Cranial Nerve How Elicited Normal Response Actual Response

Ask the client to close eyes, Patient must be able

occlude one nostril, and to identify the
identify a scented object scented object, with
CN I: Olfactory that you are holding such eyes closed, the
as soap, coffee, or orange. student nurse is
Repeat procedure for the holding with each
other nostril. nostril occluded one
at a time.

Ask client to read a Patient must be able

newspaper or magazine to read the words in
CN II: Optic paragraph to assess near the newspaper or
vision. magazine at a
distance of 2 feet.

Perform corneal light reflex Patient must be able

test. Hold a penlight
approximately 12 inches
CN III: Oculomotor from the client's face. Shine
the light towards the bridge
CN IV: Trochlear of the nose while the client
stares straight ahead. Note
CN VI: Abducens
the light reflected on the
corneas.
to move eyes with
coordination; Eyes
must constrict as the
light moves closer
and dilates as the
light moves farther.

To test direct pupil reaction,

shine a light obliquely into
one eye and observe the
pupillary reaction.

Test accommodation of
pupils. Hold your finger or a
pencil about 12 to 15 inches
from the client. Ask the
client to focus on your
finger or pencil and to
remain focus on it as you
move it closer in toward the
eyes.

Test sensory function. Tell Patient must be able

the client: "I am going to
touch your forehead,
CN V: Trigeminal cheeks, and chin with the
sharp or dull sensation. Also
tell me where you feel it."
Vary the sharp and dull
stimulus in facial areas and
compare sides. Repeat test
for light touch with a wisp
of cotton.
to feel the stimulus of
the cotton wisp as it
touches his face; feel
the difference and
sensation of sharp
and dull

Test corneal reflex. Ask the

client to look away and up
while you lightly touch the
cornea with a fine wisp of
 cotton. Repeat on the other
side.

Ask client to smile, frown Patient must be able

and wrinkle forehead, show
teeth, puff out cheeks,
CN VII: Facial purse lips, raise eyebrows,
close eyes tightly against
resistance
to smile, frown and
wrinkle forehead,
show teeth, puff out
cheeks, purse lips,
raise eyebrows, and
close eyes tightly
against resistance.

Rinne Test: Strike a tuning Air conduction should

fork and place the base of
the fork on the client's
mastoid process. Ask the
CN VIII: client to tell you when the
sound is no longer heard.
Vestibulocochlear
Move the prongs of the
tuning fork to the front of
the external auditory canal.
Ask the client to tell you if
the sound is audible after
the fork is moved.
be longer than bone
conduction (positive
Rinne).
Patient must hear the
two-syllable word
spoken at a distance
of 2 feet on both
ears.

Whisper a two-syllable word

at a distance of 2 feet unto
the client's ears and let her
repeat the whispered word.

Test gag reflex by touching Gag reflex must be

the posterior pharynx by present.
the tongue depressor. Warn
CN X: Vagus the client that you are going
to do this and that the test
may feel a little
uncomfortable

Ask client to shrug Patient must be able

shoulders against to shrug shoulders
resistance. and turn head to the
CN XI: Accessory right and left against
Ask the client to turn the resistance.
head against resistance first
to the right then to the left.

Ask client to protrude Patient must be able

tongue, move it to each to protrude tongue,
CN XII: Hypoglossal side against the resistance move it to each side
of a tongue against the resistance
of the tongue