trigeminal Nerve

• Type: Both (motor and sensory)
• Function:
• Motor: Involves opening and clenching the jaw, chewing, and mastication
• Sensory: Relates to sensations in external eye structures, eyelids, forehead, nose, nasal/mouth mucosa, teeth, tongue, ear, and facial skin
• Sensory assessment: Have the patient close their eyes and lightly touch their face to identify where they feel the touch.
• Motor assessment: Instruct the patient to open their mouth against resistance or clench their teeth to observe facial muscle strength.

CN VI: Abducens Nerve

• Type: Motor
• Function: Lateral eye movement
• Assessment:
• Examine the patient for droopiness, asymmetry, twitches, or flutters in the eyes or eyelids.
• Ask the patient to follow an object from side to side, looking for symmetrical and smooth eye movements.

CN VII: Facial Nerve

• Type: Both (motor and sensory)
• Function:
• Motor: Movement of facial expressions excluding jaw, closing eyes, and labial speech sounds (b, m, w, and rounded sounds)
• Sensory: Taste on the anterior 2/3 of the tongue, sensation on the pharynx
• Motor assessment: Instruct the patient to puff out their cheeks, smile, raise eyebrows, close eyes tightly, or show their teeth, checking for asymmetrical facial movements.
• Sensory assessment: Apply distinct tastes to the anterior 2/3 of the tongue and ask the patient to identify.

CN VIII: Acoustic Nerve (Vestibulocochlear)

• Type: Sensory
• Function: Hearing and equilibrium
• Hearing assessment: Use the whisper test by standing behind the patient, occluding one ear, and whispering, then asking the patient to repeat.
• The patient should repeat 50% of what was whispered.
• Weber test: Activate a tuning fork and place it midline on the head, asking the patient which ear hears the sound louder. The patient should hear the sound equally in both ears.
• Rinne test: Compares air conduction to bone conduction using a tuning fork on the mastoid process, then near the ear. A 2:1 ratio is normal.
• Equilibrium assessment includes the Nystagmus and Postural assessment: Have the patient close their eyes and stand to assess balance.

CN IX: Glossopharyngeal

• Type: Both (motor and sensory)
• Function:
• Motor: Voluntary muscles for swallowing and phonation
• Sensory: Sensation to the nasopharynx, gag reflex, and taste on the posterior 1/3 of the tongue
• Assessment: Use a tongue depressor gently to trigger the gag reflex.

CN X: Vagus

• Type: Both (motor and sensory)
• Function:
• Motor: Voluntary muscles for swallowing and phonation
• Sensory: Sensation behind the ear and part of the external ear canal
• Assessment: Evaluate the palate and uvula movement when the patient says "ah”. Check the gag reflex and observe for swallowing difficulties.

CN XI: Spinal Accessory

• Type: Motor
• Function: Turning the head, shrugging shoulders, and some phonation actions
• Assessment: Ask the patient to rotate their head and shrug their shoulders, both normally and against resistance.

CN XII: Hypoglossal Nerve

• Type: Motor
• Function: Tongue movement for speech articulation and swallowing
• Assessment: Ask the patient to stick out their tongue and press it against the side of their cheek.

Head and Neck Assessment

• The nurse assessing the head and neck is Darina

Thyroid Gland Assessment

• Palpate for size, consistency, tenderness, and nodules when patients report an enlarged mass or have hyper/hypothyroidism symptoms.
• Procedure: Use a gentle touch. Have the patient flex their neck slightly to relax the sternocleidomastoid.
• Can be palpated using posterior or anterior approach.
• Posterior approach: Stand behind, use fingers to push the trachea, and have the patient swallow.
• Anterior approach: Stand in front, push trachea, and palpate below the cricoid process while the patient swallows.
• Normal findings: Often not detected, but if felt, it should be small, smooth, soft, freely moving, and non-tender.
• Abnormal Findings: An easily palpable thyroid, especially before swallowing, suggests enlargement. Auscultate for vascular sounds (bruit), which may indicate a goiter. Lumps, nodules, or tenderness are abnormal too.

Lymph Nodes Assessment

• Palpate for size, consistency, mobility, and tenderness during inflammatory processes, suspected malignancy, or in patients reporting pain.
• Palpation procedure: Use the pads of the second, third, and fourth fingers and compare both sides, starting with preauricular nodes. Then, proceed to the parotid, postauricular, occipital, retropharyngeal, submandibular, and submental nodes. Examine cervical chains and supraclavicular nodes.
• Normal findings: Lymph nodes may or may not be palpable but should be soft, mobile, non-tender, and bilaterally equal if they are.
• Abnormal findings: Enlarged, tender, firm, freely movable nodes may indicate infection. Hard, asymmetric, fixed, and non-tender nodules may suggest malignancy.

Carotid Arteries Assessment

• Located deep and parallel to the sternocleidomastoid muscle's anterior aspect.
• Palpate carotid pulses for amplitude along the medial edge of the sternocleidomastoid in the lower third of the neck, one at a time.
• Auscultate for bruits, especially with a history of atherosclerosis, dizziness or syncope. Use the bell of the stethoscope while the patient holds their breath.
• Normal findings: Pulse should have a regular rhythm with a smooth contour and 2+ amplitude, with no sounds heard during auscultation.

Abnormal Findings for Carotid Arteries

• Irregular rhythm and weak or bounding upstroke
• Bruits suggest occlusion of the carotid arteries and increase risk for transient ischemic attack (TIA).

Headaches

• Headache classifications include migraine and tension types.

Tension Headache Characteristics

• Most common in adults (20-40 years)
• Described as bilateral, diffuse, tight band
• Gradual onset, lasts several days
• Possible skeletal muscle contraction in face, jaw, neck

Migraine Headache Characteristics

• Second most common headache syndrome
• Occurs in childhood, adolescence, or early adult life
• More prevalent in women
• Throbbing, unilateral pain caused by vasospasm of intracranial arteries
• Symptoms: depression, restlessness, photophobia, nausea, vomiting
• Can last up to 72 hours

Cluster Headache Characteristics

• Most painful primary headache, common from adolescence to middle age
• Intense episodes of unilateral pain
• Lasts 30 minutes to 1 hour daily for weeks with remission periods

Cluster Headache Symptoms

• Burning, boring, stabbing pain behind one eye
• Unilateral ptosis, ipsilateral lacrimation, nasal drainage
• Occurs without warning, sometimes vague premonitory nausea

Posttraumatic Headache Characteristics

• Occurs after head injury or concussion
• Symptoms: dull, generalized head pain, lack of concentration, giddiness, dizziness

Eyes Assessment (Frank)

• Assessed using PERRLA

PERRLA

• Pupils are Equal, Round, React to Light, and Accommodation
• Pupils constrict with near focus and dilate with distant focus

Pupil Abnormalities

• Abnormal pupil diameter of less than 2 mm or greater than 6 mm
• Failure to constrict to light or abnormal pupillary response rate indicates oculomotor nerve dysfunction

Eye Conditions

• Strabismus is the improper eye alignment
• Nystagmus is the involuntary eye movement viewed when assessing gaze tests.
• Chalazion is the nodule of the meibomian gland in the eyelid.
• Hordeolum (stye) is the acute inflammation of the eyelash follicle or gland.

Ears Assessment (Frank)

• Top of the pinna aligns with the outer canthus, angled no more than 10 degrees vertically
• Low-set or misaligned ears are considered abnormal and are found in congenital disorders

Balance and Equilibrium Testing

• Romberg test: Assessing vestibular system by having the client stand with their eyes closed to observe for swaying

Romberg Test

• Balance assessment with feet together, arms at sides, eyes open, then closed
• The body should remain balanced with only mild swaying for 30 seconds
• Excessive swaying, moving feet, or falling indicates a problem with proprioception

Weber Test

• Tuning fork is placed midline on the head
• Normal hearing: sound is heard equally in both ears
• Abnormal hearing: sound lateralizes to one side, suggesting conductive or sensorineural hearing loss

Rinne Test

• Air conduction (AC) to bone conduction (BC) comparison using a tuning fork on the mastoid process
• Normal hearing; tone in front of ear should last twice as long
• Abnormal hearing; sound is heard longer by bone conduction suggests conductive loss

Whisper Test

• Used to assess hearing
• The patient should be able to hear and repeat at least 50% of all whispered words.

Examination of the Structure of the Tympanic Membrane

• Each tympanic membrane must be inspected for landmarks, color, contour, translucence, and fluctuations.
• Normal findings: pearly gray, translucent with specified landmarks, and the structure fluctuates slightly.
• Abnormal findings: distortion of landmarks or a hole is considered abnormal.

Appearance of the Tympanic Membrane

• Yellow/amber means there is serous fluid
• Redness means there is an infection
• Chalky white means there is an infection
• Deep red/ blue can mean that there is blood
• Red streaks show increased vascularization
• Dullness show scarring
• White flecks can show healed inflammation

Sinuses Assessment

• Done by Transillumination

Transillumination

• Done when a patient is complaining of sinus pain or congestion
• The health professional transilluminates frontal and maxillary sinuses using a bright penlight.
• Frontal sinuses: observe the medial aspect of the supraorbital rim
• Maxillary sinuses: observe lateral to nose beneath the medial aspect of the eye
• The absence of illumination may indicate sinus congestion.

Mouth Assessment

• Assess lips for color, symmetry, moisture, and texture

Normal Lip Findings

• Should be pink, symmetrical to vertical & horizontally, smooth, moist, and have vertical linear markings.
• Should have a distinct vermillion border

Abnormal Lip Findings

• Pale lips: anemia/shock
• Blue/cyanotic: hypoxemia/hypothermia
• Dry/flaking/cracked: dehydration, exposure to dry wind or wind
• Cracks/erythema: Vitamin B deficiency
• Lesions, plaques, vesicles, nodules, and ulcerations: infection, irritation, or cancer

Teeth and Gum Assessment

• Observe the patient's teeth and gums
• Normal Findings: whiye yellow or gray teeth and pink gums
• Abnormal Findings: missing teeth, darkened teeth

Teeth and Gum Pathologies

• caries: Brown spots in crevices
• aging or gingival disease: Excessively exposed tooth neck
• gingivitis: Redness, edema & bleeding
• misalignment of teeth: Malocclusion

Tongue Assessment

• Should appear symmetric, pink, and moist with a glistening surface

Deviation from Normal Tongue Appearance

• vitamin B deficiency: Smooth or Beefy red tongue with a slick appearance
• geographic tongue: Irregular patches with a map-like appearance
• secondary causes such as antibiotic therapy: Hairy tongue with elongated papillae.

Buccal Mucosa Inspection

• Inspect anterior and posterior pillars of the mouth
• Normal findings: pale coral/pink with slight vascularity. Molar mucosa should be smooth.

Pathologies in the Buccal Mucosa

• White round or oval lesions: Aphthous ulcers
• White patch cannot be scraped off: Leukoplakia
• Red patch: Erythroplakia

Assessment for the Uvula, Posterior Pharynx & Tonsils

• Patient tilts head back for better inspection of palate and uvula
• The tonsils should appear slightly pink
• Use a scale to grade the enlargement of the tonsil from a scale of 1+ to 4+

Lungs and Respiratory System

• Inspection and patient should be relaxed
• The patient should have correct posture
• The patient should be breathing quietly, effortlessly, and at an appropriate rate for their age.

Evaluation of the Signs of Respiratory Distress

• Signs: elevated amounts of apprehension, elevated amounts of restlessness, nasal flaring, etc.
• The patient may experience pursed-lip breathing
• Note if the patients is in the tripod position

Evaluation of the Patient's Nails

• White patients: beds should be pink
• Darker pigmented patients: beds should be yellow or brown
• Patients should not have cyanosis
• Patients should not have clubbing

Breathing Rate

• Normal breathing rate: 12-20 (Eupnea)

Evaluation of Abnormal Breathing Patterns

• Abnormal Patterns: bradypnea, tachypnea, hyperventilation, air trapping, Cheyne-stokes, Kussmaul, biot, and ataxic.
• Differentiating from dyspnea and tachypnea
• Evaluation of chest retractions

Breathing Descriptions

• Regular and comfortable: 12-20 per min
• Bradypnea: Slower than 12 breaths per min
• Tachypnea: Faster than 20 breaths per min
• Hyperventilation: Deeper and faster than 20 breaths per min
• Sighing: Deeper breaths that happen frequently
• Air trapping: Trouble getting the air out
• Cheyne-Stokes: Increaing depth
• Kussmaul: Deep and Rapid
• Biot: Irregular
• Ataxic: Disorganized

Abnormal Breath Sounds Characteristics

• Stridor; often caused by laryngeal or tracheal obstruction
• Diminished breath sounds; patients with emphysema
• Diminished or absent sounds; from pts with with collapsed alveoli

Examination for Posterior Thoracic Expansion

• Patient should be observed for if they have asymmetry

Examination for Crepitus

• The chest has a crackly sensation

Examination for Vocal Fremitus

• Men have lower voices
• Instructor should tell the patient to recite “one-two-three'

Examination For Pneumonia

• Location of sounds: Lung
• Causes: infection
• Mild to severe symptoms
• Changes in vital signs

Breast and Axillae Assessment

• Most common site for breast cancer is the upper outer quadrant
• Orange: Like Texture

Peau d'orange

• Cause: Edema near mass
• Orange: Like Texture
• Lesion can be fixed

Evaluation for Paget's Disease

• May indicated increased amounts of red scaly areas
• Evaluate nipple discharge

Risk Factors for Breast Cancer

• Gender: 99% are female
• Age: Increases with age
• Race: White women hold greater risk
• Genetic: mutations of BRCA1/BRCA2
• Family History: Evaluate if one's sister or mother has/had it

Risk Factors

• Medical history can result increase the evaluation
• Breast cancer in men: patients will experience hardness around the pimple