Page 2039 - Saunders Comprehensive Review For NCLEX-RN

Corneal (Blink) Reflex

▪ Involuntary closure of the eyelids in response to stimulation of the cornea
▪ Loss of the blink reflex indicates a dysfunction of cranial nerve V.

Gag Reflex

▪ Contraction of pharyngeal muscle, elicited by touching the back of the throat
▪ Loss of the gag reflex indicates a dysfunction of cranial nerves IX and X.

Box 58-4

Assessment of Meningeal Irritation

General Findings

▪ Irritability

▪ Nuchal rigidity
▪ Severe, unrelenting headaches
▪ Generalized muscle aches and pains
▪ Nausea and vomiting
▪ Fever and chills
▪ Tachycardia
▪ Photophobia
▪ Nystagmus
▪ Abnormal pupil reaction and eye movement

Brudzinski’s Sign

▪ Involuntary flexion of the hip and knee when the neck is passively flexed;
indicates meningeal irritation

Kernig’s Sign

▪ Loss of the ability of a supine client to straighten the leg completely when it is
fully flexed at the knee and hip; indicates meningeal irritation

Motor Response

▪ Hemiparesis, hemiplegia, and decreased muscle tone
▪ Cranial nerve dysfunction, especially cranial nerves III, IV, VI, VII, and VIII

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