Cranial Nerve V

(Trigeminal)

Test motor function

Ask client to clench teeth

together
while
palpating
temporal and masseter muscles
for contraction
Normal finding
Temporal and Masseter muscle
contract bilaterally
Abnormal finding
Decrease in contraction on one
side
Asymmetric
strength
when
moving the jaw
May be caused by lesion or
injury of 5th cranial nerve
Pain occurs with clenching

Test Sensory function

1. Tell client you are going to
touch the forehead, cheeks,
and chin with dull and sharp
end of a paperclip
2. Ask patient to tell you when
he or she feels it
Normal Finding:
.
Correctly identify sharp &
dull touch
Abnormal finding:
.
Inability to feel sharp/dull
.
May be caused by lesions in
Trigeminal nerve or
spinothalamic tract or
posterior columns
3. Repeat sensation with light
touch with cotton swab
Normal Finding:
.
Eyelids blink bilaterally
Abnormal finding:
.
absent reflex which may be
caused by lesions of
Trigeminal nerve

Cranial Nerve VII

Test(Facial)
motor function
Ask client to smile/show teeth,
frown and wrinkle forehead,
purse lips, raise eyebrows, and
close eyes tightly.
Normal Finding:
Symmetrical movements
Abnormal Finding:
Inability to make movements
Bells Palsy: Inability to close
eye, raise eyebrows, wrinkle
forehead with paralysis of the
lower part of the face on one
side of the face
Paralysis of lower part of the
opposite face may be seen
with a central lesion caused by
stroke.

Cranial Nerve VII (Facial)

Sensory function
1. Not routinely tested
2. Use a taste test by placing
a moistened applicator with
sugar, lemon, or salt on the
anterior of the tongue and
have the patient to identify
taste
Normal finding:
Client identifies the correct
taste
Elderly may have altered
taste ability
Abnormal Finding:
Inability to identify taste

Cranial Nerve VIII

(Acoustic/Vestibulocochl
ear) in both
Test clients hearing
ears
Perform Whisper test
Stand 1-2 ft behind client
and whisper a 2 syllable
word and have them repeat
it
Perform Weber test:
Strike tuning fork and place
on top of the head
Normal:
client should hear equal
vibrations in both ears
equally

Rinne Test:
Strike tuning fork and place
on the mastoid process

Cranial Nerves
V, VII & VIII

have client tell you when they

no longer hear it then move
the fork to by the ear
Make sure you time it
AC time should be twice as
long as BC
Abnormal finding:
Sensorineural loss
Vibratory sound lateralize to
good ear
AC will not be twice as long
with this kind of hearing loss

Mini-Presentation

Emily
Demay
Sources: Shawn
Weber, J., Murali
& Kelley, J. (n.d.).

Assessing Neurologic
System. In Health
Assessment in Nursing (Fifth
ed., pp. 559-561). Lippincott
Williams and Wilkins.
Neter, F. 2015. Web. 1 Nov.
2015.
Rhea, Ann. 2015. Web. 1 Nov.
2015.
Rhea, Ann. 2015. Web. 1 Nov.
2015.