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Health Ass Skills Lab > Neuro Assessment > Flashcards

Neuro Assessment Flashcards

1
Q

The evaluation of the health status of a client with a neurologic disorder or dysfunction

A

Neurological System Assessment

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2
Q

To obtain a _______ on the client’s neurological status abilities.
2. To _____, ___, and _____ data obtained in the nursing history.
3. To obtain data that will help _______ and plan of care.
4. To evaluate the ________ of health care and thus the progress of a client’s health.
5. To make ________about a client’s health status.
6. To identify areas for ______ and _____

A

To obtain a baseline data on the client’s neurological status abilities.
2. To supplement, confirm, or refute data obtained in the nursing history.
3. To obtain data that will help establish nursing diagnoses and plan of care.
4. To evaluate the physiologic outcomes of health care and thus the progress of a client’s health.
5. To make clinical judgments about a client’s health status.
6. To identify areas for health promotion and disease prevention.

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3
Q

what are the equipments used in neuro assessment

Clue: ENTSPTT COPOSSR

A

Examination gloves
Newspaper
Tape Measure
Snellen Chart
Penlight
Tuning Fork
Tongue depressor
Cotton-tipped applicators
Ophthalmoscope
Paper clip
Objects to feel
Sterile cotton ball
Substances to smell
Reflex hammer

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4
Q

Prior to performing the Neuro assessment Procedure, what should be done first and arrange in order

(Provide Client Privacy, Explain/ Discuss to client procedure, Introduce self, Perform Hand Hygiene, ask Client identity)

A
  1. Introduce Self
  2. Ask client Identity
    3.Explain/Discuss to client procedure
    4.Perform Hand hygiene and other prevention protocol
  3. Provide Client Privacy
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5
Q

2 Types of Assessing the Neurological System

A
  1. Assess Level of Consciousness and Orientation
  2. Assess CNs (Cranial Nerves)
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6
Q

Type of Assessing Neuro System

“by asking client to identify name, location, day of the week, and year, note behavior and appearance.”

A

Assessing LOC and Orientation

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7
Q

Rationale for assessing Loc and Orientation

A

To determine spontaneity of responses to questions

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8
Q

For all assessments of the cranial nerves, have client ____ in a comfortable position at your ___ level.

A

sit, eye level

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9
Q

What are the 12 Cranial Nerves

A

Olfactory, Optic Oculomotor, Trochlear, Abducens, Trigeminal, Facial, Acoustic/Vestibulocochlear, Glossopharyngeal, Vagus, Spinal Accessory, Hypoglossal

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10
Q

What CNs Assessment and fill out the blank

To identify the ___ or ____ of the sense of smell

A

Olfactory (I)

absence & presence

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11
Q

In Assessing Optic (II), what is used to assess the DISTANT VISION

A

Snellen Chart

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12
Q

In assessing the visual fields in Optic, what should u do

A

Confrontation

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13
Q

what should the Client Read during optic Assessment

A

Newspaper or Magazine

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14
Q

Rationale for Optic (II)

A

To measure central (convergence) and peripheral vision

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15
Q

In Oculomotor (III)/Trochlear (IV)/Abducens (VI)

A. Inspect margins of the ____
B. Assess ____ movements
C. Assess ______ response to light and ____ in both eyes

A

A. Inspect margins of the eyelids
B. Assess Extraocular Movements
C.Assess pupillary response to light and accommodation in both eyes

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16
Q

Rationale for

Oculomotor (III)/Trochlear (IV)/Abducens (VI)
A. Inspect margins of eyelid
B. Assess extraocular movements

A

To determine parallel eye movement

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17
Q

Two Test Function for Trigeminal (V)

A

Test Motor Function
Test Sensory Function

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18
Q

In Trigeminal (V), what kind of Test Function and fill out the blank

ask client to clench teeth while you ___ the —- and ___ muscles for contraction

A

Test Motor Function

ask client to clench teeth while you palpate the temporal and masseter muscles for contraction

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19
Q

in Trigeminal (V), Rationale for test motor Function

To determine_____ of muscles

A

To determine bilateral contraction of muscles

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20
Q

What Equipment is used for Test Sensory Function in Assessing the Trigeminal Cranial Nerve?

A

Paper Clip

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21
Q

What Cranial Nerve Assessment is this?

Ask client to smile, frown, wrinkle forehead, show teeth, puff out cheeks, purse lips, raise eyebrows, and close eyes tightly against resistance

A

Facial (VII)

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22
Q

What is the Rationale of the test sensory function of the Trigeminal Cranial Nerve Assessment

  • To determine ___ of the trigeminal nerve and ___ tract*
A

To determine lesions of the trigeminal nerve and spinothalamic tract

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23
Q

Rationale for Facial (VII) Cranial Nerve Assessment

To determine for ___ facial movement and central —- on the upper ____ neurons

A

To determine for symmetric facial movement and central lesionon the upper motor neurons

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24
Q

3 Kinds of test for Acoustic/Vestibulocochlear (VIII)

A

A. Testhearingability
B. PerformWebertest
C. Perform Rinne test

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25
Q

Rationale for Acoustic/Vestibulocochlear (VIII)

To determine g___ H___ A____

A

To determine gross hearing acuity

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26
Q

What kind of Cranial Nerve Assessment and Fill out the Blank

A. Test ___ function: ask
client to open mouth wide and say “ah” while using ____ on client’s tongue
B. Test ___ reflex
C. Check ability to ____

A

Glossopharyngeal (IX), Vagus (X)

A. Test motor function: ask
client to open mouth wide and say “ah” while using tongue depressor on client’s tongue
B. Test gag reflex
C. Check ability to swallow

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27
Q

Rationale for Acoustic/Vestibulocochlear

To check for presence of protective reflexes such as -, -, or -

A

To check for presence of protective reflexes such as gagging, coughing, or swallowing

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28
Q

What kind of Cranial Nerve Assessment and fill out blank

A. _____ against resistance
B.______ against resistance

A

Spinal Accesory (XI)

A. Shrug shoulders against resistance
B. Turn the head against resistance

29
Q

Rationale for Spinal Accessory (XI) Cranial Nerve Assessment

Clue: (fill out blank) To check for ___ and ____ of contractions of ___ and ___ muscle

A

To check for smoothness and strength of contractions of sternocleidomastoid and trapezius muscle

30
Q

What Cranial Nerve is this? And fill out the blank

Ask the client to ___ tongue, move it to side against resistance of a ____ and then put it back in the mouth

A

Hypoglossal XII

Ask the client to protrude tongue, move it to side against resistance of a tongue depressor, and then put it back in the mouth

31
Q

Equipment used for Hypoglossal (XII) Assessment

A

Tongue Depressor

32
Q

Rationale for Hypoglossal (XII)

To assess the ____ and ___ of the tongue

A

To assess the strength and mobility of the tongue

33
Q

In assessing the extremities for sensation a nurse must perform all sensory testing with
client’s eyes _______ so he/she is unable to see when or where the stimulus strikes the skin. It is done through: _____, ______, ______

A

closed
Pain, light touch, sensitivity to position

34
Q

a. Pain: Use the blunt and sharp
ends of a ______ or _______ to
skin surface. Apply in symmetrical
areas of extremities.

A

safety pin
paper clip

35
Q

b. Light touch: use a wisp of _______ to different points along a surface of skin in symmetrical areas of extremities.

A

cotton

36
Q

___________: Ask client to close both eyes. Then grasp finger or toe, holding it by its sides with your thumb and index finger. Move part alterately up and own. Ask client to tell you the direction it moved. Repeat with toes.

A

Sensitivity to position

37
Q

How to test the motor and cerebellar function

A

Gait
Romberg’s test

38
Q

Have a client walk across, tum and comeback (e.g. heel to toe, on their toes, on their heels)

A

Gait:

39
Q

__________: have a client stand with feet together, arms at sides, both eyes open and eyes closed (for 20 - 30 sec). Protect client’s safety by standing at the side; observed for swaying.

A

b. Romberg’s test

40
Q

In Assessing Deep tendon Reflex, what is the first step you should do?

A. Introduce Self
B. Provide Privacy
C. Obtain Equipment Needed
D. Explain each test to your patient

A

C. Obtain Equipment Needed

41
Q

In assessing the superficial reflex of the Abdomen, patient must lie on the bed in________ position and legs should be ________ at the knees.

A

supine
slightly flexed

42
Q

In abdominal superficial reflex assessment, Normally the umbilicus will _______ and toward the area being touched. If your patient has an upper or lower _______, his abdominal reflex may be absent.

A

move up
neuron disturbance

43
Q

In Assessing Deep Tendon Reflex WHY should you explain each test to your patient and WHY should you encourage him to relax each part of his body as you test it?

A

For a Valid Finding , this include a Relaxed Patient

proper use of reflex hammer, proper positioning of the extremity and a relaxed patient.

DO NOT FORGET THE RELAXED PATIENT

44
Q

During the abdominal superficial reflex assessment, it is expected that the umbilicus will move _____

A

Down

45
Q

During the plantar reflex assessment, If everything is okay, his toes will curl ________.

A

downward

46
Q

Dorsiflexion of the _______ and fanning of the other toes (Babinski sign) is an abnormal response.

A

great toe

47
Q

If your patient is male, you will need to test the _______

Gently draw the stick down the upper portion of his right ______ thigh.

A

cremasteric reflex.
inner

48
Q

Expect cremasteric muscle to ______ and the right testicle to _______ slightly.

A

contract
rise

49
Q

what are the five reflexes in assessing the Deep Tendon Reflex

A

Bicep Reflex
Tricep Reflex
Brachioradialis Reflex
Patellar Reflex
Achilles Tendon Reflex

50
Q

Absence of cremasteric reflex may be present in upper and lower motor _______

A

neuron disturbance.

51
Q

In Corneal reflex It is tested carefully
using a clean wisp of ______. Lightly touch the outer corner of each eye on the ______.

A

cotton
sclera

52
Q

In Assessing your patient’s deep tendon reflexes: Biceps Reflex
Why should you Slightly flex pt’s right elbow?

A

To allow it to swing freely

53
Q

Condition such as _______ or ______ might result in loss of corneal reflex, either unilaterally or bilaterally

A

CVA
coma

54
Q

What Equipment is used when assessing the deep tendon reflex?

A

Reflex Hammer

55
Q

e.__________
This is elicited by gently touching the back of the pharynx with a cotton-tipped applicator

A

Gag or Swallowing Reflex

56
Q

For the Bicep Reflex

  1. Then, with your ____ pressed
    ____ against his biceps muscle
    tendon, hold your patient’s ___.
  2. Keeping the reflex hammer held
    ____ between your ___ and
    ___, strike your ____.
  3. Repeat the test on your
    patient’s left bicep
A
  1. Then, with your thumb pressed
    firmly against his biceps muscle
    tendon, hold your patient’s elbow.
  2. Keeping the reflex hammer held
    loosely between your thumb and
    fingers     , strike your thumb
  3. Repeat the test on your
    patient’s left bicep
57
Q

During gag reflex, a positive response is an equal elevation of the ______ and “gag” with _______.

Absent response on one or both side can be seen following a CVA and requires careful evaluation

A

uvula
stimulation

58
Q

In assessing the Bicep Reflex, what rationale is for this?

Then, with your thumb pressed
firmly against his biceps muscle
tendon, hold your patient’s elbow.

Keeping the reflex hammer held
loosely between your thumb and
fingers, strike your thumb.

Repeat the test on your
patient’
s left bicep

A

Expect your patient’s biceps
muscle to contract, flexing his
arms at the elbow

59
Q

For Tricep Reflex,

To do this, have pt __ his arm
at the elbow.

Then, hold his arm at the wrist.

With the reflex hammer, strike
the triceps tendon ___ over
his elbow.

Repeat the test on the other
elbow.

A

To do this, have pt flex his arm at the elbow.

Then, hold his arm at the wrist.

With the reflex hammer, strike
the triceps tendon directly over
his elbow.

Repeat the test on the other
elbow.

60
Q

Choose the Correct Letter
A. Flexing or B. Extending

In Bicep Reflex, Expect your patient’s Biceps muscle to contract, ___ his arms at the elbow

In Tricep Reflex, Expect your patient’s Triceps muscle to contract, ___ his arms at the elbow

A

In Bicep Reflex, Expect your patient’s Biceps muscle to contract, FLEXING his arms at the elbow

In Tricep Reflex, Expect your patient’s Triceps muscle to contract, EXTENDING his arms at the elbow

61
Q

In Brachioradialis Reflex

  1. Have pt ___ his forearm on his ___. His palm
    should be facing ____.
A

rest, lap, down

62
Q

when assessing the brachioeadialis, when striking the radius, should the palm turn upward or downward?

A

upward

63
Q

the radius is located ____ the wrist

A

1”-2” above the wrist

64
Q

In Patellar Reflex, what should you expect to see to the knee when striking the patellar tendon?

A

Knee Extension, his knee to swing forward

65
Q

In the Patellar Reflex, where is the Patellar tendon Located?

Below or Above the Patella?

A

Below the Patella

66
Q

In Achilles Tendon Reflex, if the Relaxation period is slowed, what should you suspect?

A

Hypothyroidism

67
Q

In achilles Tendon Reflex, Hold your patient’s Right foot with you__ (left or right) hand

Gently Rotate his foot ___ (outward or inward)

A

Left, Outward

68
Q

When Striking the Achilless Tendon, what flexion should you watch on his ankle?

What should you Observe after the contraction?

A

Plantar Flexion,

Obserbe quickly the Muscle relaxes after contraction

Health Ass Skills Lab (1 decks)

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