For USA based nursing class. No references needed but answers should be correct. Answer needs to be returned in Word Doc
N.T. is a 79-year-old woman who had a stroke 5 days ago. N.T. was just transferred to the inpatient rehabilitation unit and the nurse has just finished her initial assessment of N.T.
Mental Status – Appears alert with appropriate eye contact and is listening intently. Dressed appropriately and is sitting in a wheelchair. Speech is slow, requires a lot of effort, can give one or two word answers only. Appears to understand all words spoken to her and follows requests within limits of motor weakness.
Cranial nerves – Normal visual acuity with loss of left field of vision. Able to track movement with just eyes, left pupil is slightly dilated, and eyes accommodate. Weak jaw strength on left side. Able to wrinkle forehead bilaterally but unable to smile, show teeth, or puff out cheek on left side. Hearing intact. Difficulty swallowing. Shoulder shrug and head movement weak on left side. Tongue protrudes midline.
Sensory – Unable to distinguish between sharp and dull on left side of face, arm or leg.
Motor – Left hand grip is weak, left arm drifts, left leg is weak, unable to support weight. Spasticity in left arm and leg muscles. Limited range of motion on passive motion. Unable to stand up and walk unassisted.
Identify four cranial nerves that you would assess on N.T. and how would you perform the test. Based on the information above what would you document for N.T. assessment results for these six cranial nerves? (Note: You can only use one of the eye cranial nerves in your answer ).