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Nursing Skills

Test 3- LP 20

QuestionAnswer
What are the two components of the CNS? Brain, Spinal Cord
What is the peripheral nervous system made up of? Cranial nerves, Peripheral Nerves
What is the autonomic nervous system made up of? Sympathetic and Parasympathetic
Is responsible for stimulating activities associated with the fight-or-flight response Sympathetic
Responsible for stimulation of activities that occur when the body is at rest, including salivation, lacrimation, urination, digestion and defecation Parasympathetic
Lobe in cerebrum responsible for voluntary movements, memory, abstract thinking, judgment, ethics, emotions Frontal
Lobe in the cerebrum responsible for understanding speech and in using words to express thoughts. Parietal
Lobe in cerebrum responsible for visual reception/recognition, spatial orientation. Occipital
Lobe in cerebrum responsible for auditory reception/hearing. Temporal
System responsible for olfaction, visceral responses to moods, behavioral responses; alertness/attention; sexual behavior; pain/pleasure Limbic
What are the two components of the brain stem? Cerebellum, spinal cord
Cerebellum assists the ____ with making ______ smooth and coordinated Cerebral cortex, movements
Cerebellum controls _____ in order to maintain ______. Skeletal muscle, equilibrium
What factors are important when obtaining a neuro history? headache, dizziness, fainting, vision changes, numbness, weakness, past head injuries, medications, recent medications, recent moves or changes in one's life, nutritional status and fluid intake, mood changes, any change in neuro functioning
What is the first/PRIME indicator that central neurological functioning has declined? A change in LOC
What are the five LOC “statuses”? Alert, Lethargic, Obtunded/Stuperous, Semi-comatose, Comatose
Person is awake and readily responds to verbal/tactile stimuli Alert
Sleepy but interacts when shaken Lethargic
Very sleepy, requires constant stimulation to respond; disoriented, responds to painful stimuli with purposeful movements Obtunded/Stuperous
unable to awaken, but may stir/moan when stimulated; corneal, gag, cough reflexes intact. Semi-comatose
No voluntary response, even to painful stimuli; reflexes not intact, thus you must protect the airway and cornea. Comatose
Standardized assessment tool that assesses LOC, predicts recovery. Glasgow Coma Scale
What three things are assessed as a part of the Glasgow Coma Scale? Eye opening, motor response, verbal response
A score of less than ___ on the Glasgow Coma Scale indicates coma 7
What are two abnormal postures Decorticate, Decerebrate
Abnormal posturing that involves rigidity, flexion of the arms, clenched fists, and extended legs (held out straight). The arms are bent inward toward the body with the wrists and fingers bent and held on the chest. Decorticate
Abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backwards. The muscles are tightened and held rigidly. Deceberate
What three tools can be used to monitor a change in status? Glasgow coma, mini mental, NIH Stroke Scale
This tool helps predict recovery after a stroke NIH Stroke Scale
We assess cognitive function, in part, by the client’s ability to orient to what three things? Person, place, time
We access cognitive function according to what three types of memory? Remote, recall, immediate
What can we ask a client to determine their thought process? Ask them the meaning of proverbs, etc.; young are not able to relate
How can we assess the attention of our client? Ability to repeat a series, such as numbers
How can we assess the language and copying of our client? Ask client to copy a picture such as a shape
How can we assess a higher level function such as abstract reasoning? Ask about favorite hobbies, current events, name of presidents, meanings of proverbs.
What type of impairment does the mini mental exam screen for? Cognitive
Nerve responsible for sense of smell Olfactory 1
Nerve responsible for vision Optic 2
Nerve responsible for ability to open and close eyelids and pupil constriction Oculomotor 3
Nerve responsible for movement of the eye downward Trochlear 4
Nerve responsible for facial sensation, chewing, opening and closing of the jaw Trigeminal 5
Nerve responsible for the movement of the eye inward and outward Abducens 6
Nerve responsible for facial movements (smile/frown), taste anterior 2/3 of tongue Facial 7
Nerve responsible for the ability to hear and equilibrium Acoustic 8
Nerve responsible for the sense of taste on the posterior 1/3 of the tongue, swallow reflex Glossopharyngeal 9
Nerve responsible for the control of the muscles of the larynx (quality of the voice) and the gag reflex Vagus 10
Nerve responsible for shoulder shrug, turn head side to side, flex/extend neck Accessory 11
Nerve responsible for tongue movement Hypoglossal 12
What are the five sensory functions of the nerves? Touch, pain, temp, position, tactile discrimination
When would we test temperature sensation? Tested when pain sensation is not normal
How is temp pain tested? When is it abnormal? Touch skin with tubes filled with hot or cold water//areas of dulled or lost sensation
How is position or kinesthetic sensation tested? When is it abnormal? With clients’ eyes closed, move a finger or toe up and down and ask the person to tell you which finger or toe//client unable to determine position.
How is point location tested? When is it abnormal? Touch the skin and withdraw the stimulus promptly. Tell the person to put their finger where you touched them//unable to identify spot touched.
How is stereognosis tested? When is it abnormal? Place familiar objects in a person’s hand and have them identify; or write a number or letter in the palm of their hand//unable to identify.
How is light touch sensation tested? When is it considered abnormal? Compare light touch sensations of symmetric areas of the body with cotton swab. Proceed from hands and arms and feet or legs to trunk//unable to feel one side or both sides.
How is pain sensation tested? When is it considered abnormal? Have client distinguish between sharp pain and soft or dull touch//heighted, reduced or absent sensation
Why and how do we test finger to finger? What would be an abnormal finding? Fine motor coordination/cerebellum. With the person’s eyes open, ask them to use the index finger to touch your finger. After a few times, move your finger to a different spot//moves slowly and unable to touch fingers.
Why and how do we test finger to thumb? What would be an abnormal finding? Fine motor coordination/cerebellum. Touch finger and thumb on the same hand together rapidly//unable to coordinate with one or both hands
Why and how do we test heel to shin? What would be an abnormal finding? Fine motor coordination/cerebellum. Ask the person who is lying down to place his heel on the opposite knee and run it down the shin from the knee to the ankle//tremors or awkward
Why and how do we test finger to nose? What would be an abnormal finding? Fine motor coordination/cerebellum. Ask the person to close the eyes and stretch out arms. Ask them to touch the tip of their nose with each index finger, alternating hands//misses nose or does slowly.
Why and how do we test Alternating Supination/Pronation of Hands on Knees? What would be an abnormal finding? Fine motor coordination/cerebellum. Slap knees with both hands, then both backs of hands//clumsy or unable to do.
Why do we test Finger to Nose then to Examiner’s Finger? What would be an abnormal finding? Fine motor coordination/cerebellum/ misses finger, moves slowly.
Why and how do we test Walking Gait? What would be an abnormal finding? Gross Motor/Balance. have client walk across the room looking straight forward//unsteady, irregular gait; rigid
Why and how do we test Romberg? What would be an abnormal finding? Gross Motor/Balance. Have client stand with legs together and arms at side. (eyes open/closed); then arms out with palms up//unable to maintain and sways considerably
Why and how do we test Standing on one foot? What would be an abnormal finding? Gross Motor/Balance. Have client close eyes then stand on one foot, then the other//unable to maintain for 5 seconds
Why and how do we test Heel/Toe Walking on one foot? What would be an abnormal finding? Gross Motor/Balance. Have client walk a straight line placing heel in-front of other foot’s toes//wider foot gait to stay upright.
Why and how do we test Toe or Heel Walking? What would be an abnormal finding? Gross Motor/Balance. Ask client to walk several steps on toes, then heels//unable to maintain balance.
Why and how do we test Plantar reflex? Deep Tendon/Muscle Stretch Reflex. With the reflex hammer, draw a light stroke up the lateral side of the sole of the foot and inward across the ball of the foot.
What would be an abnormal finding for the Plantar reflex test? Dorsiflexion of the big toe with extension and fanning of the other toes. Normal in infants and abnormal in children and adults (Babinski sign)
continuous rhythmic reflex tremor initiated by the spinal cord below an area of spinal cord injury, set in motion by reflex testing Ankle clonus
How are reflexes graded? What is the scale? 0 = no response through 4+ hyperactive with clonus, 2+ average normal
Is asymmetry of reflexes normal or abnormal? Abnormal
What four general things are measured when evaluating mental status? Memory, attention, language, cognition
What four general things are measured when assessing the cranial nerves? Senses, motor function, cerebellar function, reflex activity
What two general things do we evaluate during the assessment of motor function? Muscle strength, cerebral/brainstem integrity
What two general things do we evaluate during the assessment of cerebellar function? Coordination, gait, equilibrium
What two general things do we evaluate during the assessment of reflex activity? Deep tendon reflexes, Babinski’s sign
What three things does a focused neuro assessment consist of? Glasgow coma scale, response to painful stimuli, pupil assessment
What does PEERLA stand for? Equal in size, round & regular in shape, and react to light and accommodation
When testing the extremities for strength, we would expect that the right and left sides would be_____. symmetrical
What are some examples of lab tests that could be performed to provide insight as to neurological functioning? Lab tests, radiographic exams, CT Scan, MRI, Lumbar puncture, EEG, EMG, CBF
What are five common mistakes made during neuro assessment? Inadequate stimulation of patient, inadequate/inaccurate baseline data, inaccurate description of assessment, failure to recognize subtle clues. Failure to persist and pursue
What three things does the Cushing’s triad consist of? Widening pulse pressure, bradycardia, abnormal respiration
At birth the brain is what fraction of the mature size? Two Thirds
Does the brain grow rapidly before birth? Yes
How is brain volume of infants measured? Head circumference
How much does brain volume increase in the 1st year? Six times
At birth, do babies have a lot of control over their body movements? No, primitive reflexes are responsible for most movement.
When is the Babinski reflex present? 12-24 months
When is the grasp reflex present? Birth
In what sequence does motor control develop in newborns? Head, neck, trunk and extremities
In the older adult, transmission of the nerve impulse_____. Slows
In the older adult, the thought process ____ Slows
In the older adult, the verbal response is usually ____. In tact
The older adult has a decreased sense of what three things? Taste, hearing, smell
What happens to the coordination and voluntary movements of the older adult? Slow
What happens to the ankle reflex in the older adult? It is decreased
What three things happen to the gait of the older adult? It slows, a wider base of support is used, the hips and knees become flexed
Created by: anastasia158