EXAM 2 Flashcards
Cranial Nerve I: Olfactory Test
test sense of smell with familiar odor
Cranial Nerve II: Optic Test
test visual acuity and visual field with confrontation
Confrontation Test
gross measure of peripheral vision
-stand 2 fett from person
-have patient cover one eye, then cover your own eye opposite to the persons covered one
-hold finger as target midline between you and patient, slowly advance to periphery
-as person to say “now” as target is first seen
Confrontation Test: normal
50 degrees upward
90 degrees temporal
70 degrees down
60 degrees nasal
Cranial Nerve III, IV, VI: Oculomotor, Trochlear, Abducens Test
PERRLA
6 cardinal positions of gaze
PERRLA
pupils equal, round, reactive to light (direct and consensual) and accommodation
6 cardinal positions of gaze
right & up
right
right & down
left & up
left
left & down
nystagmus
back-and-forth oscillation of the eyes
nystagmus: amplitude
fine, medium or coarse movement
nystagmus: frequency
constant or fades after few beats
nystagmus: plane of movement
horizontal, vertical, rotary or combo
Cranial Nerve V: Trigeminal Test
Motor: asking the client to clench her teeth while you palpate the masseter (muscle of mastication)
Sensory- test light touch by having a client closer their eyes while you toucher her face gently with a wisp of cotton, patient identifies location
What does the corneal reflex test?
CN V sensory, CN VII motor
Corneal reflex test
-remove contacts, bring cotton wisp from side, lightly touch cornea
NORMALLY: patient blinks bilaterally
Cranial Nerve VII: Facial Test
Motor: have client smile, frown, puff out her cheeks, raise her eyebrows, close her eyes tightly
Sensory: anterior 2/3 taste (sugar, salt, lemon juice)
Cranial Nerve VIII: Vestibulocochlear Test
Whispered voice test
Cranial Nerve IX & X: Glossopharyngeal and Vagus Test
Motor: open mouth say “ahh” & gag reflex
NORMALLY: uvula and soft palate rise in midline
Sensory: CN IX does posterior 1/3 taste
Cranial Nerve XI: Accessory Test
shrug shoulders
Cranial Nerve XII: Hypoglossal Test
say “light, tight, dynamite”
screening neuro exam
perform on well persons who have no significant subjective findings
complete neuro exam
perform on person with neuro concerns
screening neuro exam
perform on well persons who have no significant subjective findings
neuro recheck exam
perform on person with demonstrated neuro defect, who requires period ic assessment
ansomia
Decrease or loss of smell occurs bilaterally
hemianopsia; hemianopia
Defective vision or blindness in one half of the visual field
ptosis
drooping eyelid
paresthesias
tingling, prickling, “pins & needles” (sensory loss)
diplopia
double vision
dysphagia
difficulty swallowing
What are the test to evaluate cerebellar function?
Balance Test (Gait)
Romberg Test
Rapid Alternating Movements (RAM)
Balance Test (Gait)
-observe as the person walks 10 to 20 feet, turns and returns to the starting point
NORMALLY: gait is smooth, rhythmic and effortless opposing arm swing is coordinating
Romberg test
-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed for ~20 seconds
NORMALLY: patient can maintain posture and balance
Rapid Alternating Movements (RAM)
pat the knees with both hands, turn hands over, then faster
NORMALLY: done with equal turning and quick rhythmic pace
flaccidity
decreased muscle tone (hypotonia), muscle feels limp, soft, flabby
spasticity
increased muscle tone (hypertonia)
rigidity
constant state of resistance; resists passive movement in any direction (dystonia)
cogwheel rigidity
Increased tone is released by degrees during passive range of motion so it feels like small, regular jerks.
paralysis
decreased or loss of motor power
hemiplegia
Spastic or flaccid paralysis of one side of the body
paraplegia
symmetric paralysis of both lower extremities
quadriplegia
paralysis of all four extremities
paresis
weakness of muscles rather than paralysis
tic
involuntary, compulsive, repetitive twitching of a muscle group
myoclonus
Rapid, sudden jerk or a short series of jerks at fairly regular intervals. (ex: hiccup)
fasciculation
rapid continuous twitching of resting muscle without movement of limb
chorea
sudden, rapid, jerky, purposeless movement involving limbs, trunk, or face
irregular intervals, not rhythmic or repetitive
athetosis
slow, writhing involuntary movements
tremor
involuntary contraction of opposing muscle groups resulting in rhythmic movement of one or more joints
rest tremor
occurs when muscles are quiet and supported against gravity (hand in lap), coarse and slow, partly or completely disappears with voluntary movement
intention tremor
worse with voluntary movement (like reaching to a target)
spastic hemiparesis
Arm is immobile against the body, with flexion of the shoulder, elbow, wrist, and fingers and adduction of shoulder; does not swing freely. Leg is stiff and extended and circumducts with each step (drags toe in a semicircle).
cerebellar ataxia
staggering, wide-based gait; difficulty with turns; uncoordinated movement with positive Romberg sign
parkinsonian (festinating)
Posture is stooped; trunk is pitched forward; elbows, hips, and knees are flexed. Shuffling gait. Difficulty with any change in direction.
scissors
knees cross or are in contact, like holding an orange between the thighs.
steppage or foot drop
slapping quality, looks like walking up stairs with no stairs there
waddling
weak hip muscles- when the person takes a step, the opposite hip drops, which allows compensatory lateral movement of pelvis
short leg
Leg length discrepancy >2.5 cm (1 inch).
cerebral palsy
damage to cerebral cortex from a developmental defect (infancy and childhood), intrauterine meningitis or encephalitis, birth trauma, anoxia
muscular dystrophy
a chronic, progressive wasting of skeletal musculature producing weakness contracture and respiratory dysfunction or death
Parkinsonism
loss of dopamine-producing neurons causing motor tract disorder
symptoms: resting tremor, bradykinesia, cogwheel rigidity
cerebellar
A lesion in one hemisphere produces motor abnormalities on the ipsilateral side.
Multiple Sclerosis (MS)
chronic, progressive, immune mediated disease which axons experience inflammation, demyelination, degeneration and finally sclerosis
decorticate rigidity
upper: flexion of arm, wrist fingers, adduction of arms
lower: extension, internal rotation, plantar flexion
*tippy toes, puppy cry
decerebrate rigidity
Upper: stiffly extended, adducted, internal rotation, palms pronated.
Lower extremities: stiffly extended, plantar flexion; teeth clenched; hyperextended back
*tippy toes, sheet gripper, arched back, head back
flaccid quadriplegia
complete loss of muscle tone and paralysis of all four extremities (completely nonfunctional brainstem)
Opisthotonos
prolonged arching of back, with head and heels bent backward (meningeal irritation)
*doing the superman on stomach
stereognosis
Test the persons ability to recognize objects by feeling their forms, sizes and weights
position (kinesthesia)
test person’s ability to perceive passive movements of extremities
Tactile discrimination (fine touch)
measure the discrimination ability of the sensory cortex
Graphesthesia
ability to “read” a number by having it traced on the skin
two point discrimination
test ability to distinguish separation of two simultaneous pin points on skin
extinction
simultaneously touch both sides of body at the same time, both sensations should be felt
point location
touch skin and withdraw stimulus promptly; ask person to put finger where you touched
peripheral neuropathy
Loss of sensation involves all modalities; loss most severe distally at feet and hands
*complete loss at fingers and toes, diminished loss up to half forearm/half calf
individual nerves or roots
Decrease or loss of all sensory modalities; corresponds to distribution of involved nerve
*such as one entire arm
Spinal Cord Hemisection (Brown-Sequard Syndrome)
injury to one-half of the cord, causing contralateral loss of pain and temp
the ipsilateral side side of the lesion has paralysis and loss of vibration and touch sensation
*one leg has complete loss and the other has semi loss
Complete transection of spinal cord
Complete loss of all sensory modalities below level of lesion; associated with motor paralysis and loss of sphincter control
thalamus
loss of all sensory modality son the face, arm and leg on the side contrateral to lesion
cortex lesion
loss of discrimination on contralateral side; loss of graphesthesia, stereognosis, recognition of shapes and weights, finger findings
deep tendon reflexes (DTR)
measurement of stretch reflex reveals intactness of reflex arc at specific spinal levels and normal override on reflex of higher cortical levels
DTR scale
0 - no response
1+ - diminished low normal or occurs w reinforcement
2+ - normal
3+ - brisker than average may indicate disease
4+ - hyperactive w/ clonus, very brisk, indicative of disease
Clonus
test when reflex are hyperactive
how do you test clonus?
support lower leg in one hand and with other hand move foot up and down to relax muscle; then stretch muscle by briskly dorsiflexing fort, hold stretch
what do you normally and abnormally see in a clonus test?
NORMALLY: you feel no further movement
ABNORMALLY: note rapid rhythmic contractions of calf and foot
Tempomandibular Joint (TMJ) assessment
note smooth movement without limitations or tenderness, clicking or popping when jaw opens and closes
how do you assess the thyroid gland?
ask client to take a sip of water, hold in mouth, the swallow while palpating thyroid gland
-one hand palpates and the other displaces
what is abnormal in palpating the thyroid gland?
an enlarged thyroid
What does the nurse do next if the thyroid gland is enlarged?
LISTEN FOR BRUIT (turbulent blood flow)
check the area they drain from for source of the problem
how do you examine lymph nodes?
gentle circular motion of finger, palpate lymph nodes
visual acuity test: snellen chart
person 20 feet from chart, ask to read smallest line possible
what does 10/20 vision mean
patient reads 10 feet way what a normal person reads 20 feet away
visual acuity: jaeger card
normal: 14/14 without hesitancy or moving card
Corneal Light Reflex (Hirschberg Test)
Assess the parallel alignment of the eye axes by shining a light toward the person’s eyes.
what is normal for the corneal light reflex test?
light reflection on cornea should be in same spot on each eye
pupillary light reflex
normal constriction of pupils when bright light shines on retina
consensual light reflex
simultaneous constriction of the other pupil
red reflex
red glow that appears to fill the person’s pupil caused by reflection of light of inner retina
what is a normal finding for the whispered voice test
person can repeat back a the combo of letters and numbers
tuning fork test
Measure bone and air conduction of sound
what is vestibular apparatus and what test is used?
a sensory organ for detecting sensations of equilibrium.
-romberg test
palpation of the sinus area
Using thumbs, press frontal sinuses by pressing up and under the eyebrows and over maxillary sinuses below cheekbones
tonsil scale
1+ visible
2+ halfway between tonsillar pillars and uvula
3+ touching uvula
4+ touching each other
NORMAL IS 1-2
presbyopia
lens loses elasticity, becoming hard and glasslike. decrease ability to change shape and accommodate near vision
cataracts
transparent fibers of lens begin to thicken and yellow, resulting from a clumping of protein in lens
glaucoma
increased intraocular pressure
macular degeneration
breakdown of cells in macula of the retina
- loss of central vision is the most common cause of blindness (person may be unable to read fine print, sew, etc)
pingueculae
common non-cancerous growth that forms on conjunctiva
otosclerosis
gradual hardening that causes foot plate of stapes to become fixed in oval window, impeding of sound transmission causing progressive deafness
impacted cerumen
common but reversible cause of hearing loss in older people
presbycusis
type of hearing loss occurring w aging
gradual sensorineural loss
caused by nerve degeneration in inner ear to auditory nerve
what tone loss is noticed first in older adults
high-frequency
senile tremors
benign and include head nodding (as if saying yes or no) and tongue protrusion (older adult)
kyphosis
humpback
when performing ROM on older adult…
PERFORM ROM SLOWLY to prevent lightheaded/diziness
tension headache
occurs on both sides across frontal, temporal and occipital region, BAND LIKE TIGHTNESS, non throbbing, non pulsatile
migraine headache
commonly one sided but can occur on both sides, pain behind eyes, temples and forehead, throbbing, pulsating
cluster headache
rare HA, intermittent, excruciating , unilateral, always one sided, often behind or around eye, temple, forehead, cheek, continuous, burning or piercing
Parkinsons syndrome facial appearances
immobility of features produces face that is flat, expressionless, “MASK LIKE” with elevated eyebrows, staring gaze, oily skin, drooling
Cushing syndrome facial appearances
rounded “MOONLIKE” face, prominent jewels, red cheeks and chin, acneiform rash on chest
Graves disease facial appearance
(hyperthyroidism) goiter, eyelid retraction and exophthalmos (bulging eyeballs)
Hypothyroidism (myxedema)
puffy, edematous face, periorbital edema, puffy hands feet, coarse face feature, cool dry skin, coarse hair and eyebrow
bells palsy facial appearance
complete paralysis of one side of face, person cannot wrinkle forehead, raise eyebrows, close eyelids, whistle or show teeth on left side. usually presents w smooth forehead, wide palepral fissure
stroke (brain attack/cerebrovasular accident) facial appearance
note paralysis of lower facial muscle but also note the upper half of the face is NOT affected, person is able to wrinkle forehead and close eyes
*paralyzed quadrant of face
cachexia appearance
sunken eyes, hollow cheeks and exhausted defeated expression
scleroderma
“hard skin”. a chronic connective tissue disorder associated with decreased mobility
strabismus
crossed eyes
diplopia
double vision
what do normal conjunctiva look like
clear and show normal color, pink lower ids and white sclera
normal eye appearance in African Americans
have gray/blue or darker color to sclera, normally my see small brown macule (like freckles) on sclera
-may have yellowish fatty deposits beneath lids away from cornea
esotropia
inward turning of the eye
exotropia
outward turning of the eye
periorbital edema
edema around the eyes
exophthalmos
protruding eyeballs
Enophthalmos
sunken eyes
ptosis
drooping upper lid
upward palpebral slant
seen in Asians, also it indicates Down syndrome.
ectropion
the rolling out (eversion) of the edge of an eyelid
entropion
inward turning of the rim of the eyelid
blepharitis
inflammation of the eyelid
chalazion
beady nodule protruding on the lid (an obstruction and inflammation of meibomian gland)
hordeolum
stye, acute localized staph infection of hair follicles at lid margin, painful red swollen
dacryocystitis
inflammation of the lacrimal (tear) sac
basal cell carcinoma
small painless nodule with central ulceration and sharp, rolled out pearly edges, removal, usually cures it
anisocoria
unequal pupil size
monocular blindness
When light is directed into blind eye, no response in either eye. When it is directed to normal eye, both pupils constrict.
miosis
constricted & fixed pupils
mydriasis
dilation & fixed pupil
mydriasis
dilation & fixed pupil
Argyll Robertson pupil
Constricts w/ accomodation but is not reactive to light.
Tonic (Adie’s) Pupil
reaction to light and accommodation is sluggish
CN III damage
Unilateral dilated pupil has no reaction to light or accommodation. Ptosis with eye deviating down and laterally may be present.
*ptosis, mydriasis, down and out
Horner’s syndrome
Unilateral, small, regular pupil does react to light and accommodation. also note Ptosis and absence of sweat (anhidrosis) on same side.
*ptosis, miosis, and anhidrosis
Conductive hearing loss causes
partial loss caused by impacted cerumen, pus, perforated TM, decrease mobility of ossicles
sensorinerual hearing loss
path of inner ear and CN VIII or auditory area of cerebral cortex
mixed hearing loss
combination of sensorineural and conductive hearing loss
*sens: dmg to nerve = muffled sound
*cond: blockage/dmg to outer ear; earwax impaction, perf TM
dry cerumen
gray, flaky, and frequently forms thin mass in ear canal
wet cerumen
honey brown to dark brown and moist
otitis externa
swimmers ear
sebaceous cyst
a nodule with central black punctum indicates blocked sebaceous glands
tophi
Small, whitish yellow, hard, nontender nodules in or near helix or antihelix; contain greasy, chalky material of uric acid crystals and are a sign of gout.
Chondrodermatitis Nodularis Helicus
Painful nodules develop on the rim of the helix as a result of repetitive mechanical pressure or environmental trauma
keloid
overgrowth of scar tissue
bifid uvula
uvula split completely or partially
cleft lip and palate
congenital split of the lip and roof of the mouth
torus palatinus
bony ridge running in middle of hard palate
leukoedema
a benign lesion occurring on buccal mucosa, is seen more often in African Americans
epistaxis
nosebleed
xerostomia
dry mouth
what is a normal appearance in mouth of African Americans
bluish lips and dark line on gingival margin
Edentulous
lacking teeth
furuncle
A small boil located in the skin or mucous membrane; appears red and swollen and is quite painful.
foreign body
putting an object up the nose
perforated septum
hole in septum
acute rhinitis
(nonallergic) first sign is watery discharge which can become purulent with sneezing
rhinorrhea
discharge from the nose
allergic rhinitis
abnormal immune response, rhinorrhea , itching of nose eyes, lacrimation, congestion sneezing
Sinusitus
acute inflames sinus area may have mucopurulent drainage with face pain/pressure
nasal polyps
smooth, pale gray nodules (overgrowth of mucosa) from chronic allergic rhinitis
Angular Cheilitis (Stomatitis, Perleche)
Erythema, scaling, and shallow and painful fissures at the corners of the mouth
what is the acronym for a stroke?
FAST
F: facial drooping
A: arm weakness
S: speech impairment
T: time to call 911
use abbreviation of neurologic examination in the following sequence:
Level of Consciousness (LOC)
Glasgow Coma Scale (GSG)
Motor function
Pupillary respinse
Vital signs
Level of Consciousness (LOC)
state of awareness of self and environment
-change in LOC is the single most important factor in this examination
Glasgow Coma Scale (GCS)
rate patient on :
-Eye-opening response (4-1):
spontaneous, to speech, to
pain, no response
-Motor response (6-1): obeys
verbal command, localizes pain, flexion (withdrawal), flexion (abnormal), extension (abnormal), no response
-Verbal response (5-1): oriented x3 (appropriate), conversation confused, speech inappropriate, speech incomprehensible, no response
what is normal on the GCS?
15 - AOx3
what is the sequence of a Neuro exam
mental status
cranial nerves
motor system
sensory system
reflexes
Spinothalmic Tract
pain
temperature
light touch
posterior column tract
vibration, position, tactile discrimination
normal response: biceps reflex
contraction of biceps muscle and flexion of forearm
normal response: triceps reflex
extension of forearm
normal response: brachioradialis reflex
flexion and supination of forearm
normal response: quadriceps reflex
extension of lower leg
normal response: achilles reflex
foot is plantar flexes against your hand
Superficial (cutaneous) reflexes
sensory receptors in skin rather than in muscles;
motor response is localized muscle contraction
Babinski reflex
Reflex in which a newborn fans out the toes when the sole of the foot is touched
-for those 1 year old or younger otherwise its abnormal
normal response: abdominal reflexes
ipsilateral contraction of abdominal muscle with observed deviation of umbilicus toward stroke
normal response: planter reflex
plantar flexion of toes and inversion and flexion of forefoot
dyskinesia
difficult movement
older adults: repetitive stereotyped movements in jaw, lips, or tongue may accompany senile tremors; no associated rigidity present
lymph node palpation technique order
-Preauricular: in front of ear
-Posterior auricular (mastoid): superficial to mastoid
process
-Occipital: at base of skull
-Submental: midline, behind tip of mandible
-Submandibular: halfway between angle and tip of
mandible
-Jugulodigastric (tonsillar): under angle of mandible
-Superficial cervical: overlying sternomastoid
muscle
-Deep cervical: deep under sternomastoid muscle
-Posterior cervical: in posterior triangle along edge
of trapezius muscle
-Supraclavicular: just above and behind clavicle, at
sternomastoid muscle
hydrocephalus
obstruction of drainage of cerebrospinal fluid results in
excessive accumulation, increasing intracranial pressure, and enlargement of the head
objective vertigo
room is spinning
subjective vertigo
Person feels like he or she spins
