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Stack #154928
kilgore lvl1, neuro assessment
| Question | Answer |
|---|---|
| Cranial Nerve I | olfactory nerve |
| Cranial Nerve II | optic nerve |
| Cranial Nerve III | oculomotor nerve |
| Cranial Nerve IV | trochlear nerve |
| Cranial Nerve V | Trigeminal nerve |
| Cranial Nerve VI | Abducens nerve |
| Cranial Nerve VII | Facial nerve |
| Cranial Nerve VIII | Auditory nerve |
| Cranial Nerve IX | Glossopharyngeal nerve |
| Cranial Nerve X | Vagus nerve |
| Cranial Nerve XI | Spinal accessory nerve -test by having client push shoulders and cheeks against nurse's hand -look for symmetry and equal bilateral strength against resistance |
| Cranial Nerve XII | hypoglossal nerve |
| What is your name? Can you tell me where you are right now? What is the date? | question to ask to assess LOC and orientation |
| what to look for in appearance and behavior/response | signs of sufficient grooming and ability to understand and follow commands appropriately |
| How to test for pupillary response and accommodation? | -PERRLA PUPILS EQUALLY ROUND -Measure pupil diameter and assess shape RESPONSIVE TO LIGHT -instruct client to look at a fixed point, then shine light to initiate response ACCOMODATION -have client look at fixed point and then bring object into close |
| How to assess upper extremity function bilaterally? | instruct client to grasp nurse's extended fingers and squeeze -client strength s/b equal in both arms |
| How to assess lower extremity function bilarterally? | instruct client to dorsal flex and plantar flex against resistance -client strength s/b equal in both legs for both actions |
| ASK client if there is any numbness or tingling? | assesses whether there is any nerve damage |
| rate client on Glasgow Coma Scale | 15 is highest, 3 is lowest score possible |
| LOC: Awake and alert | -is aware of the surroundings -responds appropriately to internal & external stimuli -awake means not asleep, s/n/b confused w/ alert |
| LOC: Lethargic or Somnolent | -easily drifts off to sleep -is not fully alerts even if awake -can be aroused w/ difficulty |
| LOC: Obtunded | -more difficult to arouse than lethargic -typically refers to being heavily dosed w/ narcotics -may not be breathing adequately |
| LOC: Stupor, Semicoma, Comatose | -almost complete unconsciousness -may respond to STRONG stimuli (stupor is most arousable) |
| LOC: Coma | -cannot be arounsed even by painful stimulus |
Created by:
gfcfnina
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