Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NS Final > Final > Flashcards

Final Flashcards

1
Q

What specifically is being tested during a sensation evaluation?

A

Part 1: Sensitivity to touch – sharp from dull- 2- point discrimination

Part 2: Tactile Discrimination- Sterognosis & Graphesthesia

Part 3: Proprioception, or position sense (which way are you pointing their toes?)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is the Romberg test used to evaluate and how is it performed?

A

Cerebellar Function
Have patient stand with their feet together, arms at their sides, and eyes open; he should be able to stand upright with no swaying.
• If he can do that, have him close his eyes and stand the same way.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

When Evaluating Cerebellar Function using the Romberg test, what would indicate a positive test?

What does this indicate?

A

If he falls or breaks his stance after closing his eyes, the Romberg test is positive, indicating proprioceptive or vestibular dysfunction.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

How do you Evaluate the lower extremities for Cerebellar Function?

A

Have patient bend their leg and slide that heel along the opposite shin, from the knee to the ankle. This movement, too, should be accurate, smooth, and without tremors.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

How do you perform a deep tendon reflex on Biceps

A

• Biceps- Patient’s arm should be flexed slightly with the palm facing up. Hold arm with your thumb in the antecubital space over the biceps tendon. Strike your thumb with the hammer; the arm should flex slightly.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

How do you perform a deep tendon reflex on Triceps

A

• Triceps- Patient’s arm should be flexed 90 degrees. Support the arm and strike it just above the elbow, between the epicondyles; the arm should extend at the elbow.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

How do you perform a deep tendon reflex on Brachioradialis

A

• Brachioradialis- Patient’s arm should be flexed slightly and resting on the lap with the palm facing down. Strike the outer forearm about two inches above the wrist; the palm should turn upward as the forearm rotates laterally.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

How do you perform a deep tendon reflex on Patellar

A

• Patellar- With th patient’s legs dangling (if possible), place your hand on one thigh and strike the leg just below the kneecap; the leg should extend at the knee.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

How do you perform a deep tendon reflex on Achilles tendon

A

• Achilles tendon- With patient’s foot in slight dorsiflexion, lightly strike the back of the ankle, just above the heel; the foot should plantar flex.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are the 6 areas that are assessed during a neurological assessment?

A 
Vital Signs
Mental Status
Cranial Nerves
Motor and Cerebellar System
Sensory
Reflexes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are the 6 Functional Health Patterns associated with a neurological assessment?

A 
Nutrition –Metabolic
Activity –Exercise
Cognitive
Sensory-Perceptual
Role –relationship
Coping Stress
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What 5 things are assessed to determine mental status?

A 
LOC
General appearance
Mood, feelings, affect
Language/speech/com
cognitive
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

How is LOC assessed?

A

( alert, lethargic, stupor, coma) Glasgow Coma scale (parameters: eye opening, motor response, verbal response), 3= deep coma, >14 is optimal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

How is General appearance assessed?

A

(posture, dress, hygiene)and Behavior

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

How mood and feels assessed compared to Affect?

A

Mood, feelings (pt describes) and Affect ( facial expressions)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

How is Cognitive assessed?

A

Orientation- to person, place, time and situation (? What is confused?)
Memory (Short and Long Term); lose time, then place, then person
Thought process- judgement, clarity, concentration, problem solving

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Which Crainal nerve is III

What does it do?

A

OccularMotor
Reaction to Light
Pupil constriction and dilation
Open and close eye lids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Which Crainal nerve is IX

What does it do?

A

Glossopharyngeal
Ability to swallow-gag reflex
Sensory-taste on posterior 1/3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Which Crainal nerve is X

What does it do?

A

Vagus
Swallowing, sensation of pharynx
Movement of soft palate “ah”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Which Crainal nerve is XII Hypoglossal?

What does it do?

A

movement and strength of tongue (midline, side-side)

Movement of food in mouth

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

what are some considerations that need to be taken when Assessing an Older Adult?

A

Decrease in deep tendon reflexes
Transmission of impulses-delayed reaction time-slower voluntary movement time
Sensory-decrease light touch due to atrophy of nerve endings
Movement (slower gait); decreased fine motor coordination (difficult to button shirts)-cerebellar
Decrease in the 5 senses

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

How do you assess Cranial Nerves III,-

A

Inspection & Ocular Alignment
Pupillary Light Reflex
• Have patient “follow your finger with their eyes without moving their head”.
• Move your finger side to side, then up and down (in an “H” pattern)
• Look for failure of movement and nystagmus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

How do you assess Cranial Nerves IX & X-

A

Motor
• Observe ability to cough, swallow, and talk.
• Test motor function:
• Ask patient to open mouth and say “ah” while you depress the tongue with a tongue blade.
• Observe soft palate and uvula
• Soft palate and uvula should rise medially.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

How do you assess Cranial Nerves XII- Motor

A
  • CN XII- Controls movement of the tongue.

* Have patient stick out their tongue and assess for midline

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

How are Vital Signs & Neuro Status related?

A
  • The brain stem & Vagus nerve (CN X) play an important part in vasomotor tone.
  • Conditions affecting these areas can cause vital signs to change
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What vital sign indications may represent neurological deficiencies

A
  • Change in Respirations, often irregular, deep, & bradypnea rate- such as Cheyne Stokes
  • Bradycardia
  • Increasing systolic BP with widening pulse pressure (the difference between the systolic and diastolic BP)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

How is a deep tendon reflex assessment documented?

A
  • Tested with reflex hammer.
  • Graded from 0-5+
  • 0- no reflex
  • 2+- normal
  • 5+ hyperreflexia with clonus (repeated rhythmic contractions)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What is Glaslow’s scale assessing?

A 
•	Eye opening
•	Motor response
•	Verbal response
Score range from 3-15.
•	Higher the number, the better.
<3  indicates deep COMA
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Describe what should be documented before and after a suctioning episode.

A

Pre-procedure assessment findings.
Color, amount, odor, consistency of secretions.
Number of suctioning passes per episode.
Any complications and interventions implemented.
Post-procedure assessment findings.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Hypoxia versus hypoxemia and nursing interventions to minimize or prevent them

A

Hypoxemia (decreased oxygen in the blood) leads to hypoxia (decreased oxygen to body tissues

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Define Hyperoxygenate –

I

A

ncrease oxygen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Define Hypoxemia –

A

Decreased oxygen in the blood

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Hypoxia and hypoxemia assessment signs and symptoms

A

Skin color changes (pallor to cyanosis); tachycardia (increased HR); tachypnea (increased RR); dyspnea; increased noisy respirations, LOC changes (decreased); mental status changes (confusion); anxiety; restlessness; other clinical signs dependent on body tissue that is oxygen deprived (heart = chest pain)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

What personal protective equipment should be worn during airway suctioning?

A

Gown is not always required, but should definitely be used if copious secretions (large amount)
Sterile gloves and face shield/mask and goggles are always necessary

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

List the suction settings (mm Hg) based on client’s age.

A 
Adult = 100-150 mm HG
Adolescent = 80-150 mm HG                
Children = 80-125 mm HG
Infants = 80-125 mm HG                          
Neonates = 60-80 mm HG
36
Q

Does the procedure for suctioning a tracheostomy involve clean or sterile technique?

A

Sterile technique and sterile gloves (keep the suction catheter being introduced into the trachea sterile); other sterile glove will become a clean glove as it occludes the Y-PORT on the catheter during suctioning

37
Q

What is the maximum number of passes per suctioning episode?

A

Maximum of three suctioning passes per suctioning episode.

38
Q

Identify how much time should be allowed between suction passes during a suctioning episode.

A

30 seconds to 1 minute between passes.

39
Q

Describe why and how to clean the suction catheter.

A

Clean the suction catheter with sterile normal saline before each suctioning pass to maintain patency of the suction catheter from thick secretions obtained from the previous suctioning pass.

40
Q

When would you discontinue a suctioning episode prior to completing?

A

Stop suctioning if there is cyanosis; excessive increase, decrease or irregularity in heart rate/rhythm; excessive lowering of BP; bloody secretions; or excessive changes in respirations. Be sure to administer oxygen.

41
Q

Oropharyngeal Airway

A

A semicircular tube of plastic or rubber inserted into the back of the pharynx through the mouth in a patient who is breathing spontaneously.
Used to keep the tongue clear of the airway until person regains consciousness

42
Q

Nasopharyngeal Airway

A

Nose to pharynx
A semicircular tube of plastic or rubber inserted into the back of the pharynx through the nose in a patient who is breathing spontaneously.

43
Q

Endotracheal Tube

A

An airway that is inserted through the nose or the mouth into the trachea, using a laryngoscope as a guide.

Used to administer oxygen by mechanical ventilator, to suction secretions easily, or to bypass upper airway obstructions (i.e. tongue or tracheal edema).

44
Q

Tracheostomy

A

Artificial opening in the trachea (2nd or 3rd cartilaginous ring) through which a tube is placed.

45
Q

Hyperventilate

A

Condition in which there is more than the normal amount of air entering and leaving the lungs

46
Q

Hypoxia

A

Inadequate amount of oxygen available to the cells

47
Q

What should be kept at the bedside for a client with a tracheostomy?

A

Obturator from current tracheostomy tube
New, same size and type of tracheostomy tube
New, smaller size, but same type of tracheostomy tube
Suctioning equipment
Oxygen & oxygen supplies
Bag-valve mask

48
Q

Describe the reasoning behind the need to hyperventilate or hyperoxygenate before and immediately after withdrawing the suction catheter.

A

Give 3-6 breaths if using the ambu bag OR have patient take several deep breaths before
beginning suctioning episode and immediately after each suction pass to prevent hypoxemia because oxygen is lost with each suction pass.

49
Q

Describe the procedure for withdrawing the suction catheter and applying suction.

A

When cough is stimulated, apply suction intermittently for a maximum of 10-15 seconds at a time while withdrawing & rotating the suction catheter. Suction is applied by intermittently occluding the Y-PORT on the suction catheter with your clean hand (sterile hand is holding the suction catheter.

50
Q

Describe the procedure for inserting and advancing the suction catheter.

A

Check suction and lube catheter with NS first; hyper-oxygenate or hyperventilate; insert until cough is stimulated (4-6 inches); do NOT apply suction when inserting/advancing the suction catheter

51
Q

Describe patient positioning related to tracheostomy suctioning procedure.

A

Position conscious patient in a semi fowlers or hi fowlers position to facilitate client’s coughing effectiveness, ability to breathe more easily, and aid in suction catheter insertion through the use of gravity. Position unconscious patient with HOB up & in a lateral side-lying position facing you.

52
Q

What are clinical signs of hypoxemia/hypoxia indicating possible need to suction?

A

Skin color changes (pallor to cyanosis); tachycardia (increased HR); tachypnea (increased RR); dyspnea; increased noisy respirations, LOC changes (decreased); mental status changes (confusion); anxiety; restlessness; other clinical signs dependent on body tissue that is oxygen deprived (heart = chest pain)

53
Q

What are some key points when performing Nasopharyngeal suctioning ?

A

may stimulate the gag reflex less than oropharyngeal suctioning. The suction catheter is inserted along the floor of the nostril 5-6 inches. Nares should be alternated. A nasal trumpet may be used to decrease irritation to the nares.

54
Q

What is a contraindication for using Nasopharyngeal suctioning ?

A

Nasopharyngeal suctioning is contraindicated for patients with deviated septum, nasal polyps, bleeding tendencies.

55
Q

How is Oropharyngeal suctioning different from nasopharyngeal suctioning and what are some key point?

A

requires patient to be cooperative. It may produce more gagging compared to nasopharyngeal suctioning. The suction catheter is guided down the side of the mouth 3-4 inches. The suction catheter is flushed with sterile NS between catheter insertions.

56
Q

When is suctioning done?

A

Done when client able to cough effectively, but not able to clear secretions. If not contraindicated, client’s should be taught to increase fluid intake to thin secretions making it easier for the client to clear the secretions.
Suctioning is also done to clear secretions by stimulating coughing when client has no, weak, or ineffective cough.

57
Q

How is Yankauer

used for oral suctioning?

A

Oropharyngeal suctioning requires patient to be cooperative. It may produce more gagging compared to nasopharyngeal suctioning. The suction catheter is guided down the side of the mouth 3-4 inches. The suction catheter is flushed with sterile NS between catheter insertions.

58
Q

How do you assess the Cerebellar System by assessing Motor/Movement

A

Motor/Movement: Movement-gait, stance, button shirt, hold a spoon

59
Q

How do you assess the Cerebellar System by assessing Coordination

A

Coordination: rhythmic movements, finger to thumb, finger to nose, hand slaps on thigh

60
Q

How do you assess the Cerebellar System by assessing strength?

A

Strength: -muscle tone (see hand out on testing strength of various muscle and joints)

61
Q

How do you assess the Cerebellar System by assessing balance?

A

Balance: Romberg, balance -walk on toes, heels, then heel to toe,

62
Q

Describe what the following picture is documenting (what do the +’s mean?)

A
  • 0= no response
  • 1+=diminished or low
  • 2+=normal
  • 3+=brisker than normal
  • 4+=hyperactive
63
Q

List the tests/assessments used to assess the Cerebellar System

Motor/Movement: –

A

Movement-gait, stance, button shirt, hold a spoon

  • -Coordination: rhythmic movements, finger to thumb, finger to nose, hand slaps on thigh
  • -Strength: -muscle tone (see hand out on testing strength of various muscle and joints)
  • -Balance: Romberg, balance -walk on toes, heels, then heel to toe,
64
Q

Describe how to test for functioning of CN XII (hypoglossal) XII

A

Hypoglossal -movement and strength of tongue; press against cheek bilaterally

65
Q

Cranial nerve III: Describe the correct technique for assessment of pupillary response to light and accommodation

A

Eye III Pupils Reaction to Light
• PERRLA: (PER)-(RL)-pupils equal, round, react to light and accommodate
• Open and close eye lids

66
Q

Explain how orientation is accurately documented.

A

Orientation
Ox3= (Person, place, time)
A & O x3 (or X4-includes situation)

67
Q

Define confusion

•

A

Loss of awareness, not oriented to person, place or time
• Difficult to assess in nonverbal patients or aphasic patients.
• Give examples of orientation:
• Verbalizes own, spouses name, knows he is at hospice in Madison, Believes it is March

68
Q

List the 7 parts of the Mental Status Assessment

A
  • LOC
  • Appearance and behavior
  • Mood, feelings, affect
  • Thought processes + perceptions
  • Orientation
  • Short and LT memory
  • Speech
69
Q

Describe how to assess level of awareness.

A

Normal=awake and alert to events occurring around them, eyes open, responding appropriately

70
Q

Describe how to assess level of awareness.

A

Normal=awake and alert to events occurring around them, eyes open, responding appropriately

71
Q

Define Lethargy-

A

drowsy, sleepy, can be aroused by gentle shaking or verbal name, spontaneous movements, responds verbally

72
Q

Define Global/Total Aphasia=

A

loss of or deficiency in the power to use or understand language as a result of injury to or disease of the brain

73
Q

Define Expressive aphasia=

A

unable to express self with spoken language, word finding difficulties, using inappropriate words in place of meaningful words in context

74
Q

Define Receptive aphasia=

A

unable to understand spoken language from others

75
Q

Define Dysarthria=

A

disturbance in speech due to paralysis, incoordination, or spasticity of muscles used to speak

76
Q

Define Graphesthesia-

A

ability to distinguish a number drawn on the palm with eyes closed

77
Q

Define Stereognosis-

A

ability to recognize a common object held in the hand with eyes closed

78
Q

Define Proprioception-

A

sensing movement of a body part in space

79
Q

Define Ataxia-

A

uncoordinated, shuffling gait

80
Q

Define Dysphagia=

A

difficulty swallowing, CN IX & X

81
Q

Define Hemiplegia=

A

total or partial paralysis of one side

82
Q

Define Dysphasia=

A

difficulty speaking (speech center affected)

83
Q

Define Hemiparesis=

A

muscular weakness restricted to one side

84
Q

Define Paralysis=

A

complete inability to move

85
Q

List the 5 unique reflexes for an infant. Review how to test these.

A
  • Unique reflexes
  • Rooting-turns head to side when stroked
  • Sucking-to feed
  • Grasp-touch palm->flexion of fingers
  • Moro-sudden jarring or noise->extension and abduction of extremities (gone at 3-4 months)
  • Babinski-extension and abduction of toes with sole stroking
86
Q

What are some non-neurological factors that could affect mental status assessment results? •

A

Neurological Obtains data r/t the function of a patients nervous system
• Often performed last due to integrated in other systems
• The frequency and depth depend on patient condition & how rapid changes are occurring or expected to occur

NS Final (2 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions