The nurse is performing a cranial nerve exam on an older adult client. The nurse notes that the client has a reduced upward gaze, a decreased corneal reflex, a high frequency hearing loss, and a reduced gag reflex. Which action should the nurse take next?

Review past history for any episodes of a cerebral cortex lesion.

Continue the assessment of the next pairs of cranial nerves.

Assess the spinal reflexes for demyelination symptoms.

Implement neurological (neuro) vital signs every 2 hours to detect Cushing's triad.