cranial nerves

Inability to identify odor

1 (olfactory)

Hoarse or nasal quality to voice Slurred speech

10 (vagus)

Inability to shrug shoulders

11 (spinal accessory)

Facial paralysis Facial asymmetry, droop of mouth Absent nasolabial fold Decreased ability to taste

7 (facial)

Inability to move the eyes in the visual field described Ptosis of affected eye Nonreactive or dilated pupil

3 (oculomotor)

Inability to look down and in

4 (trochlear)

Inability to look laterally, double vision

6 (abducens)

Tongue weakness

12 (hypoglossal)

Decreased visual acuity Decreased visual fields

2 (optic)

Absence of corneal reflex Diminished sensation to forehead, maxillary and mandibular region Weakness of muscles responsible for chewing

5 (trigeminal)

Decreased hearing in affected ear

8 (acoustic)

Dysphagia Absence of gag reflex

9 (glosssopharyngeal)

The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to refrain from eating or drinking for now. have their spouse bring in the client's glasses. wear any hearing aids while in the hospital. use the walker when walking

Significant findings of CN IX (glossopharyngeal) include difficulty swallowing (dysphagia) and impaired taste, and significant findings of CN X (vagus) include weak or absent gag reflex, difficulty swallowing, aspiration, hoarseness, and slurred speech (dysarthria). Based on these findings, the nurse should instruct the client to refrain from eating and drinking and should contact the health care provider. The other instructions are associated with abnormalities of CN II (optic) and CN VIII (acoustic).