Laboratory work up included Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR). Results revealed CBC and CMP are WNL except aspartate aminotransferase (AST) and alanine transaminase (ALT) are elevated. CRP and ESR are also elevated. Imaging ordered which included computed tomography (CT) angiogram of the head and neck which revealed no aneurysms and a magnetic resonance imaging (MRI) of the brain (figure 1) which showed abnormal enhancement along the labyrinthine segment of the left facial nerve compatible with Bell’s palsy, and no enhancement demonstrated elsewhere. The patient was diagnosed with Bell’s Palsy and prednisone and valacyclovir were ordered. 

Your preceptor asked you the following questions:

1. Which cranial nerve is commonly linked to Bell’s palsy and how would you assess this cranial nerve?

2. Though definitive etiology is undetermined, based on patient’s history, what could have possibly triggered her current medical condition?

3. Why were prednisone and valacyclovir prescribed for this patient? 

Model Answer

Anatomy, Physiology and Assessment:

The anatomy and function of the seventh cranial nerve (CN VII) and its involvement with unilateral facial paralysis were first described by Sir Charles Bell (1774–1842). Briefly, the anatomy of the facial nerve is complex but contains numerous branches responsible for sympathetic, parasympathetic and sensory functions. Arising in the pons, the facial nerve begins as a large motor root and a small sensory root which then travel through the internal acoustic meatus near the inner ear and exit into the facial canal, fusing together to form the geniculate ganglion and lastly branching into its smaller branches (Bushnaq, Zafar & Silva, 2022). The facial nerve has both motor and sensory functions. The motor component is responsible for facial expression, lip movement and tone, speech articulation, and corneal reflex response. The sensory component innervates the anterior two-thirds of the tongue, which detects taste. Imagine drawing a "7" across the eyebrows with the base ending at the mouth. Abnormalities can be assessed when a noticeable droop in either the eyebrows, mouth, or both appear along the "7" when the patient is at rest. Asymmetry when the patient is asked to raise their eyebrows, smile, or open and close their eyes also is an abnormal finding. Place your finger on the patient's closed eye. They should exhibit resistance as they attempt to open the eye. The nasolabial folds should be symmetric and not flattened. Because CN V is the sensory component of the corneal reflex and CN VII is the motor response, both must function for an intact blink response (Morena and Hill, 2022).

Etiology

The etiology of the disease is hypothesized to be secondary to viral infection, particularly Herpes Simplex Virus (HSV), whereas other studies have suggested that herpes zoster virus (VZV) can also be a cause. Although the facial nerve is classically affected in Bell’s palsy, other cranial nerves can be involved, such as the involvement of the parasympathetic fibres of the oculomotor nerve (Bushnaq, Zafar & Silva, 2022). 

Pharmacology

The mainstay of treatment of Bell’s palsy is steroids, and antiviral therapy can also be considered (Bushnaq, Zafar & Silva, 2022). This premise was supported by Otaka, Harada, & Shimizu (2022) in their study stating that patients with bilateral facial paralysis under the suspicion of Bell’s palsy should be immediately started on steroid therapy.

The Intention of the Question: 

As an Emergency Department RN, we get various medical conditions and health acuity anytime in our shifts and some are serious and life-threatening conditions. It is warranted that as front liners and ED RNs, we are able to assess patient quickly and efficiently and provide immediate medical interventions as necessary and appropriate. The symptoms of Bell’s Palsy are similar to those of serious medical conditions like stroke and identifying and differentiating them at the early stages of our patient’s ED visit is crucial. I intentionally phrased the question as a scenario-base more like the same as when we get reports from AMR to get the whole picture of the case presentation as much as possible. Though lengthy, I believe that this kind of questioning format is thought-provoking and triggers critical thinking and active learning on the nature of the presented medical condition and its related principles.

References

Bushnaq, S., Zafar, A., & Silva, F. (2022). Unusual presentation of idiopathic Bell's palsy with involvement of the oculomotor nerve. BMJ case reports, 15(9), e248756. https://doi.org/10.1136/bcr-2022-248756 

Moreda, M., & Hill, M. (2022). Cranial nerve assessment: A practical approach. American Nurse Journal, 17(3), 14–18.

Otaka, Y., Harada, Y., & Shimizu, T. (2022). Case of bilateral Bell's palsy. BMJ case reports, 15(6), e250364. https://doi.org/10.1136/bcr-2022-250364 

Model Answer:

How will you assess CN II-VII and what potential abnormalities do you expect to find? Identify at least three abnormalities.

Assessment

• CN II

  • Perform a visual field assessment

    • Face the patient directly and ask them to cover their right eye while you cover your left eye. Ask the patient to look at your nose. Either wiggle your fingers or ask them to state how many fingers you are holding up in each visual field quadrant – lateral, medial, superior, and inferior. Repeat on the opposite side (Blackwell & Goolsby, 2022)

  • Perform a visual acuity exam

    • Stand approximately 20 feet away from the patient. Using a Snellen chart, ask the patient to cover one of their eyes and read each row of letters. Perform this test again on the opposite eye and then with both eyes simultaneously (Blackwell & Goolsby, 2022)

• CN II and III

  • Test pupillary light reflex

    • Penlight: Dim the lights as much as possible in the patient’s room.  Using a pen light, point the light at the patient’s nose and inspect the size of both pupils. Shine the light into the right eye and assess for reactivity in both eyes, and repeat with the left eye (Gelb, 2022).     

    • Pupillometer: If available, the pupillometer provides a more accurate assessment of pupillary response and should be utilized. Prepare the equipment and instruct the patient to open their eye or assist them to open it gently. Apply the pupillometer device at a 90-degree angle and press the appropriate button (Left or Right depending on which eye you are assessing). Document both the size and NPi (neurological pupil index) value which assesses the rate of reactivity to light. (Bazil, 2023).

• CN III, IV, and VI 

  • Extraocular movements

    • Stand approximately 2 feet away and instruct the patient to follow your finger with their eyes. Move your finger vertically, horizontally, and diagonally across all visual fields while assessing their eye movements (Gelb, 2022).

• CN V

  • Facial Sensation

    • Gently touch the patient’s forehead on one side and then repeat on the opposite side. Ask the patient if it felt the same on both sides. Repeat this on the cheeks and lower jaw (Gelb, 2022).

  • Corneal Reflex

    • If Sally deteriorates, testing the corneal reflex is appropriate, but it may not be for patients without other neurological disturbances. Use your nursing judgement on whether this is necessary. Instruct the patient to look to the left and then gently brush their cornea with a piece of gauze. If the corneal reflex is intact, the patient will blink. In a patient with decreased level of consciousness gently assist them to open their eye and place a drop of saline in their eye to illicit the corneal reflex (Gelb, 2022).

• CN VII

  • Facial symmetry

    • Instruct the patient to tightly close their eyes, raise their eyebrows, puff out their cheeks, and smile. Observe for signs of asymmetry (Gelb, 2025; Zychowicz, 2022).

Potential Abnormalities

Explanation: Sally has a large tumor of unidentified etiology that is causing a midline shift and compression of the brainstem. This has led to increased intracranial pressure which is the cause of her symptoms. Abnormalities are based on guidance from (Smith & Amin-Hanjani, 2024).

• CN II

  • Visual field cuts

  • Impaired visual acuity

• CN II/III

  • Impaired pupillary response

    • Anisocoria - One pupil may be bigger than the other (Gelb, 2022).

    • Non-reactive pupils 

• CN III, IV, and VI

  • Nystagmus

• CN V

  • Asymmetrical sensation

  • Absent corneal reflex (if Sally’s ICP is severely elevated)

• CN VII

  • Asymmetrical facial movements

  • Cushing’s Triad – bradycardia, respiratory depression, and hypertension is a possible complication of Sally’s condition and is an appropriate answer to the question. However, in this scenario, this is a less likely answer (Smith & Amin-Hanjani, 2024).

If Sally’s condition deteriorates, what interventions do you anticipate and why? Identify at least two.

Students should name interventions to decrease ICP.

• Mannitol

  • Mechanism of action: osmotic diuretic which blocks the reabsorption of water and causes increased excretion of sodium and chloride. It decreases ICP by moving intracellular water to the extracellular space (Smith & Amin-Hanjani, 2024). 

  • Explanation: Mannitol is a quick way to reduce ICP while waiting to correct the primary problem (Smith & Amin-Hanjani, 2024).

• Hypertonic Saline

  • Mechanism of action: increases osmolarity of the blood drawing water from the intracellular space to the vasculature (Smith & Amin-Hanjani, 2024).

  • Explanation: Hypertonic saline works quickly to reduce ICP, and typically is a safer alternative to Mannitol (Smith & Amin-Hanjani, 2024).

• Ventriculostomy (EVD)

  • Mechanism of action: EVDs can lower ICP by releasing CSF through a pressure monitoring system at a prescribed rate

  • Explanation: An EVD will allow for real time monitoring of ICP and immediate intervention if she decompensates

• Surgical Resection

  • Relieving the primary problem is the ideal way to approach Sally’s condition (Smith & Amin-Hanjani, 2024).

  • Considering the size of Sally’s tumor, an appropriate approach would be to consider her quality of life and desire to receive this type of treatment. 

• Glucocorticoids (Dexamethasone)

  • Dexamethasone will decrease swelling overall and is effective when combined with other interventions.

The Intention of the Question: 

This question is intended to apply basic cranial nerve assessment skills to critically ill patients with neurological conditions. Students should be able to identify a normal assessment of cranial nerves first and then think critically about what aberrations may be seen in patients who have increased ICP. Sally displays classic symptoms of elevated ICP, and in conjunction with her MRI imaging students should be able to correlate their assessment knowledge to appropriate interventions to reduce ICP.

References

Bazil J. (2023). Pupillometer. In K. Johnson, AACN procedure manual for progressive and critical care (8th ed., pp. 866-870). St. Louis: Elsevier.

Blackwell, J., & Goolsby, M. J. (2022). The eye. In M. J. Goolsby & L. Grubbs, Advanced assessment: Interpreting findings and formulating differential diagnoses (5th ed., pp. 185-222).

Gelb, D. (2022). The detailed neurologic examination in adults. UpToDate. Retrieved April 3, 2025, from https://www.uptodate.com/contents/the-detailed-neurologic-examination-in-adults?search=cranial%20nerve%20exam&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1 

Lobera, A. (2022). Glioblastoma (multiforme) imaging. Medscape. Retrieved April 3, 2025, from https://emedicine.medscape.com/article/340870-overview?form=fpf  

Rogers, M. S. (2023). Intracranial pressure monitoring, nursing care, troubleshooting and removal. In K. Johnson, AACN procedure manual for progressive and critical care (8th ed., pp. 834-847).

Smith, E. R., & Amin-Hanjani, S. (2024). Evaluation and management of elevated intracranial pressure in adults. UpToDate. Retrieved April 3, 2025, from https://www.uptodate.com/contents/evaluation-and-management-of-elevated-intracranial-pressure-in-adults?search=ICP&source=search_result&selectedTitle=1%7E138&usage_type=default&display_rank=1 

Zychowicz, M. (2022). Neurological system. In M. J. Goolsby & L. Grubbs, Advanced assessment: Interpreting findings and formulating differential diagnoses (5th ed., pp. 593-626). 

Question #3 by Li-Fang Hsieh

A 62-year-old female with a history of hypertension and type 2 diabetes, presents to the emergency department (ED) because of uncontrol glucose, and admitted to hospital for hyperglycemia. Next day, after morning shift report, nurse was going to give morning medication. Found patient’s left eye feels like it is “drooping,” and she has difficulty raising her left eyebrow. The patient reports that sudden-onset weakness and numbness on the left side of her body and her symptoms began approximately an hours ago while she was using her cellphone. Nurse also noticed her speech has become slurred.

The nurse activated the code “Stroke “, and provider ordered the CT scan, result came back with right middle cerebral artery infraction.

If you were her nurse, what assessment would you perform, and what management care can be?  

DynaMedex. Acute ischemic stroke. EBSCO Information Services. Accessed April 3, 2025. https://www-dynamedex-com.offcampus.lib.washington.edu/condition/acute-ischemic-stroke 

Model Answer:

An ischemic stroke is a medical emergency that results from inadequate blood flow to the brain, ultimately causing tissue damage and neurological dysfunction (Xue et al., 2023). As the patient’s nurse, my initial step would be to check her blood glucose level to rule out hypoglycemia as a potential cause of her symptoms. Simultaneously, I would conduct a thorough neurological assessment, including the use of the NIH Stroke Scale to determine the severity and neurological impact of the stroke. A detailed cranial nerve evaluation would also be necessary, focusing on facial muscle function, eye movement, gag reflex, and tongue position. I would closely monitor the patient’s vital signs and perform a bedside swallowing assessment to evaluate the risk of aspiration. Continuous cardiac monitoring would be initiated to identify any arrhythmias, such as atrial fibrillation. If the patient was within the 4.5-hour therapeutic window and met the criteria, I would prepare for the potential administration of thrombolytic therapy (tPA). According to Coben (2022), the use of alteplase is clearly beneficial for patients experiencing an acute ischemic stroke with significant or disabling neurological deficits, provided they arrive for treatment within 4.5 hours of symptom onset. Supportive interventions would include ensuring a patent airway, adequate oxygenation, managing blood pressure in accordance with stroke guidelines. During the recovery phase, I would collaborate with the physical, occupational, and speech therapy teams, maintain tight glucose control, and provide stroke education to both the patient and her family to prevent future occurrences.

The Intention of the Question: 

Stroke is the fifth leading cause of death in the United States, with healthcare costs associated with stroke care surpassing $70 billion annually. Each year, approximately 800,000 people in the U.S. experience a stroke, with nearly 700,000 cases being acute ischemic strokes (Mendelson & Prabhakaran, 2021). Stroke is also a common diagnosis in my unit, Med/Surg. It is either one of a patient’s medical history, or the primary reason for hospital admission due to a stroke episode. Another reason stroke is significant to me is that my grandpa had a stroke. He experienced one-sided weakness, aphasia, and swallowing difficulties. He was qualified t-PA treatment that time, and he required extensive physical therapy and was never able to return to his baseline. 

Nurses play a vital role as the primary healthcare providers responsible for identifying stroke symptoms, ensuring prompt intervention. Accurate stroke assessment is an essential nursing skill, as early detection and timely treatment can greatly improve patient outcomes. Since stroke is a medical emergency, rapid recognition is crucial, the sooner it is diagnosed, the faster treatment can begin, such as administering thrombolytic therapy within 4.5 hours for ischemic stroke. Additionally, stroke assessment results help facilitate collaborative care with physicians, physical therapists, speech therapists, and occupational therapists.

References

Cohen, V. L., Anderson, A., Noah, P., & Super, J. (2022). A nursing approach to improving critical care compliance with vital signs and neurological assessments in post-iv-alteplase stroke patients. Critical Care Nursing Quarterly, 45(4), 352–358. https://doi.org/10.1097/CNQ.0000000000000427 

DynaMedex. Acute ischemic stroke. EBSCO Information Services. Accessed April 3, 2025. https://www-dynamedex-com.offcampus.lib.washington.edu/condition/acute-ischemic-stroke 

Mendelson, S. J., & Prabhakaran, S. (2021). Diagnosis and management of transient ischemic attack and acute ischemic stroke: a review. JAMA : The Journal of the American Medical Association, 325(11), 1088–1098. https://doi.org/10.1001/jama.2020.26867 

Xue, L., Deng, J., Zhu, L., Shen, F., Wei, J., Wang, L., Chen, Q., & Wang, L. (2023). Effects of predictive nursing intervention on cognitive impairment and neurological function in ischemic stroke patients. Brain and Behavior, 13(3), e2890-n/a. https://doi.org/10.1002/brb3.2890 

Question #4 by Erin Woods

A three year old presented to the emergency room due to persistent emesis and a recent history of ataxia. A subsequent CT scan was positive for large cerebellar tumor in the posterior fossa, so the patient was sent to the OR and had a tumor resection.  The patient is now post-op day #1 in the PICU, showing signs of posterior fossa syndrome and with post-op swelling expected to peak in the next 12-24 hours. 

What assessment findings would indicate that there was cranial nerve dysfunction as a result of the surgery and/or post-op swelling? What are other symptoms of posterior-fossa syndrome (also called post-operative cerebellar mutism syndrome (pCMS)?

Model Answer:

Because posterior fossa tumors are found in the fourth ventricle and their surgical resection can lead to swelling near the brainstem, all cranial nerves can be affected. Commonly affected are cranial nerves VI-IX affecting eye deviation, facial expressions, hearing and balance, and swallowing (Slota, 2006).

pCMS presents most commonly as mutism and also includes cranial nerve dysfunction in the post-operative phase. pCMS effects also include deficits in cerebellar motor function, behavioral issues and cognitive changes. (Paquier et al., 2020). 

The Intention of the Question: 

Posterior fossa tumors are common tumors in the young pediatric population. We see these children frequently in the PICU and the subsequently on the acute care floor. Being aware of the expected post-operative course, including swelling, potential cranial nerve dysfunction and the very real possibility of posterior fossa syndrome is important. By being prepared for possible negative sequelae of the surgery, the nurse can better educate the family and work with them and their young child through the post-operative course.

References

Paquier, P. F., Walsh, K. S., Docking, K. M., Hartley, H., Kumar, R., & Catsman-Berrevoets, C. E. (2020). Post-operative cerebellar mutism syndrome: rehabilitation issues. Child's Nervous System : ChNS : Official Journal of the International Society for Pediatric Neurosurgery, 36(6), 1215–1222. https://doi.org/10.1007/s00381-019-04229-6

Slota, M.C. (2006). Core curriculum for pediatric critical care nursing. Saunders.

Model Answer:

Based on the facial drooping the nurse suspects that the student sustained damage to the 8th cranial nerve and will need to rule out if it’s due to the fall or if it’s idiopathic. (Nurse will also assess for concussion, but not relevant regarding the facial drooping).

HX: Gather that facts. Subjective and objective data. 

• Student report falling and hitting his left temporal area on a ball storage cart, minutes prior to coming to the nurses office. 

• Ask about recent illnesses within the last week. 

• Ask if they are taking any medications

Physical Assessment (Ball, 2023) 

• Look at facial features

  • Eyes: drooping-ask to close eyes, note if they are unable to close one- look for dry eye of affected side. 

  • Mouth: corner of lip drooping-  ask for them to smile showing teeth- look for evenness. Have them puff cheeks- look for unevenness. 

  • Gestures: ask they raise eyebrows and to make a “mad” face- look for symmetry 

• Ear check- with otoscope look for S/SX of infection

• Glands- look for swelling of the parotid gland by palpitating. 

• Tonge- assess for taste

The Intention of the Question: 

The intention of the question is to elicit a thorough assessment. In my experience I have seen nurses quick to assume a condition. This way the nurse can offer the patient support for next steps. In the school nurse setting, the parent or guardian would be notified, the nurse will encourage they take the student to the doctor and provide documentation of school assessment. 

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., Stewart, R. W., & Seidel, H. M. (2023). Seidel’s guide to physical examination (Tenth edition.). Elsevier.

Cleveland Clinic. (2024, December 19). Facial Nerve. Retrieved April 2, 2025, from https://my.clevelandclinic.org/health/body/22218-facial-nerve 

Cleveland Clinic. (n.d.). Facial paralysis: Treatment options. Retrieved April 2, 2025, from https://my.clevelandclinic.org/services/facial-paralysis-treatment 

Question #6 by Hillary Viswanathan

A 13 year old boy presents to the preoperative area to be checked in and prepped for a tonsillectomy and adenoidectomy. The patient appears pale and fidgets nervously while the preoperative history is conducted and visibly flinches when approached with a blood pressure cuff and O2 pulse oximeter for vitals. The patient’s mother expresses worry about his stress response to being in a surgical center. She also reports he recently visited a vaccine clinic and “briefly slumped or something” when vaccinated. Additionally she reports he has “passed out” before and she isn’t sure why but that he wakes up within a few seconds. 

The patient appears to tolerate the vital sign measurements; however, when the preop nurse attempts to insert a peripheral IV, he becomes very pale, his eyes roll back and he slumps over. 

What just happened to the patient, which cranial nerve is involved, and what might the preop nurse do in immediate response? What might the recovery nurse educate the mother and the patient about post-surgically?

Model Answer:

The patient is stressed and has a history of syncope. It is likely he experienced vasovagal syncope in response to the stress, specifically around needles and the healthcare environment. Vasovagal syncope is a trigger of Cranial Nerve X, the Vagus Nerve, in which the heart rate slows and blood vessels widen. This response decreases blood pressure and causes the brain to not receive enough blood flow resulting in syncope.

An immediate response would be to reposition the patient with feet up and head down to bring blood flow back to the brain. The preop nurse may also attempt to stimulate the patient. 

Recurrent syncope can have a significant impact on a patient’s quality of life. In recovery after surgery, the PACU nurse provides education to the patient and family. Education could include a definition of vasovagal syncope and its triggers, as well as potential physical maneuvers and lifestyle modifications that can help prevent episodes in the future. Physical maneuvers include leg crossing, sustained handgrip, or arm tensing when the patient anticipates the syncope. Evidence-based lifestyle measures include yoga practice and increased fluid and salt intake. The patient can also be advised that if these measure are inadequate, medication may also be an option. It is also beneficial to reassure the patient and his family that the condition is benign and can be managed by recognizing and avoiding triggers.

The Intention of the Question: 

The question is meant to engage the learner in analyzing a real-life patient situation and applying knowledge of Cranial Nerve X dysfunction and interventions. 

References

Alharbi, A., Shah, M., Gupta, M., Rejent, K., Mahmoud, M., Alsughayer, A., Alryheal, A., Sayeh, W., Siddiqi, R., Jabr, A., Kwak, E. S., Khuder, S., Assaly, R., & Grubb, B. (2024). The efficacy of non-pharmacological and non-pacing therapies in preventing vasovagal syncope: Tilt training, physical counter pressure maneuvers, and yoga - A systematic review and meta-analysis. Autonomic Neuroscience: Basic & Clinical, 251, 103144. https://doi.org/10.1016/j.autneu.2023.103144 

Ali, M., Pachon Maetos, J. C., Kichloo, A., Masudi, S., Grubb, B. P., & Kanjwal, K. (2021). Management strategies for vasovagal syncope. Pacing and Clinical Electrophysiology: PACE, 44(12), 2100–2108. https://doi.org/10.1111/pace.14402 

Model Answer:

Diagnostic Workup:

• 1. CT Head:

  • Findings: A large subdural hematoma was noted on the left side of the brain, with a midline shift. There was also evidence of cerebral edema. The subdural hematoma was suspected to be the result of the ejection from the vehicle and subsequent head impact on the road surface.

• 2. Chest X-ray:

  • Mild rib fractures noted, but no signs of pneumothorax or significant pulmonary injury.

• 3. Pelvic X-ray:

  • Negative for any fractures or internal injuries.

• 4. Laboratory Studies:

  • CBC: Mild anemia with a hemoglobin level of 10.5 g/dL.

  • Coagulation profile: Within normal limits.

  • Serum glucose: 98 mg/dL.

The Intention of the Question: 

When a patient arrives at the hospital with suspected subdural hemorrhage (hematoma), especially following a trauma like a car accident, the primary concern is to assess the severity of the head injury, rule out life-threatening conditions, and determine the necessary course of action. 

References

Choudhary, A. K., Servaes, S., Slovis, T. L., Palusci, V. J., Hedlund, G. L., Narang, S. K., Moreno, J. A., Dias, M. S., Christian, C. W., Nelson, M. D., Jr, Silvera, V. M., Palasis, S., Raissaki, M., Rossi, A., & Offiah, A. C. (2018). Consensus statement on abusive head trauma in infants and young children. Pediatric radiology, 48(8), 1048–1065. https://doi-org.offcampus.lib.washington.edu/10.1007/s00247-018-4149-1 

Wang, A., Cohen, A. R., & Robinson, S. (2009). Neurological injuries from car surfing. Journal of neurosurgery. Pediatrics, 4(5), 408–413. https://doi-org.offcampus.lib.washington.edu/10.3171/2009.4.PEDS08474 

Model Answer:

The physician ruled out a stroke and immediately diagnosed Bell’s Palsy, or inflammation/damage to the Facial Nerve (Cranial Nerve VII) based on their assessment of forehead involvement and otherwise non-focal neurological exam.

Facial droop in strokes typically occurs suddenly as the result of upper motor neuron damage. Upper motor neurons innervate the lower face and upper face separately, so strokes will not involve the forehead. In lower motor neuron disease such as Bell’s Palsy, the nerve is peripherally affected and thus affects the entire side of the face (Ball, et al., 2023, Chapter 23)

Pertinent assessments would include recent medical history and a head-to-toe assessment, as Bell’s Palsy can be precluded by viral illnesses like herpes zoster or upper respiratory infections. The patient might also report pain behind the ear, and/or taste changes. Other risk factors include diabetes, pregnancy, obesity, and age 15-45 years (Cleveland Clinic, 2023). 

You affirm the nurse in their calling the code, because just like in this case, it can be cancelled as needed!

The Intention of the Question: 

Facial droop is a common complaint in the ER and a frequent presenting symptom for our code stroke calls. When the patient has an otherwise non-focal exam (no speech changes, vision problems, one-sided weakness), and is alert and oriented, (no signs of brainstem stroke), stroke can quickly be ruled out with a thorough medical history and physical assessment, with focus on the cranial nerves. The care team can then allocate or conserve resources.  Applying your understanding of the cranial nerve anatomy can elevate your nursing assessment, recommendations, and grasp of the clinical picture in emergency situations.  

References

Ball, J., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). Elsevier. 

Cleveland Clinic. (2023, August 14) Bell’s Palsy. Retrieved April 3, 2025. https://my.clevelandclinic.org/health/diseases/5457-bells-palsy 

National Institute of Neurological Disorders and Stroke. (2025, January). Bell’s Palsy. Retrieved April 3, 2025. https://www.ninds.nih.gov/health-information/disorders/bells-palsy 

Question #9 by Hannah Pankratz

A 53-year-old female presents to a clinic with complaints of sharp, shooting, stabbing pain that comes in small bursts like electricity across her face.

In reviewing the patient’s history, you see that she has multiple sclerosis. You are concerned with trigeminal neuralgia.

How would you assess the patient for trigeminal neuralgia? Which cranial nerve does this impact?

Model Answer:

Important assessment for the nurse will be to assess the trigeminal nerve (cranial nerve V). This can be done by asking the patient to clench their jaw and assessing if there is any pain with this action. Most common factors for eliciting pain in this manner including talking and chewing (Maarbjerg et al., 2017). Additionally, assessing for a pain response with gentle touching around the patient’s mouth, cheeks and nose areas would be helpful as these are the most common trigger zones for trigeminal neuralgia (Ashina et al., 2024).

The Intention of the Question: 

To assess understanding of trigeminal neuralgia and how it affects the fifth cranial nerve. This question also helps apply the assessment skills necessary for a nurse to assess function of a patient’s cranial nerve when there is a concern for a condition that may affect its function. 

References

Maarbjerg, S., Di Stefano, G., Bendtsen, L. & Cruccu, G. (2017). Trigeminal neuralgia – diagnosis and treatment. Cephalalgia, 37(7), 648-657. https://doi.org/10.1177/0333102416687280 

Ashina, S., Robertson, C.E., Srikiatkhachorn, A., Di Stefano, G., Donnet, A., Hodaie, M., Obermann, M., Romero-Reyes, M., Seok Park, Y., Cruccu, G. & Bendtsen, L. (2024). Trigeminal neuraligia. Nature Reviews Disease Primers, 10(1), 39-60. https://doi.org/10.1038/s41572-024-00523-z 

Question #10 by Jennifer Ofiana

In the Post anesthesia Care Unit (PACU), you, the nurse, receive a 58-year-old female post-operative patient who had just undergone a right total parotidectomy. As she wakes up from anesthesia, you notice that she has difficulty keeping her right eye closed. Later, the patient also complains that the right side of her face feels itchy, and she also feels a “zapping” sensation. You report this to the surgeon who reports that this is expected post-operatively, but to closely monitor her symptoms. 

Which cranial nerve is at risk of damage during parotid gland surgery and how do you assess for injury to this cranial nerve? What should be included in the post-operative care of the patient?

Model Answer:

Iatrogenic injury during parotid gland surgery to cranial nerve VII or the facial nerve is due to the close anatomic relationship of these paired clusters of salivary tissue to the facial nerve. The dissection of the parenchyma of the gland from the branches of the facial nerve could cause functional impairment (Molinari, et al., 2024). Since cranial nerve VII provides innervation for the muscles of facial expression (Damodaran, 2013), to assess the facial nerve’s function on physical examination, one may start with observation of the patient’s face and clues of asymmetrical expression (Damodaran, 2013; Singh, et al., 2023). The examiner may ask the patient to look upwards, which can emphasize the wrinkling of the forehead, grimace, smile, show his/her teeth, and puff out the cheeks (Damodaran, 2013; Singh, et al., 2023). The cheeks are then palpated to assess any difference in tone (Damodaran, 2013). 

The following should be included in the postoperative care and instructions of the patient: temporary facial nerve palsy is primarily a cosmetic concern, and patients should be reassured that their appearance will return to normal. However, it is important to ensure adequate eye protection. If facial paresis leads to incomplete eyelid closure, patients should be advised to use eye drops frequently throughout the day, as well as an ophthalmic ointment and eye protection at night (Marchese-Ragona, et al., 2005). 

The Intention of the Question: 

Using Bloom’s Taxonomy, the intention of this question is to promote higher-order and critical thinking skills. Using the basics of physical assessment, anatomy, and physiology, these can be analyzed and applied to a practical clinical situation. 

References

Damodaran, O., Rizk, E., Rodriguez, J., & Lee, G. (2014). Cranial nerve assessment: A concise guide to clinical examination. Clinical Anatomy (New York, N.Y.), 27(1), 25–30. https://doi.org/10.1002/ca.22336 

Marchese-Ragona, R., De Filippis, C., Marioni, G., & Staffieri, A. (2005). Treatment of complications of parotid gland surgery. Acta Otorhinolaryngologica Italica, 25(3), 174–178.

Molinari, G., Calvaruso, F., & Barbazza, A., Vanelli, E., Nizzoli, F., Reggiani, E., Guidotti, M., Borghi, A., Marchioni, D., Presutti, L., & Fernandez, I. J. (2024). Patterns and timing of recovery from facial nerve palsy after nerve-sparing parotid surgery: The role of neuromuscular retraining. European Archives of Otorhinolaryngology, 281, 5465–5472. https://doi.org/10.1007/s00405-024-08758-y 

Singh, R., Pollock, J. R., Moore, L. M., Lee, Y. S., Hudson, M., Bendok, B. R. & Patel, N. P. (2023). The New England Journal of Medicine, 389(1), e2(1)-e2(4). https://doi.org/10.1056/NEJMvcm2103640 

Model Answer:

The physiological mechanism most likely responsible for this patient’s response is the stimulation of the vagus nerve (cranial nerve X). The patient is demonstrating a vasovagal response to the vagus nerve being stimulated in the colon as a result of pressure from the colonoscope. A vasovagal response leads to a sudden decrease in heart rate and blood pressure and can include feelings of being warm and sweating (Jardine et al., 2018). 

Immediate priorities for physical assessment include continued and increased monitoring of vital signs including heart rate and rhythm, blood pressure, respiratory status, and neurologic status including responsiveness. 

Vagal-induced bradycardia is often sudden and includes both hypotension and bradycardia with the involvement of a stimuli, like a colonoscope. Other potential causes of hypotension and bradycardia during procedural sedation could include over-sedation or allergic reaction to medications. 

While pharmacologic interventions can be utilized in cases of repeated vasovagal syncopal episodes, a conservative approach is often utilized and achieved, in this case with the removal of the stimuli (the colonoscope) (Jeanmonod et al., 2023). 

The Intention of the Question: 

The purpose of this question is to assess the student's understanding of the vagus nerve (cranial nerve X) and how it relates to pathophysiology in clinical situations. It aims to test the student's ability to apply, analyze, and explain how the vagus nerve and broader physiological concepts contribute to clinical presentations, specifically in this case, bradycardia and hypotension.

References

Jardine, D. L., Wieling, W., Brignole, M., Lenders, J. W. M., Sutton, R., & Stewart, J. (2018). Pathophysiology of the vasovagal response. Heart Rhythm, 15(6), 921–929. https://doi.org/10.1016/j.hrthm.2017.12.013 

Jeanmonod, R., Sahni, D., & Silberman, M. (2023). Vasovagal episode. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK470277/ 

Question #12 by Muskan Priya

Cranial Nerves: Jake was previously a healthy child. Recently, he began experiencing recurring illness with symptoms such as chills, fever, and decreased appetite. These issues caused him to miss significant time from school. Eventually, he was admitted to the hospital, where imaging revealed a tumor. The tumor was surgically removed, but after multiple procedures, Jake became tracheostomy- and ventilator-dependent. He also sustained a brainstem injury, though he retains some voluntary movements.

How would you assess cranial nerves 3-12 with this child?

Mental Health: Henry is an 8-year-old child who was born healthy into a family of five. He has a younger brother, Jake, who was also born healthy. However, Jake was later diagnosed with a brain tumor and spent over a year in the hospital. Although the tumor was successfully removed and Jake initially began to recover, he later became seriously ill. As a result, Jake is now tracheostomy- and ventilator-dependent and remains sedated for most of the day.

Henry and Jake were extremely close and spent a lot of time playing together. Since Jake’s hospitalization and change in condition, Henry has begun showing signs of emotional distress. His parents have noticed that he has become more agitated, sometimes isolates himself, and his mood changes, some days are good, while others are not. His parents are becoming increasingly concerned about his behavior and emotional well-being.

What questions are necessary to ask the child about how he feels with his brother’s diagnosis? What steps would we take to ensure that the child is doing okay? 

Model Answer:

Cranial Nerves: Since we would be looking at cranial nerves 3-12 for this brainstem injury. The patient has decreased level of consciousness this assessment may be difficult. Cranial nerve III, IV, and VI can be seen if Jake is tracking his eyes in different directions. Jake’s pupillary reaction can be tested if he seems more alert than usual. Cranial V can be checked by using light touch on cheeks and jaw, since client can’t verbalize, then check for any facial grimace. For cranial VII, ask Jake to raise his eyebrows or smile and watch for spontaneous facial movement or response to stimuli. 

Mental Health: We should make sure that there was a safe space and normalize his feelings. We can make sure that there is a therapist available to his family and child as well during this transition. We can encourage client to share his thoughts and feelings with open-ended questions. 

The Intention of the Question: 

My idea began with a focus on mental health assessment because, in my work, I frequently see families and younger siblings visiting the facility. These families try to engage with their child, who is tracheostomy- and ventilator-dependent, yet lacks awareness of their surroundings. For the siblings, this experience is particularly profound—they once knew their medically fragile brother or sister as someone entirely different. Now, at a very young age, they are faced with a completely.

References

Moreda, M., & Hill, M. (2022). Cranial nerve assessment: A practical approach. American Nurse Journal, 17(3), 14–18.

Johnson, C. L., Kelly, C. M., Jorm, A. F., Garvey, W., & Hart, L. M. (2025). How to Approach a Child About Concerns for Their Mental Health and Seeking Help: A Delphi Expert Consensus Study to Develop Guidelines on Mental Health First Aid for Supporting Children. Health Expectations, 28(1), 1–15. https://doi-org.offcampus.lib.washington.edu/10.1111/hex.70126 

Question #13 by Suman Roy

How does trigeminal neuralgia correlates to an individual’s cardiovascular health and mental health? 

Model Answer:

Trigeminal neuralgia is a chronic condition that affects the trigeminal nerve or the fifth cranial nerve, which provides feeling and nerve signaling to parts of the head and face. Intensity of pain very sever. It feels like that someone is stabbing with a sharp knife. Trigeminal neuralgia mimics the MI symptoms since some patients experience the symptoms of a MI, like Jaw pain and neck pain. Cardiovascular health effects : high BP and shallow breathing. Mental health effects: anxiety, sleep deprivation, depression and N/V. 

The Intention of the Question: 

I have been dealing with this pain for many years. Initially, it was not frequent but as I am aging, the severity and frequency has been increasing. I am not officially diagnosed with it yet since I can’t find a neurologist. One of my doctor friend has educated me on the condition and symptoms are very similar to trigeminal Neuralgia. 

References

Fazlyab, M., Esnaashari, E., Saleh, M., Shakerian, F., Akhlagh Moayed, D., & Asgary, S. (2015). Craniofacial Pain as the Sole Sign of Prodromal Angina and Acute Coronary Syndrome: A Review and Report of a Rare Case. Iranian endodontic journal, 10(4), 274–280. 

Question #14 by Baylee Bortz

You are a triage nurse in an emergency department, and you are preparing to go see your next patient. In the electronic health record, you note see that your patient is a 24-year-old female with a past medical history of generalized anxiety disorder with depressive features. It is also noted that the patient came in due to concerns about mood swings, difficulty sleeping, inability to concentrate, restlessness, and decreased appetite. When you enter the room and begin talking to the patient, they report that about a month ago they started taking citalopram (Celexa).

As their nurse, what do you think could be causing their symptoms and why? What additional assessment information would you want to get from the patient to help determine the cause of the symptoms?

Model Answer:

Given that citalopram is an SSRI which can cause activation, these symptoms could be the result of mania/hypomania related to underlying bipolar disorder or activation syndrome (DynaMedex, 2025; Reid et al., 2010). These symptoms could also be caused by serotonin syndrome, given that SSRIs are the medication class most associated with serotonin syndrome (UpToDate, 2025). Given that serotonin syndrome is an emergency, I would start by getting vital signs to check for tachycardia, hypertension, and hyperthermia. While doing this, I would also check for dilated pupils and ocular clonus. I would then follow up by asking the patient if they had taken more medication than prescribed (either accidentally or on purpose), if they take any other medications or supplements, and if the symptoms developed quickly or seemed to develop over time. If the patients vitals are normal, did not take more medication then prescribed, take no other medications/supplements, and the symptoms developed gradually that would suggest that serotonin syndrome is not the cause and therefore the patient is not experiencing a medical emergency. From there, I would proceed with mental status exam questions regarding suicidal ideation, homicidal ideation, auditory hallucinations, and visual hallucinations. Additionally, I would assess the patient for delusion-based thought content with questions about if they have felt like others are out to get them, if they feel as though media is talking specifically to them, and if they feel as though there are people watching them or taking special interest in them. Finally, I would ask if the patient has any known family history of bipolar disorder.

The Intention of the Question: 

While I did not end up in the emergency department, the case scenario is based on my experience with Celexa. Luckily, I work in inpatient psychiatry and knew that my symptoms warranted a call to my primary care office. Within four days of stopping the medication I was completely back to my normal self, and the psychiatrist I saw determined that I was experiencing activation syndrome. Even though I work in psychiatry, I hadn’t heard about it before this experience, and I now love educating people on this being a potential reaction to this class of medication.

References

DynaMedex. (2025). Dynamedex.com. https://www.dynamedex.com/drug-monograph/citalopram#GUID-936AC941-8DA6-4311-9EFB-5E20CB63D07E 

Reid, J. M., Storch, E. A., Murphy, T. K., Bodzin, D., Mutch, P. J., Lehmkuhl, H., Aman, M., & Goodman, W. K. (2010). Development and Psychometric Evaluation of the Treatment-Emergent Activation and Suicidality Assessment Profile. Child & youth care forum, 39(2), 113–124. https://doi-org.offcampus.lib.washington.edu/10.1007/s10566-010-9095-5 

UpToDate. (2025). Uptodate.com. https://www.uptodate.com/contents/serotonin-syndrome-serotonin-toxicity?search=serotonin%20syndrome&source=search_result&selectedTitle=1%7E133&usage_type=default&display_rank=1#H2

Model Answer:

Serotonin syndrome occurs due to an increased amount of serotonergic activity in the central nervous system (Boyer & Shannon, 2005; Scott & McGowen, 2025). It is caused when a patient takes multiple serotonergic based medications such as SSRIs and antidepressants, in this case being sertraline and trazadone (Boyer & Shannon, 2005; Scott & McGowen, 2025). Other medications such as analgesics and antiemetics can also contribute to the occurrence of serotonin syndrome (Boyer & Shannon, 2005; Scott & McGowen, 2025). Many of the signs and symptoms of serotonin syndrome may go unnoticed or may be associated with other conditions (Boyer & Shannon, 2005; Scott & McGowen, 2025). For example, nausea is one of the primary side effects of many chemotherapy drugs and could be overlooked as a chemo side effect compared to a serotonin syndrome-based symptom. Since many of these signs and symptoms could be viewed as mild, diagnosing serotonin syndrome could be overlooked and/or delayed and patients need to recognize that these mild symptoms should not be overlooked. These symptoms can also manifest rapidly and normally occur due to medication changes, increase in dosage, and use of multiple serotonergic based medications (Boyer & Shannon, 2005; Scott & McGowen, 2025). 

The primary signs and symptoms of serotonin syndrome relate to mental status changes, neuromuscular hyperactivity, and autonomic dysfunction (Boyer & Shannon, 2005; Scott & McGowen, 2025). The following is a list of possible symptoms that can be seen in each category (Boyer & Shannon, 2005; Scott & McGowen, 2025): 

• Mental Status Changes – anxiety, agitation, confusion, delirium 

• Neuromuscular Hyperactivity – clonus, myoclonus, tremor, hyperreflexia, muscle rigidity 

• Autonomic Dysfunction – nausea/vomiting, increased bowel tones/diarrhea, hypertension, fever/hyperthermia, tachycardia, diaphoresis, dilated pupils 

As a nurse you should look out for these symptoms, especially paying attention to neuromuscular changes such as clonus and hyperreflexia as it is one of the main symptoms that points to serotonin syndrome when in combination with the other signs (Scott & McGowen, 2025). Additionally, it’s important that the patient not only be educated on what serotonin syndrome is and its symptoms but should understand that it is treatable. Stopping serotonergic based medications is the first step to treating serotonin syndrome amongst other supportive treatments, especially when the syndrome is in the mild stages (Boyer & Shannon, 2005; Scott & McGowen, 2025). At its most severe and life-threatening stages, the patients could experience seizures, hyperthermia, rhabdomyolysis, and respiratory arrest which would require inpatient care focused on treatments to address vital signs, protect their airway through intubation, take benzodiazepines to help control agitation, take serotonin antagonists, etc (Boyer & Shannon, 2005; Scott & McGowen, 2025). 

The Intention of the Question: 

While working with oncology patients, many of them experience varying levels of anxiety and depression that could predate their diagnosis or be related to the challenges of cancer treatment and journey. Though I haven’t had a patient experience serotonin syndrome before, relearning about it inspired me to write a question on the topic because I think many of us forget that serotonin syndrome is a risk factor related to many antianxiety and antidepressant medications. Cancer often causes patients to experience varying symptoms in addition to impacting their mental health such as pain, nausea/vomiting, diarrhea, cardiac and respiratory depression, etc. All of these combined result in patients taking increasing amounts of medications that are often difficult to navigate, and patient education is important regarding the risk factors. 

References

Boyer, E. W., & Shannon, M. (2005). The serotonin syndrome. The New England Journal of Medicine, 352(11), 1112-1120. DOI: 10.1056/NEJMra041867

Scott, M. T., & McGowen, A. (2025). Ferri’s Clinical Advisor 2025. Elsevier Inc. https://www-clinicalkey-com.offcampus.lib.washington.edu/#!/content/book/3-s2.0-B978044311724400911X?scrollTo=%23hl0000168 

Question #16 by Emily Watson

Anna, a 38-year-old nurse, worked in the COVID-19 unit of her hospital for several months during the pandemic’s peak. Since returning to her regular duties, Anna has been experiencing increased emotional exhaustion, difficulty sleeping, and heightened anxiety. She also struggles with feelings of emotional detachment from her work and is having difficulty connecting with her peers and patients. Anna has nightmares and frequently experiences flashbacks to traumatic events she witnessed while caring for COVID-19 patients. During a physical examination, she exhibits symptoms such as an elevated heart rate, muscle tension in her shoulders, and shallow breathing. Anna’s symptoms are significantly affecting her daily functioning, causing her to avoid conversations about her experiences and avoid certain aspects of her nursing role.

What are the key physical, psychological, and PTSD-related signs of stress and burnout that Anna is exhibiting, and how should these be assessed and documented in her care plan?

Model Answer:

Physical Signs: An elevated heart rate is indicative of hyperarousal, which is common in individuals experiencing chronic stress or PTSD. It reflects the body’s heightened state of alertness. Muscle tension in the shoulders is common in burnout and stress and can be a physical manifestation of emotional and psychological exhaustion. Shallow breathing is a typical sign of anxiety and PTSD. It can be associated with the body's fight-or-flight response, which is common in individuals experiencing trauma.

Psychological Signs: Anna’s reports of feeling emotionally drained and detached from her work indicate emotional exhaustion, a core component of burnout. This also manifests as a sense of reduced personal accomplishment. The difficulty connecting with her peers and patients reflects depersonalization, which is an emotional coping mechanism that creates distance from the trauma experienced in healthcare settings.

PTSD Signs: Nightmares about traumatic events, along with flashbacks to critical moments in her nursing role, suggest unresolved trauma and are classic signs of post-traumatic stress disorder. Anna’s heightened anxiety and hyperarousal, evidenced by her elevated heart rate, are common symptoms of PTSD. She may be overly alert to perceived threats and experience difficulty relaxing, even in safe environments. Anna’s avoidance of work-related discussions and activities, such as avoiding conversations about her experiences, is a symptom of PTSD. This behavior can limit emotional processing and lead to further detachment from her role.

Assessment and Documentation: Document Anna’s elevated heart rate, muscle tension, and shallow breathing during assessments. Regular monitoring of these physical signs will help track her stress response and physical recovery over time. Document nightmares, flashbacks, and avoidance behaviors as part of her PTSD symptoms. Emotional exhaustion and depersonalization should also be noted, indicating burnout. Regular psychological screenings and tracking of symptom progression or improvement should be part of Anna’s ongoing care plan.

The Intention of the Question: 

I was the nurse manager of the COVID unit in my hospital during the pandemic. Many of the nurses on my team came to me with various symptoms of stress, burnout, and fatigue. I had some who resigned, retired early, and transferred out of my department. I did my best to support them, offering our employee assistance program (EAP) benefits and encouraging them to seek treatment for their physical and mental well-being and time off if needed. It can be challenging to be their leader while also being a nurse myself. I think being open and vulnerable gave them the courage to come forward if needed. Providing an environment where they felt safe to speak up and talk about what they were going through was one of my goals. Naming the signs and symptoms in this quiz question offered an opportunity for me to describe what so many of the nurses on my team experienced.  

References

DynaMedex. Posttraumatic Stress Disorder (PTSD). EBSCO Information Services. Accessed April 3, 2025. https://www-dynamedex-com.offcampus.lib.washington.edu/condition/posttraumatic-stress-disorder-ptsd 

Sagherian, K., Steege, L. M., Cobb, S. J., & Cho, H. (2023). Insomnia, fatigue, and psychosocial well‐being during COVID‐19 pandemic: A cross‐sectional survey of hospital nursing staff in the United States. Journal of Clinical Nursing, 32(15–16), 5382–5395. https://doi.org/10.1111/jocn.15566

Model Answer:

Some components of therapeutic communication include face-to-face interaction, mutual respect, engagement, and setting and maintaining boundaries (Xue & Hefferman, 2021). With this in mind, it is important to properly address the patient after confirming it is okay to enter the room. You will want to refrain from multitasking, giving the patient your full undivided attention. Therapeutic communication involves both verbal and non-verbal communication, such as eye contact, body language, and facial expressions between you and the patient (Amoah et al., 2019). It is important to make sure the environment is comforting, with low stimuli, and maintaining directness with the patient, limiting physical barriers such as furniture. Through therapeutic communication, patients can be empowered to learn or cope more effectively as nurses spend more time with patients, communicating and developing relationships (Xue & Hefferman, 2021). When communicating, keep the language simple, let them do most of the talking, avoid judgment, and be flexible by letting the conversation evolve as the patient grows more comfortable. It is important to be cautious by not pushing too much on a sensitive subject, such as alcohol dependency, in this instance. Nurses have heavy work schedules, which can make It difficult to be present in the moment while practicing therapeutic communication. While it is important to be mindful of time constraints, in this instance, it’s imperative to be present when possible while also knowing your limits (Xue & Hefferman, 2021). 

The Intention of the Question: 

This scenario happened to me in my first year as a nurse while taking care of four other patients. This patient was withdrawing and having a difficult time coping mentally, requiring both emotional support and comfort. Tactics that I was cognizant of at the time were ensuring the patient’s privacy, standing or sitting at a comfortable distance, decreasing stimuli in the environment such as dimming the lights and removing any unwanted sounds within reason, maintaining eye contact, being mindful of my body language to appear more open and engaged, letting the patient speak and I listen, and when speaking, I made sure to have a calm tone with nonjudgemental language. Through this interaction with the patient, they opened up to me about their alcohol use, expressed their feelings and mindset, and were able to slow down to better understand their own needs and expectations. This patient is the reason I have a DAISY Award. They nominated me, expressing that I helped them at a fearful point in their life and made them feel like a human when no one else did. 

References

Amoah, V.M.K., Anokye, R., Boakye, D.S. Acheampong, E., Budu-Ainooson, A., Okyere, E., Gifty Kumi-Boateng, G., Yeboah, C., and Owusu Afriyie, J. (2019). A qualitative assessment of perceived barriers to effective therapeutic communication among nurses and patients. BMC Nurs 18, 4 (2019). https://doi.org/10.1186/s12912-019-0328-0 

Xue, W., & Heffernan, C. (2021). Therapeutic communication within the nurse-patient relationship: A concept analysis. International Journal of Nursing Practice, 27(6), e12938-n/a. https://doi.org/10.1111/ijn.12938 

Question #18 by Teighler Gella

You receive report from the off-going nurse about your 82 y/o male patient. He has been diagnosed with acute psychosis r/t active COVID infection. He has a PMHx of HTN and late-onset dementia. He currently has a sitter because he is A&Ox1, impulsive and not able to follow instructions. The nurse tells you that he has needed several IM haloperidol over the past few days due to agitation and aggressive behavior. Upon introducing yourself to the patient during bedside report, you notice your patient has a tremor in his R forearm, his tongue is slightly protruded, and he is consistently drooling. What do you suspect is going on and what should the nurse do next?

• A. Patient is having a partial seizure. The nurse should notify the doctors and except to administer anti-epileptic medications.

• B. Patient is experiencing a medication side effect. The nurse should notify the doctor and expect to switch to a different medication.

• C. Patient has undiagnosed Parkinson’s. The nurse should notify the doctor and assess for additional Parkinson’s symptoms.

• D. Patient is over sedated. The nurse should notify the doctor and consider asking the doctor for lower doses.

• E. There is nothing wrong with the patient. The nurse should continue care as ordered.

Model Answer:

Answer: B. Patient is experiencing a medication side effect.

Haldol (haloperidol) is a dopamine receptor agonist (D2) or formerly known as a first generation antipsychotic and is used to treat acute psychosis. It works by inhibiting D2 receptors which cause a decrease in positive symptoms (hallucinations and delusions) through the limbic pathway but also effects other pathways which causes a higher risk for extrapyramidal symptoms (EPS). EPS symptoms include parkinsonian syndrome, akathisia, dystonia, neuroleptic malignant syndrome, and Tardive Dyskinesia. The patient is exhibiting signs of EPS including parkinsonian symptoms (tremors and drooling) and dystonia (tongue protruding). Elderly patients are especially at higher risk for developing EPS when using first generation antipsychotics.

The on-coming nurse should question further use of haloperidol in the patient. The nurse should notify the provider immediately to discontinue haloperidol and suggest the use of second-generation antipsychotics like olanzapine as needed for agitation. Olanzapine is also a dopamine antagonist, but works selectively with the limbic dopamine pathway, causing a decrease instance in EPS symptoms.

The Intention of the Question: 

This is a true story that happened with my father-in-law. He was hospitalized in 2022 with respiratory distress due to COVID-19 infection. During his hospitalization, he became increasing agitated and confused. This is likely multifactorial since he already had underlying dementia, septic from infection, and he had an increased risk of delirium due to his advanced age. The provider had order IM haloperidol for agitation which was given multiple times a day over the course of 5-6 days. My father-in-law developed EPS symptoms which were noticed by an on-coming nurse. Our family was notified by the nurse and the provider that the medication was discontinued and that he was switched over to IM olanzapine as needed for agitation. Fortunately, as his infection improved, so did his cognition and within a few more days, he was back to baseline.

References

Barak, Y., Shamir, E., Zemishlani, H., Mirecki, I., Toren, P., & Weizman, R. (2002). Olanzapine vs. haloperidol in the treatment of elderly chronic schizophrenia patients. Progress in neuro-psychopharmacology & biological psychiatry, 26(6), 1199–1202. https://doi-org.offcampus.lib.washington.edu/10.1016/s0278-5846(01)00322-0 

Edmunds, M. & Mayhew, M. (2013). Pharmacology for the Primary Care Provider (4th ed.). Elsevier Health Sciences. https://www-r2library-com.offcampus.lib.washington.edu/Resource/Title/0323087906 

Question #19 by Jack Jorgensen

You are caring for a 4-year-old boy named Ben with medulloblastoma, 24 hours post-surgical resection of the tumor. Ben is presenting with dysphagia, mutism and nystagmus. Which cranial nerves do you suspect were affected by the surgery? What physical assessments would you perform to evaluate their function? 

Model Answer:

Posterior fossa syndrome is common after resection of medulloblastoma and may be secondary to post-operative swelling, or surgical trauma affecting the cranial nerves. Significant mood swings and ataxia are other symptoms that often accompany posterior fossa syndrome (Packer & Vezina, 2023). 

• Occulomotor (III), Trochular (IV), Abducens (VI) these cranial nerves work together to control eye movements (nystagmus).

  • Ask the patient to hold the head stationary while following your finger as it moves through the main directions of the gaze: Left-up, left-middle, left down, and right up, right middle, right down. Normal eyes move symmetrically and smoothly, any restriction or double vision suggests damage to one of these nerves. (Mangione 2008)

  • Nystagmus is not caused by nerve lesions per se, but rather by damage to the brain stem mechanisms responsible for coordinating eye movements (Mangione, 2008).

• Vestibularcochlear (VIII) (nystagmus)

  • Perform the Romberg Test (heels together, eyes open, arms by their side (note swaying). Then ask them to close their eyes. Obeserve for full minute. Normal patients may sway a little more with eyes closed, while vestibular patients will sway a lot more. Ataxic patients may fall. (Mangione, 2008)

• Glossopharyngeal (IX) and Vagus (X) (dysphagia and mutism)

  • These nerves are responsible for motor control of the palate and pharynx. Have them stick out their tongue and say “ahh” while observing if the soft palate rises symmetrically. Alternatively, you can evaluate the gag reflex by touching the soft palate with a cotton swab (which will likely be challenging on a moody 4 year old). (Mangione, 2008)

• Hypoglossal (XII) (dysphagia and mutism)

  • Ask ben to stick out his tongue. Hypoglossal weakness with cause the tongue to deviate towards the weak side (Mangione, 2008)

The intention of the question: 

This question touches on both pathophysiology and physical assessment. Ideally, the learner will appreciate that the location of the tumor and the associated treatment can cause temporary or permanent damage to the cranial nerves. Not only do they need to identify which nerves are associated with the identified symptoms, but also how to properly assess those nerves. 

I am hopeful that by applying these symptoms to a case study, the learner can envision the patient and imagine how they would implement age-appropriate assessments for them. I wrote this question with an actual patient in mind whom I cared for several years ago. I learned a lot from her situation and those learnings are with me to this day. 

References

Mangione, S. (2008). Physical diagnosis secrets (2nd ed., pp. 542–549). Mosby Elsevier.

Packer, R. J., & Vezina, G. (2023, July 12). Treatment and prognosis of medulloblastoma. In UpToDate. Retrieved April 5, 2025, from https://www.uptodate.com/contents/treatment-and-prognosis-of-medulloblastoma 

Question #20 by Ana Frota Penha

A 72-year-old veteran is undergoing radiation therapy for oropharyngeal cancer at the VA medical center. During a follow-up appointment, he mentions experiencing changes in taste, difficulty swallowing, and occasional weakness on one side of his face. 

Which cranial nerve should the healthcare team evaluate to further investigate his facial weakness, and how might the assessment relate to his mental health during cancer treatment?

• A) Cranial Nerve III (Oculomotor)

• B) Cranial Nerve V (Trigeminal)

• C) Cranial Nerve VII (Facial)

• D) Cranial Nerve IX (Glossopharyngeal) 

Answer Key: C) Cranial Nerve VII (Facial)

Model Answer:

The facial nerve (Cranial Nerve VII) is responsible for facial movement and might be affected by radiation therapy, leading to facial weakness. This can influence the veteran’s self-esteem and social interactions, potentially exacerbating feelings of anxiety or depression during his cancer treatment journey. Assessing this nerve can help identify any complications that might impact his mental well-being.

The Intention of the Question: 

The intention behind this question is to encourage a deeper understanding of cranial nerves, especially in the setting of cancer treatment. It’s not just about recalling facts; it’s about recognizing how physical changes like facial weakness or shifts in taste can significantly affect not only their physical health but also the veteran’s mental health. 

For many veterans, the journey through cancer therapy can be incredibly challenging, both physically and emotionally. When we dive into scenarios like the one presented, we get a clearer picture of how connected physical health, brain function, and emotional well-being really are. This holistic approach helps ensure that veterans receive comprehensive support, addressing their needs on all levels as they navigate their treatment journey.

References

Florie MGMH, Pilz W, Dijkman RH, Kremer B, Wiersma A, Winkens B, Baijens LWJ. The Effect of Cranial Nerve Stimulation on Swallowing: A Systematic Review. Dysphagia. 2021 Apr;36(2):216-230. doi: 10.1007/s00455-020-10126-x. Epub 2020 May 14. PMID: 32410202; PMCID: PMC8004503.

Zhang Y, Zhu Y, Wan H. Effectiveness of an evidence-based swallowing facilitation strategy for patients undergoing radiotherapy for head and neck cancer: a study protocol for a randomised controlled trial. BMJ Open. 2024 Jan 9;14(1):e072859. doi: 10.1136/bmjopen-2023-072859. PMID: 38199636; PMCID: PMC10806464.