Health Assessment in Nursing: Chapter 27
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| What could cause numbness/tingling? | Damage to brain, spinal core, or peripheral nerves (basically nerve damage)
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| What could cause seizures? | Epilepsy, metabolic disorders, head injuries, and/or high fevers
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| What might cause morning headaches that subside after arising? | Increased intracranial pressure (e.g. brain tumor)
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| Dysfunction of what cranial nerve would diminish one's sense of smell? | Cranial nerve I (olfactory)...could also be caused by a brain tumor--a common diagnosis the television drama House.
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| What would cause ring in one's ears, or hearing loss? | Dysfunction of cranial nerve VIII (acoustic)
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| Dysfunction of which nerve(s) would cause changes in vision? | Mostly cranial nerve II (optic); Damage to III (oculomotor), IV (trochlear), or VI (abducens) would cause double or blurred vision
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| Damage to which nerves would affect one's ability to swallow? | IX (glossopharyngeal), X (vagus) or XII (hypoglossal)
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| Bowel and/or urinary control can be caused by damage to what? | Um...the book just says spinal cord. Lame, I know.
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| What might cause one to have tremors? | Degenerative neuro-disorders (think parkinson's), or cerebellar disease, or MS
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| What may cause loss of recent (24 hour) memory? | Amnesia, Korsakoff's syndrome, delirium, and/or dementia.
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| What may cause loss of remote (think longer-term) memory? | Cerebral cortex disorders.
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| What is a CVA? | A cerebrovascular accident; a stroke
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| T/F Peripheral neuropathy can be caused by a vitamin deficiency. | True: niacin, folic acid, vitamin B12 (all B-vitamins)
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| Which American minority is twice as likely to endure a CVA than caucasian? | African Americans
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| Describe the scale used to report reflex response. | 0 to 4+; 0 being no response, 2+ being normal, and 4+ being hyperactive
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| Describe the assessment of cranial nerve I (olfactory) | Ask client to identify familiar smell (e.g. soap)
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| Describe the assessment of cranial nerve II (optic) | Use the Snellen chart (bad vision/missing letters=bad); red-reflux with irregular margins (using opthalmoscope) may equal papilledema.
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| Describe examination of nerves III, IV, and VI | Watch for droopy eyelid (think Paris Hilton); or uncoordinated motion of eye.
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| Describe the elements of a quick "nero check" | LOC, pupillary, movement/strength of extremities, VS
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| Describe the muscle strength table | Scale of 0-5
5: Active against full resistance (normal)
4: Active motion against some resistance (slight weakness)
3: Active against gravity (poor ROM)
1: Slight flicker (severe weakness)
0: No response (paralysis)
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| Why is it important to assess LOC first? | LOC validates subjective information collected from client
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| How do you test for corneal reflex? (CN VII: facial) | Touch the eye with a "fine wisp of cotton" - eyes should blink bilaterally
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| How do you assess for proper motor function of CN V (trigeminal) | Ask client to clench teeth; palpate masseter muscles; both S/B clinched bilaterally.
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| What would you ask of a client to assess motor function of CN VII (facial)? | Have them make faces; smile, frown, wrinkle forehead, etc.
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| What are normal findings of an assessment of motor function of the CNs IX (glossopharyngeal) and X (vagus)? | Demonstrates unlabored swallowing, positive gag reflex, and rising of the uvula and soft palate on phonation (CN X only; say ahhhhh).
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| Describe the method for assessing the CN XI (spinal accessory) (hint: involves resistance) | S/B able to shrug shoulders (otherwise: paralysis), and turn head (otherwise PN disease) against resistance.
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| What would an assessment of CN XII (hypoglossal) test for? | Fasciculations/Arophy caused by PN disease. Watch for deviation of tongue to affected side.
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| What kind of tests would be appropriate when evaluating the function of CN VIII? | (CNVIII=acoustic/vestibululocochlear nerve) Weber test (bilatteral hearing); Rinne test (vibratory senses); hearing (air conduction) should be 2Xs longer than vibratory conduction.
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| What does AAOx4 (or A&Ox4) mean? | Alert, aware, and oriented X4 (person, place, time, situation)
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| T/F muscle atrophy is the result of inactivity, and is not a sign of neural defect. | Fasle: neural defect can cause inactivity, and muscle atrophy (p. 581) Muscle atrophy can be a sign of lower neuron disorders.
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| Q. Elizabeth demonstrates bizarre face, tongue, jaw, and lip movements. What is likely to be the cause of Elizabeth's symptoms? | A. Chronic psychosis, or prolonged use of psychotrophic drugs.
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| Q. Jason has slow movements in his lower extremities, as if he is trying to run while half submersed in a swimming pool. What is the cause? | A. Cerebral palsy. (could also cause slow, twisting movements in his face...bummer)
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| Q. John presents with a wide-based, staggering, unsteady gate. He also demonstrates a positive Rhomberg's test. What is his diagnosis? | John is presenting with cerebellar ataxia for one of two reasons: either John has cerebellar disease, or he is drunk. hopefully the latter.
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| Q. Jake presents with a shuffling gait. He turns in a very stiff manner, has a stooped-over posture with flexed hips and knees. What's Jakes problem? | A. Jake is either doing an impression of Bill Cosby dancing, or he is presenting with Parkinsonian Gait. Either way it's painful to watch.
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| Q. Scott emerges from his low-rider with a flexed arm held close to his body. As he ambulates, you notice that he his dragging the toe of one leg behind him. WTF is up w/ Scott? | A. Scott is suffering from one of two serious issues: either he is experiencing spastic hemiparesis, or he thinks he is a gangsta from the 2c. Either way, it's likely the result of a recent stroke. Poor Scott
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| What is Nystagmus, and what is it a S/S of? | Rhythmic oscillation of the eyes; issues with CNIII, IV, and/or VI
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| What is paralytic strabismus, and what is it a S/S of? | Paralysis of the CNs III, IV, and/or VI
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