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Nursing Application > Neuro and Mental Assessment > Flashcards

Neuro and Mental Assessment Flashcards

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1
Q

What is 13 items of subjective data you could collect?

A
  1. headache?
  2. head injury?
  3. dizziness/vertigo?
  4. seizures?
  5. tremors?
  6. weakness?
  7. coordination?
  8. numbness/tingling?
  9. difficulty swallowing?
  10. difficulty speaking?
  11. environmental/occupational hazards?
  12. problems with attention span, memory, reasoning?
  13. are they meeting developmental milestones?
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2
Q

If they had a head injury what do you ask?

A

new or old?
loss of consciousness?

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3
Q

What do you ask if a child had a head injury?

A

Did they cry right away? most likely didn’t lose consciousness

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4
Q

What is vertigo?

A

inner ear problem

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5
Q

What factors do you take into consideration when asking about past seizures?

A

duration?
type?
aura?

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6
Q

What is aura?

A

warning of impending seizure

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7
Q

What does weakness on one side of the body indicate?

A

stroke

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8
Q

What is a word salad?

A

words are mixed up

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9
Q

What do you ask pertaining to drugs?

A

current medications?
alcohol use?
mood-altering drugs?

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10
Q

When should babies have head control?

A

by 4 months old

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11
Q

When is a child’s sensory assessed?

A

7-9 months

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12
Q

What is the babinski reflex?

A

fanning of toes

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13
Q

Where do senile tremors start?

A

hands and head

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14
Q

What is the most sensitive indicator of neurologic function?

A

consciousness

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15
Q

How do you describe obtunded consciousness?

A

transitional state between lethargy and stupor
-mostly sleeps, difficult to arouse
-acts confused when aroused

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16
Q

How do you describe stupor consciousness?

A

responds only to vigorous shaking or pain with groans and mumbling

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17
Q

What is 7 pieces of objective data that you could collect?

A
  1. consciousness
  2. language
  3. mood and effect
  4. orientation
  5. attention
  6. memory
  7. abstract reasoning
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18
Q

How is mood displayed?

A

by emotion

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19
Q

How is affect displayed?

A

by facial expression

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20
Q

What is dementia in relation to memory?

A

impaired recent memory and intact remote memory

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21
Q

At what age should a child be able to communicate?

A

4

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22
Q

At what age do children become logical and concrete?

A

7

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23
Q

At what age do children have abstract thinking?

A

12-15

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24
Q

What does ABCT stand for during a mental status exam?

A

Appearance
Behavior
Cognitive function
Thought process and perceptions

25
Q

When under the influence of alcohol or drugs or extremely fatigued what can be impaired?

A

cognitive function

26
Q

What is a mini-mental state exam assessing?

A

Recall
Orientation
Registration
Attention and calculation
Language

27
Q

What does a score of 24-30 on a mini-mental state exam mean?

A

normal

28
Q

What does a score of <16 on a mini-mental state exam mean?

A

more severe mental impairment

29
Q

Cranial nerves:
On Old Olympus Towering Top A Finn And German Viewed Some Hops

A

Olfactory
Optic
Oculomotor
Trochlear
Trigeminal
Abducen
Facial
Acoustic
Glossopharyngeal
Vagus
Spinal
Hypoglossal

30
Q

What is the scale used for strength

A

0-5

31
Q

What is involved when inspecting tone?

A

ROM should produce some resistance to stretch

32
Q

What is tandem walking?

A

heel-to-toe

33
Q

What is the Romberg test?

A

eyes close, 20 seconds with feet together and arms at sides

34
Q

What does RAM stand for?

A

rapid alternating movements

35
Q

What is another word for pain?

A

spinothalamic tract

36
Q

How are reflexes graded?

A

0-4+

37
Q

What is clonus?

A

abnormal rapid contraction of muscle

38
Q

What is the normal pupil size?

A

3-4mm

39
Q

What does PERRLA stand for?

A

Pupils are Equal, Round, Reactive to Light and Accommodation

40
Q

What is the highest score a person can achieve on the Glasgow Coma Scale?

A

15

41
Q

What is the lowest score a person can have on the Glasgow Coma Scale?

A

3

42
Q

What does the Glasgow Coma Scale Assess?

A

eye opening, motor response, verbal response

43
Q

What 10 factors does the Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA) assess?

A
  1. agitation
  2. anxiety
  3. auditory disturbances
  4. orientation/clouding of sensorium
  5. headache
  6. nausea and vomiting
  7. paroxysmal sweats
  8. tactile disturbances
  9. tremors
  10. visual disturbances
44
Q

What does paroxysmal mean?

A

sudden

45
Q

How would you describe tactile disturbances?

A

abnormal or false sensation of touch or perception of movement on the skin or inside the body

46
Q

What score on the CIWA is concerning and needs medication for withdrawal?

A

20-67

47
Q

What score on the CIWA is mildly concerning?

A

9-20

48
Q

How would you test CN III?

A

reactive to light and accommodation
6 fields of gaze

49
Q

How would you test CN IV?

A

6 fields of gaze

50
Q

How would you test CN V?

A

clench teeth
facial sensation, corneal reflex

51
Q

How would you test CN VI?

A

6 fields of gaze

52
Q

How would you test CN VII?

A

raise eyebrows
frown
close eyes tightly
show upper and lower teeth
smile
puff out cheeks
taste test

53
Q

How would you test CN VIII?

A

whisper test
nystagmus (involuntary movements)

53
Q

How would you test CN VIII?

A

whisper test
nystagmus (involuntary movements)

54
Q

How would you test CN IX?

A

ahh movement of soft palate and pharynx
voice quality
gag reflex

55
Q

How would you test CN X?

A

ahh movement of soft palate and pharynx
voice quality
gag reflex
taste test

56
Q

How would you test CN XI?

A

rotate head against resistance
shrug shoulders against resistance

57
Q

How would you test CN XII?

A

stick out tongue, say “light, tight, dynamite”

Nursing Application (16 decks)

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