Page 386 - Saunders Comprehensive Review For NCLEX-RN

seizures, history of head injury or surgery, exposure
to environmental or occupational hazards (e.g.,
chemicals, alcohol, drugs)

2. Objective data: Assessment of cranial nerves,

level of consciousness, pupils, motor function,
cerebellar function, coordination, sensory function,
and reflexes
3. Note mental and emotional status, behavior and
appearance, language ability, and intellectual
functioning, including memory, knowledge, abstract
thinking, association, and judgment.
4. Vital signs: Check temperature, pulse, respirations,
and blood pressure; monitor for blood pressure or
pulse changes, which may indicate increased
intracranial pressure (see Chapter 50 for abnormal
respiratory patterns).

5. Cranial nerves (Table 12-5)

6. Level of consciousness
a. Assess the client’s behavior to
determine level of consciousness (e.g.,
alertness, confusion, delirium,
unconsciousness, stupor, coma);
assessment becomes increasingly
invasive as the client is less responsive.
Use the Glasgow Coma Scale as
appropriate (eye opening, motor
response, verbal response, graded on a
scale). See Chapter 58 for a description
of this scale.
b. Speak to client.
c. Assess appropriateness of behavior and
conversation.
d. Lightly touch the client (as culturally
appropriate).
7. Pupils
a. Assess size, equality, and reaction to
light (brisk, slow, or fixed) and note
any unusual eye movements (check
direct light and consensual light
reflex); refer to Chapter 58 for
abnormal pupillary findings.
b. This component of the neurological
examination may be performed during
assessment of the eye.
8. Motor function

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