Chapter 15 Exam 2 Flashcards
Intracranial Regulation
This concept represents mechanisms that facilitate or impair neurologic function. Because brain function requires perfusion of oxygenated blood and because the respiratory & cardiovascular systems are impacted by neurologic control, strong bidirectional interrelationships among these concepts exist
Both sensory and tactile perception and motion are extensions of neurologic function that impact what?
Other interrelated concepts such as nutrition, development (functional ability), elimination and pain
Explain the example of a stroke using the interrelationships of intracranial regulation.
- A stroke results from lack of oxygenated blood to the brain
1) Following a stroke an individual may experience problems w/sensory and tactile perception and motion
2) This leads to impacting nutrition, elimination, pain perception and functional ability
Structural divisions of the nervous system
1) Central nervous system (CNS): brain and spinal cord
2) Peripheral nervous system (PNS) which includes all nerve fibers outside brain and spinal cord
3) Autonomic nervous system (ANS)
Foramen magnum
Large oval opening at the base of the occipital bone through which the spinal cord extends from the medulla oblongata
Meninges
Are between the skull and the brain.
There are 3 layers
1) Dura mater: outer fibrous layer
2) Arachnoid: middle meningeal layer, two layer fibrous, elastic membrane that covers the folds and fissures of the brain
3) Pia mater: the inner meningeal layer contains small vessels that supply blood to the brain
-between the arachnoid and the pia mater is the subarachnoid space where the cerebrospinal fluid (CSF) circulates
Falx cerebri
A fold of dura mater that separates the two cerebral hemispheres
Tentorium cerebelli
A fold of dura mater the supports the temporal and occipital lobes and separates the cerebral hemispheres from the cerebellum
Supratentorial and infratentorial
Supratentorial: structures above the tentorium cerebelli
Infratentorial: Structures below the tentorium cerebelli
CFS is colorless, odorless fluid made in the choroid plexes of ventricles that contains?
Glucose, electrolytes, oxygen, water, carbon dioxide, protein, and leukolytes. It circulates around the brain and spinal cord to provide a cushion, maintain normal intracranial pressure, provide nutrition, and remove metabolic wastes
The cerebral ventricular system consists of four interconnecting chambers or ventricles that produce and circulate CSF
1) One lateral ventricle in each hemisphere, with a third ventricle adjacent to the thalamus
2) A third ventricle adjacent to the thalamus
3) A fourth ventricle adjacent to the brainstem
- The CSF circulates from the lateral ventricles through the interventricular foramen to the third ventricle and through the aqueduct of Sylvius to the fourth ventricle & into the cisterna magna from there the CSF flows w/in the subarachnoid space up around the brain & down around the spinal cord.
- CSF absorbed through arachnoid villi that extend into the subarachnoid space and is returned to the venous system
The brain consists of what?
1) Cerebrum
2) Diencephalon
3) Cerebellum
4) Brainstem
- It is made up of gray matter (unmyelinated cell bodies) and white matter (myelinated nerve fibers)
What supplies most of the blood to the brain?
The carotid arteries & they branch off into the posterior cerebral, middle cerebral, and anterior cerebral arteries.
- Remaining blood flows through two vertebral arteries & into the posterior and anterior communicating arteries that supply blood through the circle of willis.
- Blood leaves the brain through venous sinuses that empty into the jugular veins
Cerebrum is the largest part of the brain and is composed of two hemispheres. Each hemisphere is divided into four lobes, describe each lobe
1) Frontal lobes: control intellectual function, awareness of self, personality, and autonomic responses related to emotion
2) Left frontal lobe contains broca’s area which is involved in formulation of words
- the frontal lobes contain the primary motor cortex & are also responsible for functions related to voluntary motor activity
Nerves from the motor cortex cross over in the medulla oblongata so that nerves on the right side of the frontal lobe control movement on the?
Left side of the body and nerves on the right side of the frontal lobe control movement on the right side of the body.
The parietal lobes contain
The primary somesthetic (sensory) cortex.
- one of its major functions is to receive sensory input such as position sense, touch, shape, and texture of objects
The sensory nerves from the body cross over the medulla, so that nerve impulses from the right side of the body are received in the?
Left side of the parietal lobe and impulses from the left side are received in the right side of the parietal lobe
The temporal lobe contains?
The primary auditory cortex. Wernick’s area located in the left temporal lobe, is responsible for comprehension of spoken and written language. The temporal lobe also interprets auditory, visual, and somatic sensory inputs that are stored in thought and memory
The occipital lobes contain?
The primary visual cortex and are responsible for receiving & interpreting visual information
What makes up the Diencephalon?
1) Thalamus: Relay and integration station from the spinal cord to the cerebral cortex & other parts of the brain.
2) Hypothalamus: Several functions in maintaining homeostasis & include regulation of body temp., hunger & thirst; formation of ANS responses; & storage & secretion of hormones from pituitary gland
3) Epithalamus: Contains pineal gland which causes sleepiness & helps regulate some endocrine function
4) Subthalamus: pare of basal ganglia
Basal Ganglia is between the cerebral cortex and midbrain and adjacent to the diencephalon, the structures that form the basal ganglia include?
The putamen, caudate nucleus, globus pallidus, thalamus, red nucleus, and substantia nigra.
-Function of the basal ganglia is to create smooth, coordinated voluntary movement by balancing the production of two neurotransmitters: acetylcholine and dopamine
The brainstem is made up of?
The midbrain, pons & medulla oblongata.
-10 of the 12 cranial nerves originate from the brainstem
Midbrain function
Function is to relay stimuli concerning muscle movement to other brain structures. Contains part of the motor tract pathways that control reflex motor movements in response to visual & auditory stimuli. Oculomotor nerve (CN III) & trochlear nerve (CN IV) originate in the midbrain
Pons function
Relay impulses to brain centers & lower spinal nerves. The cranial nerves that originate in the pons are trigeminal (CN V), abducens (CN VI), facial (CN VII), and acoustic (CN VIII)
Medulla Oblongata function
Contains reflex centers for controlling involuntary functions such as breathing, sneezing, swallowing, coughing, vomiting, and vasoconstriction.
- Motor & sensory tracts from the frontal & parietal lobes cross from one side to the other in the medulla, so lesions on the right side of the brain create abnormal movement & sensation on the left side & vise versa.
- Cranial nerves that originate in the medulla are glossopharyngeal (CN IX), vagus (CN X), spinal accessory (CN XI), and hypoglossal (CN XII)
The cerebellum is separated from the cerebral cortex by the tentorium cerebelli. Functions of the cerebellum include?
Coordinating movement, equilibrium, muscle tone, and proprioception. Each of the cerebellar hemispheres controls movement for the same (ipsilateral) side of the body
The spinal cord is a continuation of the medulla oblongata that begins at the foramen magnum and ends at the first and second lumbar (L1, L2) vertebrae. At L1 & L2 the spinal cord branches into lumbar and sacral nerve roots termed the?
Cauda equina
The spinal cord consists of ____ segments, each giving rise to a pair of spinal nerves. Nerve fibers,
31
White matter of the spinal cord
Myelinated nerves that contain ascending and descending tracts of nerve fibers.
- The descending, or motor, tracts (e.g. anterior and lateral corticospinal or pyramidal tracts) carry impulses from the frontal lobe to muscles for voluntary movement. They also play a role in muscle tone and posture.
- The ascending, or sensory, tracts carry sensory information from the body through the thalamus to the parietal lobe. The fasciculus gracilis track travels in the posterior (dorsal) column carrying sensations of touch, deep pressure, vibration, position of joints, stereognosis, and two-point discrimination.
- the lateral spinothalamic tract carries fibers for sensation of light touch, pressure, temperature, and pain
The gray matter of the spinal cord
Contains the nerve cell bodies, is arranged in a butterfly shape w/anterior and posterior horns
Peripheral nervous system
Cranial nerves, spinal nerves, reflex arch
Peripheral nervous system: Cranial nerves
Of the 12 pairs of cranial nerves, some have only motor fibers (five pairs) or only sensory fibers (three pairs); whereas others have both (four pairs). Each cranial nerve controls movement or sensation for the same (ipsilateral) side of the body
Peripheral nervous system: Spinal nerves
The 31 pairs of spinal nerves emerge from different segments of the spinal cord: 8 pairs of cervical, 12 pairs of thoracic, 5 pairs of lumbar, 5 pairs of sacral, and 1 pair of coccygeal
- The first seven cervical nerves exit above their corresponding vertebrae. There are 8 cervical nerves but 7 cervical vertebra.
- Remaining spinal nerves exit below the corresponding vertebrae
Each pair of spinal nerves is formed by the union of an efferent, or motor (ventral), root and an afferent, or sensory (dorsal), root. The motor fibers carry impulses from? Sensory nerve fibers?
Motor: carry impulses from the sensory receptors of the body through the spinal cord to muscles and glands
Sensory fibers carry impulses from the sensory receptors of the body through the spinal cord to the brain (parietal lobe).
Each pair of spinal nerves and its corresponding part of the spinal cord make up?
a spinal segment and innervate specific body segments
The dorsal root of each spinal nerves supplies the?
Sensory innervation to a segment of the skin known as a dermatome (e.g. is patient complains of pain w/numbness and tingling across the right knee, the nurse knows that the fourth lumbar spinal segment is involved, perhaps compressed
Reflex arc
Are tested by observing muscle movement in response to sensory stimuli.
- Deep tendon reflexes are responses to stimulation of a tendon that stretches the neuromuscular spindles of a muscle group. Striking a deep tendon stimulates a sensory neuron that travels to the spinal cord where it stimulates an interneuron that stimulates a motor neuron to create movement.
- Superficial reflexes are tested in same manner. Each reflex corresponds to a specific spinal segment
Autonomic Nervous System (ANS)
Regulates the internal environment of the body in conjunction w/endocrine system. It has two components: sympathetic nervous system (SNS) & the parasympathetic nervous system (PNS)
Autonomic Nervous System (ANS): Sympathetic nervous system
Arises from the thoracolumbar segments of the spinal cord and is activated during stress (fight or flight responses).
Actions: Increases BP, HR, vasoconstricting peripheral blood vessels, inhibiting gastrointestinal peristalsis, dilating bronchi
Autonomic Nervous System (ANS): Parasympathetic nervous system
Arises from craniosacral segments of the spinal cord & controls vegetative functions (breed and feed, rest and digest).
Actions: functions associated w/conserving energy such as decreasing HR and force of myocardial contractions, decreasing BP & respirations, & stimulating gastrointestinal peristalsis
Cranial nerves
I. Olfactory II. Optic III. Oculomotor IV. Trochlear V. Trigeminal VI. Abducens VII. Facial VIII. Acoustic or vestibulocochlear IX. Glossopharyngeal X. Vagus XI. Spinal accessory XII. Hypoglossal
Cranial Nerve I
Olfactory: sensory, smell
Cranial Nerve II
Optic: sensory, sight
Cranial Nerve III
Oculomotor: Motor, raise eyelids, most extraocular movements
Parasympathetic: pupillary constriction, change lens shape
Cranial Nerve IV
Trochlear: motor, downward, inner eye movement
Cranial nerve V
Trigeminal: motor, Jaw opening and clenching chewing and mastication
sensory, sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal & mouth mucosa, teeth, tongue, ear, facial skin
Cranial nerve VI
Aducens: motor, lateral eye movement
Cranial nerve VII
Facial
Motor: movement of facial expression muscles except jaw, close eyes, labial speech sounds (b,m,w, and rounded vowels)
Sensory: taste on the anterior two thirds of tongue, sensation to pharynx
Parasympathetic: secretion of saliva and tears
Cranial nerve VIII
Acoustic or vestibulocochlear
Sensory: hearing and equilibrium
Cranial nerve IX
Glossopharyngeal
Motor: voluntary muscles for swallowing and phonation
Sensory: sensation of nasopharynx, gag reflex, taste on the posterior one third of tongue
Parasympathetic: secretion of salivary glands, carotid reflex
Cranial nerve X
Vagus
Motor: voluntary muscles of phonation (guttural speech sounds) and swallowing
Sensory: sensation behind ear and part of external ear canal
Parasympathetic: secretion of digestive enzymes; peristalsis; carotid reflex; involuntary action of heart, lungs, and digestive tract
Cranial nerve XI
Spinal accessory
Motor: turn head, shrug shoulders, some actions for phonation
Cranial nerve XII
Hypoglossal
Motor: tongue movement for speech sound articulation (l, t, n) and swallowing
Mnemonic for the cranial nerves
On: olfactory Some: sensory
Old: Optic Say: sensory
Olympus: Oculomotor Marry: motor
Towering: trochlear Money: motor
Top: Trigeminal But: both
A: Abducens My: motor
Finn: Facial Brother: both
And: Acoustic (vestibulocochlear) Says: sensory
German: Glossopharyngeal Bad: both
Viewed: Vagus Business to: both
Some: Spinal accessory Marry: motor
Hops: Hypoglossal Money: motor
Previous injury to the central nervous system may leave residual deficits such as?
Weakness or spasticity that you can anticipate during the exam. Injury to the frontal lobe can cause changes in memory and cognition
Risk factors for cerebrovascular accident (stroke)
- Age
- Gender
- Family history
- Race
- Smoking
- Alcohol
- High blood cholesterol
- Obesity
- Hypertension
- Diabetes mellitus
- Disorders that increase risk: previous cva, transient ischemic attack (TIA), heart attack
- Atrial fibrillation
Examination for neuro health
Routine techniques -Assess mental status and LOC -Evaluate speech -Notice cranial nerve functions -Observe gait -Evaluate extremities for muscle strength and tone Techniques for special circumstances -Assess cranial nerves -Assess cerebellum -Assess sensory function -Test deep tendon reflexes
Which cranial nerves are tested together?
The oculomotor (CN III), trochlear (CN IV), & abducens (CN VI) are tested together because they control muscles that provide eye movement
Bitter & sour tastes
Cranial nerve IX Glossopharyngeal (posterior one third)
Salty and sweet tastes
Cranial nerve VII Facial (anterior two thirds)
Which cranial nerves do you evaluate for movement of the soft palate and gag reflex?
Glossopharyngeal nerve (CN IX) & the vagus nerve (CN X)’
Stereognosis
Identification of a familiar object by mouth
Graphesthesia
Draw a letter or number on palm and ask patient to identify by touch
Evaluation of Cortical Sensory Function
Stereognosis
Two point discrimination
Graphesthesia
Location of tendons for evaluation of deep tendon reflexes
1) Triceps reflex
2) Biceps reflex
3) Brachioradialis reflex
4) Patellar reflex
5) Achilles reflex
6) Babinski’s reflex
7) Ankle clonus
Triceps reflex
Expected response is the contraction of the triceps muscle that causes visible or palpable extension of the elbow
Biceps reflex
Expected response is the contraction of the biceps muscle that causes visible or palpable flexion of the elbow
Brachioradialis reflex
Expected response is pronation of the forearm and flexion of the elbow
Patellar reflex
Expected response is contraction of the quadriceps muscle causing extension of the lower leg
Achilles tendon reflex
Expected response is the contraction of the gastrocnemius muscle, causing plantar flexion of the food
Check for the plantar reflex (Babinski’s reflex)
Expected response should be plantar flexion of all toes
Disorders of the CNS
1) Multiple sclerosis: Progressive demyelination of nerve fibers of the brain and spinal cord
2) Meningitis: Inflammation of the meninges that surround the brain and spinal cord
3) Encephalitis: Inflammation of the brain tissue and meninges
4) Spinal cord injury: Any traumatic disruption of the spinal cord. Injury to the cervical spinal cord may result in quadriplegia or tetraplegia, whereas injury to the thoracic and lumbar spinal cord may result in paraplegia
5) Craniocerebral Injury (head injury): Any injury to the scalp, skull, or brain that is sufficient to alter normal function. Open head injuries result from fractures or penetrating wounds; closed head injuries result from blunt head injury producing cerebral concussion or contusion.
6) Parkinson’s Disease: Chronic & progressive movement disorder resulting from the degeneration of the dopamine producing neurons in the substantia nigra of the basal ganglia
7) Cerebrovascular Accident (Stroke): When cerebral blood vessels become occluded by a thrombus or embolus or when intracranial hemorrhage occurs, the brain tissues become ischemic, resulting in a CVA or stroke
8) Alzheimer’s Disease: This is an incurable, degenerative neurologic disorder that begins with a decline in memory.
Disorders of peripheral nerves
1) Myasthenia Gravis: This neuromuscular disease is characterized by weakness of voluntary muscles that improves with rest and administration of anticholinesterase drugs. Three types of myasthenia: 1 ocular, which affects only the eyes; 2 bulbar, which involves the nerves that innervate the muscles needed for swallowing; and 3 generalized, which affects skeletal muscles of the arms, legs, and trunk
2) Guillain-Barre Syndrome: This acute syndrome is characterized by widespread demyelination of motor nerves of the peripheral nervous system. Patients usually have a respiratory or gastrointestinal viral infection weeks before the onset
During a health history, a patient reports having difficulty swallowing. Based on this report, which assessment technique does the nurse use to collect more data about the patient’s ability to swallow?
Observe the rising of the soft palate when the patient says “ahh”
As a patient is walking into the exam room, the nurse notices his unsteady gait. What findings does the nurse anticipate during the neurologic exam?
A tremor is observed in his hands while he touches his finger to his thumb on the same hand
During a symptom analysis the patient reports a pain that radiates from the right lateral thigh, over the knee, and around to the right medial ankle. The nurse refers to the dermatome map to determine that the patient’s description of pain is consistent with dysfunction of which spinal nerve
Fourth lumbar L4
Which question gives the nurse additional information about a patient’s report of his hands shaking for the last two months?
“Does the shaking occur when your hands are at rest or when you are picking up an item?”
Which technique does the nurse use to test the triceps reflex?
Holds the patient’s relaxed arm with elbow flexed at a 90-degree angle in one hand and strikes the appropriate tendon just above the elbow with either end of the reflex hammer
Which patient behavior indicates to the nurse that the patient’s facial cranial nerve (CN VIII) is intact?
The sides of the mouth are symmetric when the patient smiles
The nurse is preparing to assess a patient’s peripheral nervous sensory function. Which assessment test would the nurse use? Light touch sensation Two-point discrimination Romberg Rinne
Light touch sensation
Light touch can also be assessed with vibratory sensation and position sense of joints. Two-point discrimination evaluates cortical sensory function. Romberg assesses balance. Rinne is a screening test for hearing.
Sensory neurologic testing cannot realistically be performed with children until they are: at least 6 months old. toddlers. kindergarten age. middle school age.
kindergarten age.
Kindergarten children will need to be able to follow some basic directions. Six-month-old babies are too young because they need to be able to follow directions. Toddlers are bit too young. Middle school children can be tested well before this age.
Which statement regarding variations in neurologic functioning is true?
African-American adults have an enhanced reflex response.
American Indian children tend to develop early motor skills more rapidly than other children.
Asians have a greater sensation than do whites.
The function of the neurologic system is consistent across racial lines.
The function of the neurologic system is consistent across racial lines.
Generally speaking, there is very little racial variation in regard to neurologic function. Reflexes do not vary by race. American Indian children tend to develop motor skills faster than other ethnic groups, but this difference is only for the first few years of life. Sensation does not vary by race.
The nurse assesses an active reflex response. Which score should be documented? 1+ 2+ 3+ 4+
2+
2+ is the expected response. 1+ indicates a sluggish or diminished response. 3+ is considered a slightly hyperactive response, but it is not necessarily pathologic. 4+ indicates a brisk, hyperactive response with intermittent clonus and is usually indicative of a disease process.
The nurse is assessing an older adult’s neurologic status. The nurse should be aware that the neurologic responses of older adults:
should be the same as those of younger adults.
may be slower than those of younger adults.
are present but difficult to evaluate.
are enhanced as a result of irritability.
may be slower than those of younger adults.
Some abnormal findings are more common in the older adult. There may be a decline in function, thus differences should be expected. Evaluation of the findings should not be difficult. Some changes may be the result of a decline in function, not of irritability.
The nurse is assessing the olfactory nerve. Which instructions should the nurse give to the patient before assessment? “Lie down on your back.” “Close your eyes.” “Close both of your nostrils.” “Breathe through your mouth.” mell.
“Close your eyes.”
The test is to determine identification of an item through the sense of smell. Closing eyes will enhance the assessment. The patient does not need to lie down for this examination. The patient will need to breathe through the nostrils to assess the sense of smell.
The nurse notices that a patient is able to understand what is said but has trouble formulating a response. The nurse suspects: Parkinson disease. Guillain-Barré syndrome. receptive aphasia. expressive aphasia.
expressive aphasia.
Expressive aphasia may be the result of a head injury or CVA. Parkinson disease is a disease that is characterized by a progressive tremor. Guillain-Barré syndrome is characterized by weakness and paresthesia. Receptive aphasia describes a patient who can talk but has a hard time understanding what is said.
The nurse notes that the patient is able to touch each finger to his thumb in rapid sequence. This finding indicates that the patient:
has intact trochlear and abducens cranial nerves.
has appropriate cerebellar function.
has an intact spinal accessory nerve.
has appropriate kinesthetic sensation.
has appropriate cerebellar function.
Option B is also evaluated by coordination tests such as hopping in place and the Romberg test. Option A is assessed by assessing extraocular movement. Option C is assessed by shoulder shrug. Option D is assessed by asking the patient about a change of position.
A 52-year-old obese male who smokes and has diabetes has risk factors for: seizures. Guillain-Barré syndrome. multiple sclerosis. cerebrovascular accident.
cerebrovascular accident.
These are strong risk factors for a stroke. Hypertension is another possible problem. Seizures result from hyperexcitation of neurons in the brain; these are not risk factors. Guillain-Barré syndrome is caused by demyelination of nerves of the peripheral nervous system; these are not risk factors. Multiple sclerosis is a neuromuscular disease; these are not risk factors.
The nurse is assessing a patient’s neurologic status. What assessment should the nurse perform? (Select all that apply.) Romberg test Glasgow Coma Scale Tonic neck Corneal reflex Mini-Mental State Exam Recall test
Glasgow Coma Scale Corneal reflex Mini-Mental State Exam Recall test Options B, D, E, and F can be performed to assess neurologic status. The Romberg test is used to assess balance. Tonic neck is used with infants to check infantile reflexes.
This is an ability to recognize an object by feeling it
Stereognosis
Oscillation of the eyes
Nystagmus
Acronym to remember signs of a stroke
FAST
This is an ability to recognize a number traced on the skin
Graphesthesia
Regulates vital signs, appetite, sleep
Hypothalamus
Client understands person, place, time, event
LOC
Cerebellar disorder detected when unable to touch finger to nose
Dysmetria
This tract senses pain
Spinothalamic
Lack of sensation of vibration with a tuning fork may reveal this abnormality
Neuropathy
Temporal lobe is responsible for this function
Auditory
This scale assesses the level of consciousness
Glasgow coma scale
This test checks the function of the cerebellum by patting knees with the hands
RAM (Rapid Alternating Movement)
This cranial nerve IX, responsible for movement of the uvula and soft palate
Glossopharyngeal
Bell’s palsy is a dysfunction of this nerve
Facial
If a DTR is absent, you can ask the person to perform this type of exercise to initiate a response
Isometric
Rapid, rhythmic contraction seen when performing DTR’s
Clonus
When the Broca’s area is damaged, this results in
Aphasia
Assessing muscles that aid in chewing checks this cranial nerve
Trigeminal
development of an infant progresses in this manner
cephalocaudal
a pathologic reflex normally present prior to one year of age
babinski
Wernicke’s area assists with comprehension of…
language
exaggerated reflex
hyperreflexia
checking this reflex assesses the C5 and C6 nerves
biceps
a dysfunction of cranial nerve III causing drooping of they eye lid
ptosis
the trigeminal nerve can be checked in an infant by initiating this response
rooting
positive romberg test would reveal this
ataxia
the area of skin supplied with afferent nerve fibers by a single posterior spinal root
dermatome
the hypoglossal nerve is responsible for this
tongue
A disorder in which both eyes do not line up in the same direction, so they do not look at the same object at the same time.
Strabismus
