The nurse is caring for a patient recovering from a percutaneous rhizotomy for trigeminal neuralgia. What techniques should the nurse use to assess this patient for adverse effects from the procedure?
Select all that apply.
1. clench the teeth
2. touch the cornea with a cotton wisp
3. stick out the tongue
4. place sugar on the front of the patient's tongue
5. move the eyes through the cardinal positions of vision
Correct Answer: 1, 2, 4, 5
Assess the motor portion of the trigeminal nerve by asking the patient to clench the teeth while the tightness of the contracted masseter and temporal muscles is palpated. Loss of motor function is indicated by loss of bulk and tightness of these muscles. Assess the corneal reflex by lightly touching the cornea with a wisp of cotton. If the reflex is intact, the patient will blink. Severing the ophthalmic division of the trigeminal nerve destroys the corneal reflex and leaves the cornea at risk for dryness and injury. Sticking out the tongue assesses the function of the hypoglossal nerve and not the trigeminal nerve. Test taste by placing bitter, salty, and sweet substances on the anterior portion of the tongue. The facial nerve also innervates the anterior two-thirds of the tongue. Assess the function of the oculomotor muscles by asking the patient to follow a finger through the cardinal positions of vision. The eyes should move together; alterations in movement indicate an abnormal response.
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