During an assessment of the cranial nerves, the nurse asks the client to "Stick out your tongue.". When the client complies, the nurse observes that the tongue deviates markedly to the right side
The nurse documents that the client is exhibiting: 1. An abnormal hypoglossal nerve response.
2. Findings consistent with first cranial nerve damage.
3. A sluggish oculomotor response.
4. Pronounced absence of the Homans' sign.
An abnormal hypoglossal nerve response
Rationale: Cranial nerve XII (hypoglossal) is tested by having the client stick the tongue out. An abnormal finding is that the tongue deviates to either side. Cranial nerve I is the olfactory nerve, and is assessed by having the client smell; cranial nerve III is the oculomotor nerve and, along with the trochlear and abducens nerves, helps the eye move. Homans' sign is a check for thrombophlebitis in the calves of the legs.
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