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PCC 1 NRSE-2350-001 > Exam 3 > Flashcards

Exam 3 Flashcards

1
Q

What is the screening tool used for Alzheimer’s?

A

Mini Mental Status Examination (MMSE)

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2
Q

How many cranial nerves are there?

A

12

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3
Q

What are components of the Neuro physical exam?

A

LOC, Glasgow coma scale (GCS), motor function, PERRLA, vital signs

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4
Q

Paresthesia

A

Numbness and tingling

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5
Q

Reflex are basic _____ mechanisms of the nervous system

A

Defense

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6
Q

What are the three types of reflexes?

A

Stretch/deep tendon reflexes (myotatic, i.e. patellar or knee jerk), superficial (cutaneous,i.e. plantar reflex), visceral (organic, i.e. pupillary response to light and accomodation)

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7
Q

How should the nurse manage the effects of immobility on the respiratory system?
-Limit fluid intake, place the client prone, teach coughing and deep breathing, always apply oxygen

A

Teach coughing and deep breathing

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8
Q

why apply SCDs?

A

If pt is at risk of DVTs

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9
Q

How does the nurse assess for orthostatic hypotension?

A

Take BP and HR laying, sitting, and standing

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10
Q

how should the nurse manage the effects of immobility on blood flow to the skin?

A

30 degree lateral turning every 1-2 hours

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11
Q

Which is a high fall risk intervention?
-put non-slip socks on the client’s feet, establish a team approach to frequent rounding, remove clutter and garbage from the client’s floor, instruct the client how to use the call bell

A

Establish a team approach to frequent rounding

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12
Q

Which is true for restraints?
-release restraints at least Q2 hours, an order must be renewed every 48 hours, an order is required within 24 hours of application , assess for discontinuation at least every 8 hours

A

Release restraints at least Q2 hours

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13
Q

which client should be the least motivated to learn?
-the client who is illiterate, the client who is blind, the client who is foreign, the client who is anxious

A

The client who is anxious

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14
Q

Immobility effects the cardiovascular/peripheral vascular system by:

A

increasing the risk for thrombus formation

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15
Q

Dysmetria

A

Incoordination

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16
Q

Dyskinesia

A

Involuntary movement

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17
Q

Paralysis

A

Full loss of movement

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18
Q

Paresis

A

Partial loss of movement

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19
Q

What is the Romberg test?

A

The client closes their eyes while standing and holding their arms out.

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20
Q

What does a positive Romberg test mean?

A

Loss of balance

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21
Q

Difficulty swallowing

A

Dysphagia

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22
Q

Define aphasia

A

Difficulty speaking

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23
Q

What are the two types of cerebellar tests?

A

Balance and coordination

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24
Q

What are the cerebellar balance tests?

A

Gait, tandem walking (heel to toe), romberg’s, shallow knee bend (mini squat)

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25
What are the cerebellar coordination tests?
Rapid alternating movements (follow finger movement w/ eyes), finger to finger test (touch finger to finger with both eyes open and closed), finger to nose (open eyes, touch examiner finger to your nose), heel to shin (sit and rub opposite shin with opposite foot i.e. left foot down right shin)
26
What Neuro tracts are responsible for sensory functions?
Spinothalmic tract and posterior column tract
27
What is the spinothalmic tract responsible for?
Temperature, pain, and light touch
28
What is the posterior column tract responsible for?
Vibration, position(kinesthesia), tactile discrimination (fine touch)
29
What are the five types of tactile discrimination?
Stereognosis, Graphesthesia, two-point discrimination, extinction, point location
30
What is graphesthesia?
Someone draws a shape on your skin and you can identify it
31
What is stereognosis?
put something familiar in a person’s hand they can identify it with eyes closed
32
What is point location?
skin is touched twice within a few seconds; client must identify if they were in the same place or not (tactual localization)
33
What is extinction?
Neuro disorder that impairs ability to perceive multiple of the same stimuli simultaneously
34
What are three ways to test motor function with hands and feet?
Finger grips, pronator drift, pedal pushes
35
what is two-point discrimination?
the ability to sense two separate objects touching skin at same time
36
What does the Glasgow coma scale measure for?
Minor, moderate, or severe brain injury
37
How is muscle strength graded?
Scale 0-5
38
what is a 0 on muscle strength scale?
Contracture
39
What is a 1 on muscle strength scale?
Trace of movement
40
What is a 2 on muscle scale
Full ROM but not against gravity (passive movement only)
41
what is a 3 on muscle scale?
Full ROM against gravity but not against resistance
42
what is a 4 on muscle scale?
Full ROM against gravity and some resistance, but weak
43
What is a 5 on muscle scale?
Full ROM against gravity with full resistance
44
What is AAOx4?
Awake, alert, and oriented to person, place, time, event (or situation)
45
What assessment is used to see if someone’s ADLs are affected?
Functional assessment
46
define kyphosis
Outward curvature of the thoracic spine, “hunchback”
47
Define lordosis
Excessive curvature of the lumbar spine “swayback”
48
Define scoliosis
Lateral curvature of the spine, can affect lumbar or thoracic spine “S”
49
Which position is best for respiratory distress?
High-Fowler
50
Which step is first when walking with a cane?
Move the can 6 inches forward
51
Use a mechanical lift to transfer a client who can not bear weight from bed to chair T/F
True
52
What is an audible crunching sound heard in a joint?
Crepitus
53
the nurse fits crutches to the client to prevent nerve damage to the axilla and the arms by:
Measuring 2-3 finger widths
54
Which is correct when using a walker? -elbows flexed at 45 degrees, walker should reach the crease of the wrist, use the walker when going up stairs, lean body weight on the walker
Walker should reach the crease of the wrist
55
What ROM is ok for a client post total hip replacement?
External rotation
56
What ROM is not okay for a client post total hip replacement?
Internal rotation, 90 degree flexion, adduction
57
what is a principle of safe body mechanic techniques?
Keep weight close to your body
58
What position is used for enemas?
SIMS
59
Full ROM against gravity with full resistance is a grade _____ muscle strength.
5
60
What is clonus?
A hyperactive strong deep tendon reflex graded a +4
61
Which ROM is performed when moving a limb toward and across the midline?
Adduction
62
The nurse will document a client’s report of partial paralysis or weakness as:
Paresis
63
Which cranial nerve assesses for wrinkling of the forehead, eyes closing, and smiling?
Facial (7)
64
Turning the sole of the foot outward is which skeletal muscle movement?
Eversion
65
How should the nurse manage the effects of immobility on the respiratory system? -turn the client every 4 hours, teach the client to use an IS (insensitive spirometer), position the client supine, always apply oxygen
Teach the client to use an IS (incentive spirometer)
66
What should the nurse do to reduce symptoms of orthostatic hypotension?
Dangle the feet over the side of the bed 1-2 min
67
Which position is best for dysphagia?
High-Fowler
68
What is last when walking with a cane?
Step with the strong leg past the cane
69
What is shortening of the connective tissue and or joint fixation?
Contracture
70
T/F: to use a walker, you lift the walker up and forward
True
71
Which position increases the risk of urinary stasis?
Supine
72
Full ROM against gravity with some resistance is a grade ______ muscle strength
4
73
T/F: clonus is a very week deep tendon reflex graded a 1+
False
74
which ROM is performed when rotating the arms internally?
Internal rotation
75
The nurse will document a client’s report of a tingling sensation as:
Paresthesia
76
Turning the forearm so that the palm is face down is what skeletal movement?
pronation
77
What are the three types of learning?
Psychomotor, cognitive, and affective
78
If someone does not seem like they are interested in learning, what should you consider?
Motivation v.s. Ability; do they understand? Do they WANT to understand? Are they ABLE to understand, what is stopping them?
79
turning the sole of the foot inwards is____
Inversion
80
jutting your chin forward is _____
Protraction
81
Pulling your chin towards your spine is______
Retraction
82
Turning your head in a “no” motion is ______
Rotation
83
Turning your palm so that it is face up is _____
Supination
84
Large arm circles or underhand softball pitching is _______
Circumduction
85
Shrugging your shoulders toward your ears is _____
Elevation
86
Pushing your shoulders down away from your ears is_____
Depression
87
What is Articular limitation to ROM?
Inside the joint,limits active and passive ROM
88
Extra-articular limitations to ROM is_____
Tendon, ligament , nerve related; limits active ROM
89
What are aging components of the musculoskeletal system?
Kyphosis with a backward head tilt, decrease in height, slight flexion of hips and knees, bony prominences, atrophy of muscles, tendons shrink and harden,reduction in bone mineral and mass, increased risk for fractures
90
what is orthopneic position for?
Dyspnea in COPD clients
91
What is the minimal position needed for NG tube feeding to prevent aspiration?
Semi-fowlers
92
What are advantages of supine position
Allows elevation of extremities and supports cardiac function
93
Where should the cane be measured to?
Greater trochanter
94
what assessment grades a client’s risk for fall?
Morse fall scale
95
Low and moderate risk for falls interventions
Place fall risk bracelet and door sign, orient client to their surroundings, fitted skid-proof footwear, keep 2 bedside rails up (never all 4)
96
what are some high fall risk interventions
Prioritize call light responses, team approach, establish elimination schedule, stay with client when toileting, apply floor mats, bed alarm, confer with PT, move client closer to nurse’s station
97
Restraints are only used after____
All other alternative measures have been used and documented as a temporary measure to ensure physical safety of client and protect others if client is violent

PCC 1 NRSE-2350-001 (5 decks)

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