301 Test 2 muscle skeletal Flashcards
1
Q
At times, you will assess the musculoskeletal system and the ____ system together
A
neurological
2
Q
Musculoskeletal Assessment: Ask clients if they have had previous problems with falls, fractures, trauma, or ___ deficit.
A
neurological
3
Q
excessive inward curvature of the spine
A
lordosis
4
Q
humpback
A
kyphosis
5
Q
5 NDX of musculoskeletal assessment
A
Impaired mobility impaired ADLs risk for fall activity intolerance self-health management
6
Q
main point of body mechanics
A
To move your body without causing injury
7
Q
Avoid bending and __
A
twisting
8
Q
when lifting ___ abdominal muscles and tuck ___
A
tighten
pelvis
9
Q
how many minutes a week of moderate and vigorous-intensity exercise are recommended
A
150–300
10
Q
a complete or partial collapse of a lung
A
Atelectasis
11
Q
Atelectasis/pneumonia can be caused by
A
Immobility
12
Q
Increased coagulability can be caused by
A
Immobility
13
Q
Glucose intolerance can be caused by
A
Immobility
14
Q
Orthostatic hypotension can be caused by
A
Immobility
15
Q
Renal calculi can be caused by
A
Immobility
16
Q
Paralytic ileus can be caused by
A
Immobility
17
Q
Urinary tract infection can be caused by
A
Immobility
18
Q
Obstruction of the intestine due to paralysis of the intestinal muscles
A
Paralytic ileus
19
Q
NDX with the external related factors: chemical substance, extremes in age, hyperthermia, hypothermia, moisture, medications, radiation
A
impaired skin integrity
20
Q
NDX with the internal related factors: change in fluid status, change in pigment, change in turgor, immunological deficit, impaired metabolic state
A
impaired skin integrity
21
Q
NDX defining characteristic: invasion of body structures
A
impaired skin integrity
22
Q
If the patient has no neural complaints, it acceptable to
A
only check if they’re alter and oriented
23
Q
If patient has neural issues, the first question you ask is
A
do they have a headache
24
Q
A headache could signify
A
increased cranial pressure which could lead to stroke
25
numbness and tingling could mean the pt is having a
stroke
26
if patient has numbness and tingling next step is to assess
motor ability
27
difficulty or discomfort in swallowing
dysphagia
28
cranial nerve, most EOM movement
oculomotor
29
cranial nerve, opening eyelids
oculomotor
30
cranial nerve, pupil constriction/lens shape
oculomotor
31
cranial nerve, down and outward eye movement
trochlear
32
cranial nerve, lateral eye movement
abducens
33
cranial nerve, chewing
trigeminal
34
cranial nerve, sensation in face, scalp, cornea
trigeminal
35
cranial nerve, sensation in mucous membrane and mouth and nose
trigeminal
36
cranial nerve, close eye
facial
37
cranial nerve, labial speech, close mouth
facial
38
cranial nerve, taste in front of tongue
facial
39
cranial nerve, saliva and tear secretion
facial
40
cranial nerve, swallowing
glossopharyngeal, vagus
41
cranial nerve, gag reflex/taste in back of tongue
glossopharyngeal
42
cranial nerve, movement of tongue
hypoglossal
43
optic disc swelling that is caused by increased intracranial pressure
papilledema
44
PERRLA tests which cranial nerve
Oculomotor
45
PERRLA
Pupils are equal, round, reactive to light, accommodate
46
which cranial nerve is tested by asking the patient to clench teeth and then you try to open them
trigeminal (which does chewing)
47
which cranial nerve is test when you do light touch on the person's face
trigeminal (sensation in the face)
48
which cranial nerve is tested when you ask the person to smile, frown, etc
facial (face muscles)
49
which cranial nerves are tested when you depress with tongue blade and ask the person to say Ahh
glossopharyngeal and vagus
50
When a person says Ahh the soft palate and uvula should rise in the midline and the tonsil pillars should move
medially
51
which nerve is tested when you ask the patient to forcefully turn their head
spinal
52
which nerve is tested when you ask the person to stick out their tongue or say "light tight dynamite"
hypoglossal (does tongue movement)
53
being unable to see might be a precursor to
MS
54
when you shine the light on one eye, the other should constrict too, this is called
consensual constriction
55
when looking at an object that's far away, your eyes
dilate
56
characterized by severe pain in the cheek. Cause can be unknown or can be from facial radiation
Trigeminal neuralgia
57
acoustic nerve problems often have to do with a
tumor
58
if someone has a hearing nerve problem, it involves the nerve on the same side as the ear (aka it's ___)
ipsilateral
59
for peripheral neuropathy and diabetes, test with light, random touch. Do not use
strokes
60
"as part of a neuro exam I'm going to ask you to identify some objects with your eyes closed"
stereogenesis
61
If someone can identify an object they are stereogenesis ___
positive
62
In scales, what number usually indicates normal
2
63
reflex that's normal from 2 1/2 months to 2 1/2 years
babinski
64
in the babinski reflex the toes
extend
65
3 areas tested in the glascow coma scale
eye
motor
verbal
66
glascow eye is a scale of what to what
1 to 4
67
glascow motor is a scale of what to what
1 to 6
68
glascow verbal is a scale of what to what
1 to 5
69
glascow opens eye spontaneous
4
70
glascow opens eye to speech
3
71
glascow opens eye to pain
2
72
glascow no response is always (not 0)
1
73
glascow moves in response to speech
6
74
glascow localizes pain
5
75
glascow flexion withdraw
4
76
glascow flexion abnormal
3
77
glascow extension abnormal
2
78
glascow oriented x3
5
79
glascow conversation confused (thinks it's 1962, but said it normally)
4
80
glascow speech inappropriate (says normal words but they dont make sense it this context)
3
81
glascow speech incomprehensible
2
82
patient holding 1 arm and liming could indicate
stroke
83
spinal cord injury increases risk for (3)
cant pee, constipated, impaction
84
to check for urinary retention, palpate
superpubic region
85
fecal impaction can lead to death because it effects which nerve
vagus
86
arms at the core, feet flexed and turned in. Means serious brain issues
decorticate rigidity
87
For pain stimulation, we do not use
sternal rubbing
88
which is more serious between decerebrate rigidity and decorticate rigidity
decerebrate
89
arms adducted to the persons sides
decerebrate rigidity
90
acute confusion is aka
delirium
91
Everyone in an ICU gets screened for
delirium
92
best test to confirm dementia is
beside cognitive exam
93
PET scan is used for
cancer patients
94
cardiac ischemia leads to
angina
95
difficult or labored breathing
dyspnea
96
the most important vital to check if someone has activity intolerance
SAO2
97
normal range for albumin
3.5 to 5.0
98
low sodium is aka
hyponutrenia
99
tensing legs and then relaxing is what kind of exercise
isometric exercise
100
walking is what kind of exercise
weight bearing
101
cycling and swimming dont do bone growth but they're good for
joint mobility
102
joint becomes fused in place
contracture
103
how often should you do range of motion
every 2 hours
104
atelectasis is caused by
ineffective breathing. Can esp be a problem for someone who is laying down and therefore can't take a deep breath. This means the lower alveoli don't get used, which can lead to bacterial infection
105
best way to prevent pneumonia is
oral care QID
106
temp of a DVT leg will be
increased
107
3 cranial nerves usually assessed together
oculomotor, trochlear, abducens
108
cranial nerve for superior oblique
trochlear
109
weakness of which nerve causes ptosis
oculomotor
110
testing how well someone can move his jaw
trigeminal
111
asking someone to open his eyes
facial
112
can you clench your eyes shut
facial
113
can you smile, puff cheeks, etc
facial
114
tuning fork is used for which 2 tests
weber and rinne
115
weber and rinne test which nerve
acoustic
116
Weber involves placing the tuning fork where?
forehead
117
can you cough?
vagus and glossopharyngeal
118
can you stick out your tongue?
hypoglossal
119
what kind of vitamin deficiency causes loss of smell
zinc
120
An intact corneal reflex is a normal finding for which nerve
trigeminal
121
being able to feel light touch in the face is a normal finding of which nerve
trigeminal
122
being able to taste at the front of the tongue
facial
123
a negative romberg test is a normal finding for which nerve
acoustic
124
ability to talk
vagus and glossopharyngeal
125
able to swallow
vagus and glossopharyngeal
126
gag reflex
vagus and glossopharyngeal
127
uvula and soft palate rise symmetrically
vagus and glossopharyngeal
128
poor voice quality is an abnormal finding for which nerve
vagus
129
test if client can say "d, l, n, t"
hypoglossal
130
optic nerve deficits may be due to __ or __
tumor or CVA
131
EOMs and pupillary reaction can result from change in
ICP
132
asymmetrical movement of the face (facial nerve) can result from CVA or
Bells Palsy
133
Ptosis is caused by damage to which nerve
oculomotor
134
horner syndrome is
decreased pupil size/ptosis
135
back and forth oscillation of the eyes
nystagmus
136
uncoordinated/unsteady gate
ataxia
137
positive romberg can indicate which disease
MS
138
loss of vibration sense occurs in diabetes and
alcoholism
139
__ and __ are unreliable indicators of CNS deficit
pulse and BP
140
muscle twitching
fasiculation
141
sudden jerk at fairly regular intervals (ie hiccup, arm jerk)
myoclonus
142
most common tremor in older adults
essential tremor
143
the 3 main medications included in risk for falls
diuretics, opiates, antihypertensives
144
Standing: crutches on __ side
bad
145
client should not to lean on ___ to support body weight
crutches
146
walk w cane on __ side
good
147
Preventing complications of immobility: Provide high-protein, high-caloric diet with vitamin _ and _ supplements
B and C
148
Preventing complications of immobility: Cough and deep breathe every
1 to 2 hours
149
Vitamin _ is needed for skin integrity and wound healing
B
150
SCDs
sequential compression device
151
CPM
continuous passive motion
152
Clients need between ___ to 3000 ml of fluids per day to help prevent renal calculi and UTIs
2000
153
head tilts to one side
Torticollis
154
Grading Muscle Strength, full ROM against gravity, full resistance
5
155
Grading Muscle Strength, full ROM against gravity, some resistance
4
156
Grading Muscle Strength, full ROM with gravity
3
157
Grading Muscle Strength, full ROM with gravity eliminated (passive motion)
2
158
Grading Muscle Strength, slight contraction
1
159
Grading Muscle Strength, no contraction
0
160
Order of the muscle examination
Inspection, palpation, ROM, muscle strength test
161
Inflammatory conditions of joints include RA and
Ankylosing spondylitis
162
Degenerative conditions of joints include
Osteoarthritis
| Osteoporosis
163
Serotonin __ pain
inhibits
164
Prostaglandins ___ pain
promote
165
bind to peripheral nerve receptors and promote pain; bind to cells to produce prostaglandins
Bradykinin
166
Body’s natural supply of morphine like substances
Neuromodulators
167
Increased blood glucose is sympathetic or para?
sympthathetic
168
Pallor, Muscle tension, Rapid irregular breathing is sympathetic or para?
para
169
pain that arises in the skin or the subcutaneous tissue.
Superficial
170
pain that originates in the ligaments, tendons, nerves, blood vessels, and bones.
Somatic
171
fracture or sprain, arthritis, and bone cancer can cause deep __ pain
somatic
172
pain that occurs in an area that is distant from the original site. For example, the pain from a heart attack may be experienced down the left arm
Referred
173
pain that is believed to arise from the mind
Psychogenic
174
complex and often chronic pain that arises when injury to one or more nerves results in repeated transmission of pain signals even in the absence of painful stimuli
Neuropathic
175
pain that is both chronic and highly resistant to relief
Intractable
176
older adult feel drugs more ___ than younger
strongly
177
Fatigue increases the perception of
pain
178
VS not valid indication of __
pain
179
TENS
Transcutaneous electrical nerve stimulation (TENS)
180
PENS
Percutaneous electrical nerve stimulation (PENS)
181
drugs used to treat other conditions but they also have analgesic qualities (tricyclic antidepressants and anticonvulsants).
Adjuvants and coanalgesics
