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Nursing 314: Assessing and Promoting Wellness > Exam 2: Sensory and mental status assessment > Flashcards

Exam 2: Sensory and mental status assessment Flashcards

1
Q

Frontal lobe

A

Personality, behavior, emotions, and intellectual function

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2
Q

Precentral gyrus of front lobe initiates

A

voluntary movement

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3
Q

parietal lobeā€™s post central gyrus is

A

primary center for sensation

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4
Q

Occipital lobe is the primary

A

visual receptor center

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5
Q

Temporal lobe behind the ear has th

A

primary auditory reception center

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6
Q

Wernickeā€™s area

A

Language comprehension (reception)

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7
Q

Brocaā€™s area

A

motor speech (expression)

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8
Q

Wernickeā€™s are is located where?

A

temporal lobe

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9
Q

Brocaā€™s are is located in the

A

frontal lobe

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10
Q

damage to specific cortical ares (wernicke/Broca)

A
  • Impaired ability to understand/process language

- impaired ability to express

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11
Q

Spinal cord nervous tissue that occupies upper 2/3 of vertebral canal from

A

medulla to lumbar vertebrae L1 to L2

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12
Q

Left cerebral cortex receive sensory information from and control function to

A

Right side of the body

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13
Q

Spinal cord is the main highway that connects

A

brain to spinal nerves; mediates reflexes

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14
Q

Pathways of the CNS

A

Crossed representation

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15
Q

Organs in body that often have referred pain

A

Heart, liver, spleen

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16
Q

Sensation travels

A

In afferent fiber in peripheral nerve, through posterior (dorsal) root, and into the spinal cord

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17
Q

Neurological system intellectual function

A 
memory 
knowledge 
abstract thinking 
association 
judgment
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18
Q

Neurological system 3 functions

A

Intellectual function
cranial nerve function
motor function

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19
Q

Neurological system motor function

A

Coordination of gross and fine motor function
integrates assessment of neurological system and musculoskeletal systems
walking, other gross, fine, movements
Balance

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20
Q

How to assess balance?

A

Rombergā€™s test

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21
Q

Reflexes are basic

A

defense mechanisms

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22
Q

How are reflexes involuntary?

A

quick reaction to painful or damaging situations

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23
Q

Reflexes help maintain

A

balance and muscle tone

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24
Q

4 types of reflexes

A

Deep tendon reflexes
superficial
visceral
pathologic

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25
Q

Example of deep tendon reflexes

A

Patellar or knee jerk

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26
Q

examples of superficial reflex

A

Corneal reflex, abdominal reflex

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27
Q

Example of visceral reflex

A

Pupillary response to light

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28
Q

example of Pathologic reflexes

A

babinskiā€™s or extensor plantar reflex

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29
Q

5 deep tendon reflexes

A 
Triceps 
Biceps 
Brachioradial
patellar 
achilles
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30
Q

Reflex is graded from 0-5

A

0 - absent
1 - sluggish/diminished
2- active/expected
3 - slightly hyperactive/ more brisk than normal
4 - brisk, hyperactive with intermittent clonus associated with pathology

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31
Q

to elicit plantar reflex (babinski test)

A

stroke the lateral aspect of the sole form the heal to ball of foot, medially crossing the ball
ā€“ Upside down ā€œJā€

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32
Q

Negative babinski test =

A

itā€™s desired! plantar flexing/scunching is normal

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33
Q

Positive babinski indicates

A

this would be fanning of the toes

abnormal findings for anyone over age of 2

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34
Q

infant babinski

A

fanning of toes is normal for newborns - 2 years due to nervous system still developing

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35
Q

Reception

A

stimulation of receptor such as light, touch, or sound

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36
Q

Perception

A

integration and interpretation of stimuli

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37
Q

reaction

A

only the most important stimuli will elicit a reaction

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38
Q

sensory deficits

A

deficit in the normal function of sensory reception and perception

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39
Q

sensory deprivation

A

inadequate quality or quantity of stimulation

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40
Q

sensory overload

A

reception of multiple sensory stimuli and cannot disregard

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41
Q

sensory overload can cause

A

behavioral change; mood swings, agitation, restlessness

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42
Q

factors affecting sensory function

A 
age 
meaningful stimuli 
amount of stimuli 
social interaction 
environmental factors 
cultural factor
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43
Q

assessment of sensation is through

A

the patients senses

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44
Q

During an assessment of sensation: mental status helps

A

paint the whole picture

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45
Q

physical assessment for assessment of sensation

A

neuro/HEENT, others PRN

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46
Q

environmental hazards for sensation

A

impaired senses increases risk

47
Q

senses

A 
Sight --- visual 
hearing ---- auditory 
touch --- tactile 
smell --- olfactory 
taste --- gustatory 
position and motion --- kinesthetic
48
Q

sight assessment

A

visual acuity

49
Q

hearing assessment

A

whisper test, audiometer, higher level

50
Q

Smell assessment

A

differentiate scents w/ eyes closed

51
Q

taste assessment

A

distinct flavors

52
Q

touch assessment

A 
pain 
temperatur 
light/firm/sharp/dull 
vibration 
position 
discrimination
53
Q

discriminatory testing assess the

A

Ability of the cerebral cortex to interpret and integrate information

54
Q

stereognosis

A
  • ask patient to close eyes, place object in hand & ask to identify
  • discriminate shape, size, weight, texture, & form of a familiar object by touching & manipulating it
  • altered stereognosis may indicate a parietal lobe or sensory nerve tract dysfunction
55
Q

Graphesthesia

A
  • ability to discriminate outlines, numbers, words, or symbols traced on the skin
  • if client cannot distinguish the number or letter, it may indicate parietal lobe lesion
56
Q

dermatomes

A

areas of skin innervated by specific dorsal root nerves

57
Q

location of spinal injury determines

A

area of altered function

58
Q

dermatomes also used to assess

A

general skin sensation

59
Q

Assessment NANDA for sensory

A 
risk for injury 
risk for fall 
impaired socialization 
impaired verbal communication 
impaired mobility
60
Q

mental statue is a

A

personā€™s emotional and cognitive functioning

61
Q

mental and emotional status can be obtained through

A

interactions and questions

62
Q

Formal mental and emotional assessment can help

A

pinpoint the problem and determine treatment plans

63
Q

Orientation: Basic and quick assessment of cognitive status

A

Person
Place
Time
Situation

64
Q

if alert and oriented to person , place, and time is documented is

A

AOX3

65
Q

Typical sequence of orientation loss is FIRST

A

time

  • then place
  • and only rarely ā€” to person
66
Q

When a comprehensive mental status examination is necessary

A
  • initial screening suggests anxiety or depression
  • behavior changes: memory loss, inappropriate social interactions
  • brain lesions: trauma, tumor, CVA/stroke
  • Aphasia: Impairment of language ability
  • S/S of psychiatric mental illness, especially with acute onset
67
Q

Subjective data for mental status assessment

A

Medical history
medications
recent changes in: Senses, behaviors, cognition
OLDCART

68
Q

Objective mental status assessment data

A

Level of consciousness
Behavior and appearance
language

69
Q

Levels of consciousness

A 
Alert 
Lethargic 
Obtunded 
Stupor/semi- coma 
Coma
70
Q

Alert

A

Awake or readily aroused

71
Q

Lethargic

A

not fully alert, drifts off to sleep when not stimulated

72
Q

Obtunded

A

sleeps most of the time, difficult to arouse

73
Q

Stupor/semi-coma

A

sleepy, limited/minimal response

74
Q

coma

A

completely unconscious, minimal/no response to stimuli

75
Q

What is standard assessment for anyone with altered level of consciousness? (LOC)

A

Glasgow coma scale

76
Q

Glasgow coma scale assesses for

A

eye opening
verbal response
motor response

77
Q

Behaviors and appearance

A 
Signs of distress 
Grooming and hygiene 
Affect/Mood 
Eye contact 
Signs of patient abuse 
Signs of substance abuse
Speech 
posture 
body movement 
dress
78
Q

Aphasia

A

Impaired/absent ability to speak, interpret, or understand language

79
Q

expressive aphasia

A

difficulty expressing thoughts through words, spoken or written

80
Q

Receptive aphasia

A

difficulty receiving/understanding language spoken or written

81
Q

global aphasia

A

inability to understand language or communicate orally

82
Q

high score of Glasgow coma scale

A

Good! the best

83
Q

Low score of Glasgow coma scale

A

not very good

84
Q

Intellectual function assessment

A

Memory: recent and remote
Knowledge: Level of understanding of what they should understand
Abstract thinking
Association: a dogs is to a poodle as a cat is to a siamese
Judgement: Able to make appropriate conclusions
ā€”-Developmentally/age appropriate

85
Q

Mini mental state exam concentrates on

A

cognitive functioning not mood or thought processes

86
Q

mini mental state exam is a good screening tool to detect

A

dementia and delirium and to differentiate these from psychiatric mental illness

87
Q

Mini mental state exam is a numerical scale of 1-30, higher is

A

Better! (20-30 is normal)

88
Q

Mini cog

A

Reliable, quick and available instrument to screen for cog impairment in healthy adults

89
Q

Mini cog test consists of

A

three item recall test and clock-drawing test

90
Q

Mini cog tests persons executive function like

A

ability to plan, manage time, and organize activities as well as working memory

91
Q

during mini cog, those with no cognitive impairment or dementia

A

can recall three words

draw a complete, round, closed circle w/ clock face number in correct sequence

92
Q

In the contaxt of the interview for remote memory, ask

A

the person verifiable past events

93
Q

remote memory is lost when

A

storage area for memory is damaged

ex) dementia or Alzheimer

94
Q

recent memory assess in context of

A

interview by 24-hour diet recall or by asking time person arrived at agency

95
Q

recent memory testing ask questions you can

A

corroborate to screen for occasional person who confabulates or makes up answers to fill in gaps of memory loss

96
Q

developmental competence for infants and children

A

follow similar guidelines with consideration for developmental milestones

    • appearance
    • behaviors
    • cognition
    • thought processes
97
Q

abnormalities for infant/children developmental competence

A

is often that they do not achieve expected milestone or are significantly delayed

98
Q

for developmental care of aging adults check

A

sensory status, vision, and hearing BEFORE any aspect of mental status

99
Q

age group that has the highest risk for sensory alterations

A

Aging adults

100
Q

many aging persons experience

A

social isolation, loss of structure without job, change in residence, or some short-term memory loss

101
Q

Aging persons may be considered oriented if they

A

know generally where they are and the present period

102
Q

Aging adults correct orientation can be

A

correct year and month

correct identification of the type of setting

103
Q

three most common cognitive problems in adults

A
  • Delirium
  • Dementia
  • Depression
104
Q

acute care for patients with altered sensation

A

Orientation to the environment
communication
controlling sensory stimuli
safety measures

105
Q

Restorative and continuing care for patients with altered sensation

A

same as acute care AND

    • maintaining healthy lifestyles
    • understanding sensory loss
  • -socialization
  • -promoting self care
106
Q

Mini cog assess the

A

executive function

107
Q

Only the ____ knows if sensory abilities are improved

A

patient !!!

108
Q

Which of the 2 Dā€™s can be reversible

A

Delirium and Depression

109
Q

Patients with Glasgow Coma Scale score of 7 or less are

A

considered in comatose

110
Q

Patients with glasgow Coma Scale score of 8 or less are

A

considered to suffer form severe head injury

111
Q

Behaviors and appearance assessment

A 
Signs of distress 
grooming and hygiene 
affect/mood 
eye contact 
signs of patient abuse 
signs of substance abuse
Speech 
posture 
body movements 
dress
112
Q

Mini mental state exam consists of

A

standard questions 5-10 minutes

113
Q

Mini mental state exam is useful for both

A

Baseline and serial measurement

114
Q

What is a common and easily misdiagnosed condition for elderly individuals

A

Confusion

Nursing 314: Assessing and Promoting Wellness (26 decks)

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