203 Exam #2 Flashcards
Neurologic system:
- balance, coordination, & movement
- speech
- senses
Cerebellum
Neurologic system:
- sight
Occipital lobe
Neurologic system:
- interpretation of smells sound & language
- Wernicke’s area
Temporal lobe
Neurologic system:
- breathing
- heart rate
- cough
- sleep
- consciousness
Brain stem
Neurologic system:
- cardiac
- vasomotor
- respiratory
- digestion
Medulla oblongata
Neurologic system:
- respiratory function
Pons
Neurologic system:
- auditory & visual reflexes
Midbrain
Three vital parts of the brain stem
Medulla oblongata, pons, midbrain
Are the following examples of subjective or objective data regarding alterations in the neurologic system:
- pain
- nervousness
- dizziness
- nausea
- vertigo
- changes in vision
- parasthesia (numbness & tingling
Subjective
What is assessed to obtain objective data relating to alternations in the neurological system?
The 12 cranial nerves
What are the five pieces of data (some subjective, some objective) from the assessment of the neurological system used to identify risk factors, analyze findings, and plan intervention?
LOC
Orientation (x4)
Speech
Behavior
PERRLA
Which two diagnostic tests are ordered to:
- check for allergies
- check renal function
Computed tomography (CT)
and
Magnetic resonance imaging (MRI)
Which diagnostic test is ordered
to measure electrical activity in the brain?
Electroencephalogram (EEG)
Which diagnostic test is ordered to:
- assess risk of infection or hemorrhage
- look for signs of CSF
Lumbar puncture
When performing a lumbar puncture, what findings are considered “normal”?
Colorless/clear fluid
After performing a lumbar puncture, what position should the patient be in and for how long?
Flat on either stomach or back for eight hours
What does the American Stroke Association’s acronym “F.A.C.E.” stand for?
Face dropping
Arm weakness
Speech
Time
Define lethargy
Drowsiness
Define hypotonia
Decreased muscle tone
Define hypertoria
Increased muscle tone
Define rigidity
Muscles contract & tense
Define spasticity
Increased muscle tone
Define hemiparesis
Loss of muscle tone & strength on one side of the body
Define paraplegic
Paralysis of lower extremities
Define quadriplegic
Loss of sensory & motor function in both lower & upper extremities
What is the sclera & what is its function?
White structure that protects eye & maintains structure
What is the lens of the eye responsible for?
Refracting light
What are the two functions of the eyelid?
Protecting & lubricating the eye
What is the conjunctiva of the eye?
Thin membrane covering ye
What are the lacrimal glands?
Tear ducts
What is the auricle (pinna):
Outer, visible portion of the ear
What is the eustachian tube?
What is the cochlea?
Organ of hearing
What is the tympanic membrane?
Shiny, translucent eardrum
What are the nostrils lined with?
Mucous membrane
What are adenoids?
Lymphatic tissue part of immune system found in the nose
What are the salivary glands responsible for?
Secreting saliva to begin digestion
What are the two pieces of subjective data relating to alterations in the HEENT?
Tinnitus & vertigo
What four things are associated w/ vertigo?
- dizziness
- pain
- headache
- difficulty swallowing
What is the Snellen chart diagnostic test & how is it used?
Visual acuity, stand 20 ft. away w/ card covering one eye then read smallest line
What is the Weber/Rinne diagnostic test?
Conduction test for hearing loss using a tuning fork
When is the swallowing evaluation diagnostic test used?
When dysphasia (difficulty swallowing) is observed or reporter
What is done after dysphasia is observed or reported aside from conducting a swallowing evaluation?
Referral to speech pathologist who will observe eating & drinking
What is the modified barium swallow study diagnostic test?
X-ray that assesses swallowing by having patient drink barium sulfate
Which 3 diagnostic tests require the nurse to check if the patient takes metformin?
CT, MRI, angiogram
Why is it important to check if a patient takes metformin prior to conducting certain diagnostic tests?
If contrast is used on a patient who takes metformin, the kidneys may be damaged
What is one way hearing impaired patients can practice health promotion & risk reduction?
Ensure there are working smoke detectors in the home
Define tinnitus
Ringing in the ears
Define vertigo
Feeling dizzy/surroundings are moving
Define diplopia
Double vision
Define nystagmus
Involuntary rhythmic movement of the eyes
Define myopia
Nearsighted- far away objects are blurry
Define hyperopia
Farsighted- close up objects are blurry
Define presbyopia
Vision loss due to old age
Legally blind
20/200
Define conjunctivitis
Viral infection causing inflammation of the conjunctiva
Define ptosis
Abnormal drooping of the eyelid
What are the four main functions of the lymph system?
- immunity spread of infection
- production of WBC
- fluid & protein balance
- absorbs lipids during digestion
What are the spleen’s two function in the lymph system?
- filters & stores blood
- produces WBC
What is the largest organ in the lymph system?
Spleen
What is the thymus’ function in the lymph system?
Matures a specific type of WBC that fight off foreign organisms
What is bone marrow’s function in the lymph system?
Produce RBC, WBC, & platelets
What are the tonsils & adenoids two main functions in the lymph system?
- trap pathogens from food
- serve as first line of defense against foreign invaders
What is the appendix’s function in the lymph system?
Contain lymphoid tissue that can destroy bacteria prior to reaching intestinal wall during absorption
What are the peyers patches in the lymph system?
Small masses of lymphatic in the mucous membrane that line the S.I.
What are lymph nodes and what do they do?
Small oval shaped lymphatic glands, network of fibers & irregular channels that slow down lymph flow
What happens as lymph fluid passes through nodes?
Fibers filter out bacteria, viruses, & cellular debris
What four substances make up lymphoma?
- proteins
- water
- impurities
- waste products
Lymph fluid seeps into tissue from ______, is stored in the _______ _______ and flows back into _______ _______
Circulation; lymphatic system; blood circulation
How does lymph fluid move?
In one direction
What are the four primary pieces of subjective data relating to alterations in the lymph system?
- pain
- tenderness
- fatigue
- feeling of fullness
What is the proper way to assess the 10 neck & face lymph nodes?
- Patient sits up & slightly flexes neck
- Use index & middle finger pads to palpate in circular motions on both sides
Assessing edema: grade 1+ pitting depth & duration
2 mm, disappears rapidly
Assessing edema: grade 2+ pitting depth & duration
4 mm, disappears in 10-15 seconds
Assessing edema: grade 3+ pitting depth & duration
6 mm, lasts more than a minute
Assessing edema: grade 4+ pitting depth & duration
8 mm, last 2-3 minutes
What are the characteristics of a “normal” lymph mode?
- less than 1 cm.
- moveable
- not tender
What are the characteristics of an “abnormal” lymph node?
- anything over 1 cm
- rubbery, rock hard
- fixed
- tender
What are the two purposes of the following diagnostic test: lymph node biopsy
- detects infection/cancer
- checks for bleeding abnormalities
The incision site must be monitored for signs of infection following which diagnostic test?
Lymph node biopsy
What is the purpose of the following diagnostic test: angiogram
Diagnose vascular insufficiencies & blockages in lymphatic system
Prior to conducting am angiogram diagnostic test, what two things does the nurse need to check regarding the patient?
- does the patient have allergies?
- does the patient have a bleeding disorder?
Relating to an angiogram, nurse needs to check for changes in _____ _____ as well as changes in ______ & _______ of skin around incision
Peripheral pulse; color; temperature
Following an angiogram, what position should the patient maintain and for how long? Why?
Supine position for 2-6 hrs, prevents stress un the puncture site
What are the 6 risk factors for lymphedema?
- family history of lymphedema
- removal of lymph nodes
- invasive surgery
- radiation therapy
- chemotherapy
- morbid obesity
Define lymphedema
Swelling/accumulation of fluid in lymphatic system
Define leukocytosis
Elevation of WBC
Define lymphadenopathy
Enlarged lymph nodes due to infection, inflammation, or cancer
Define lymphoma
Cancer of lymphatic system (hodgkins/nonhodgkins)
Define lymphocytosis
High concentration of fluid
Neurologic system:
- emotions
- reasoning
- abstraction
- consentration
- information storage
- voluntary eye movement
- Broca’s area/motor control of speech
Frontal lobe
Neurologic system:
- integrates sensory information
Parietal lobe
Neurologic system:
- controls emotions
- reasoning
- abstraction & concentration
- storage & concentration
- voluntary eye movement
- Broca’s area: motor control speech
Frontal lobe
Neurologic system:
- integrates sensory information
Parietal lobe
What do the following test evaluate: TSH, T3, T4
Thyroid function
Define nystagmus
Eyes involuntarily moving from side to side
What are the 8 structures of the lymphatic system?
- spleen
- thymus
- appendix
- bone marrow
- lymph nodes
- tonsils
- adenoids
- peyer’s patch in S.I.
