Module 07: Neuromuscular Assessment (Part 01) Flashcards
Under the neuromuscular assessment, what should the nurse observe as per general appearance and survey?
(1) Hygiene:
(a)Nails clean and trimmed; hair clean and combed
(b) Appearance – well kept (clean clothing,
appropriate for weather)
(2) Coherence
(a) Eye contact present
(b) Understandable speech
(c) Ability to follow instructions
(3) Mood and affect
(a) Subjective and objective
Under the neuromuscular assessment when observing the general appearance and survey, poor hygiene is often associated with what?
(a) Depression
(b) Alzheimer’s
(c) Schizophrenia
Under the neuromuscular assessment when observing the general appearance and survey, meticulous finicky grooming is often associated with what?
Obsessive Compulsive Disorder
Under the neuromuscular assessment when observing the general appearance and survey, poor eye contact is often associated with what?
Depression
Under the neuromuscular assessment when observing the general appearance and survey, what is often observed among patients with Parkinson’s disease?
Mask like expression
Under the neuromuscular assessment when observing the general appearance and survey, extreme anger or happiness is often associated with what?
Anxiety
Under the neuromuscular assessment when observing the general appearance and survey, slow repetitive speech is often associated with what?
(a) Parkinson’s disease
(b) Depression
Under the neuromuscular assessment when observing the general appearance and survey, loud and rapid speech is often associated with what?
Maniac Disorder
When assessing the level of consciousness, in this the patient possesses awareness to self and environment; focused response verbally with eye contact.
Alertness
When assessing the level of consciousness, in this, the patient is drowsy, can open eyes and keep eye contact, responds when spoken to a loud voice but still falls back to sleep.
Lethargic
When assessing the level of consciousness, in this, the patient possesses decreased alertness needs to be shaken gently, responds verbally but somewhat confused with short attention span minimal eye contact.
Obtunded
When assessing the level of consciousness, in this, the patient is arousable only to painful stimuli, slow to almost no verbal stimuli; responsiveness stops when stimulus stop minimal awareness to self and environment.
Stuporous
This scale is often utilized to assess the patient’s mental status under the neuromuscular assessment. This is composed by the (a) eye opening response, (b) best verbal response, and (c) best motor response.
Glasgow coma scale
When assessing the level of consciousness, in this, the patient is unresponsive to painful stimuli, unarousable to any stimuli, eyes closed.
Comatose
The Glasgow Coma Scale is composed of what?
(1) Eye opening response
(2) Verbal Response
(3) Motor Response
What is the best response under the Glasgow Coma Scale?
15
What is the grade of a comatose client under the Glasgow Coma Scale?
Eight (8) or less
What is the grade of a patient who is totally unresponsive under the Glasgow Coma Scale?
Three (3)
How should the nurse assess the patient’s orientation?
(a) Person: name, nickname
(b) Time: ask “what is the year? Month of the year? What day of the week?”
(c) Place: ask “where are you now?” city?
Region? Grocery store? Hospital?
How should the nurse assess the patient’s memory under the neuromuscular assessment?
(a) Recall three (3) words
(b) Instruct patient by saying: “I am going to say three words” Orange, paper, and table
(c) Have the patient recite them to help words register in their mind; may repeat until patient has learned the 3 words
(d) Ask patient after a few minutes (15 min), “What were those 3 words I asked you to remember”
What are some questions that the nurse can ask when assessing for the patient’s short term recall?
What did you eat this breakfast? (validate answers with family or sitter)
What are some questions that the nurse can ask when assessing for the patient’s long term recall?
Where did you graduate (or married)? When is your birthday?
When assessing the patient’s short term recall, the inability to remember recent events may be associated with what?
(1) Dementia
(2) Delirium
(3) Depression
(4) Anxiety
When assessing the patient’s long term recall, the inability to remember past events may be associated with what?
(1) MVA injury
(2) Lesion in the cerebral cortex or hippocampus