neurological assessment for exma 2

Question 1

what questions about health history should the nurse ask when assessing neurological status

Answer 1

• Have you noticed an changes in ability to move around or participate in usual activities, preform ADL’s?
• do you have any chronic diseases
• past medical history
• family history of neuro issues?
• alcohol use? when? how much?

Question 2

what are the 6 major issues to assess?

Answer 2

1. mental status
2. balance & coordination
3. cranial nerves
4. motor functions
5. sensatory function
6. reflexes

Question 3

what do you ask the PT about orientation?

Answer 3

• person, place, time, situation
• if correct = AxO x4
• if not reorient them

Question 4

what else is the nurse assessing for regarding neuro assessment?

Answer 4

• level of consciousness
• mood and affect
• memory
• motor balance and coordination
• cranial nerve assessment

Question 5

what are the different levels of consciousness

Answer 5

• awake
• lethargic
• abundant
• stuporous
• semi =
• coma = no response

Question 6

what does semi mean in regards LOC

Answer 6

• comatose
• takes a lot to wake them up, may be in pain

Question 7

what does stuporous mean regarding to LOC?

Answer 7

• a bit out of it, very sluggish and tired
• think rly drunk

Question 8

what is abundant regarding LOC?

Answer 8

• sleepy, slow to respond

Question 9

how can nurses assess short term memory?

Answer 9

• give pt 3 words to remember
• have pt repeat 3 words in 10 min
• long term memory can be hard to assess

Question 10

what is the name, motor status and function of cranial nerve 1?

Answer 10

1. olfactory, sensory, smell

Question 11

what is the name, motor status and function of cranial nerve 2?

Answer 11

• optic, sensory, vision

Question 12

what is the name, motor status and function of cranial nerve 3?

Answer 12

• oculomotor, sensory & motor (+), eyeball and eyelid movement

Question 13

what is the name, motor status and function of cranial nerve 4?

Answer 13

• trochlear, sensory & motor (+), innervates superior oblique eye muscle movement, move eye down and laterally

Question 14

what is the name, motor status and function of cranial nerve 5?

Answer 14

• trigeminal, sensory and motor, chewing, face, mouth, pain

Question 15

what is the name, motor status and function of cranial nerve 6?

Answer 15

• abducens, sensory and motor (+), turns eye laterally

Question 16

what is the name, motor status and function of cranial nerve 7?

Answer 16

• facial, sensory and motor, controls most facial expressions, tears and saliva

Question 17

what is the name, motor status and function of cranial nerve 8?

Answer 17

Vestibulocochlear (auditory), sensory, hearing

Question 18

what is the name, motor status and function of cranial nerve 9?

Answer 18

• glossopharyngeal, sensory & motor, taste and sensory awareness of body

Question 19

what is the name, motor status and function of cranial nerve 10?

Answer 19

• Vagus = sensory & motor, aortic BP, shows HR, stimulates digestive organs

Question 20

what is the name, motor status and function of cranial nerve 11?

Answer 20

• spinal accessory, sensory & motor (+), controls trapezius, sternocleidomastoid, swallowing and muscle sense

Question 21

what is the name, motor status and function of cranial nerve 12?

Answer 21

hypoglossal, sensory and motor (+), tongue movements, muscle sense

Question 22

when Inspeccion of a pt head what are nurses looking for?

Answer 22

• skull, hair, scalp, shape, configuration, size, eyes and ears should match
• Normocephalic = normal size
• Microcephaly = small size
• Macrocephaly = big size

Question 23

when doing neuro assessment how can we test cranial nerve 5

Answer 23

• Temporomandibular joint (TMJ) to test cranial nerve 5
• mouth should move smooth
• open and close side to side

Question 24

when doing an objective physical inspection of the face what are nurses looking for?

Answer 24

• symmetry (if not indicates a stroke)
• nasolabial folds
• mouth
• movement
• expression
• skin conditions

Question 25

what does PERRLA stand for?

Answer 25

- Pupils Equal Round React to Light Accommodation

Question 26

what are we looking for in the PERRLA exam?

Answer 26

- looking for pupillary response - Pupils constrict when focusing on close objects - Pupils dilate when focusing on distant objects - Shine the light in one eye, constrict in the other

Question 27

what is the normal pupillary response?

Answer 27

- between 2 - 6 - round, reactive, and equal in size

Question 28

what are the cranial nerves that help with eyes?

Answer 28

2 = vision, far, near peripheral vision 3, 5 & 7 = muscle control of the eyes, smooth and coordinated, pupil construction, dilation

Question 29

what are the objective inspection of the ears?

Answer 29

- size and shape - skin condition - tenderness - external auditory meatus - enteral canal (color, swelling, lesions, dischange)

Question 30

how to assess the nose?

Answer 30

- inspect and palpate - test nostril patency - cranial nerve 1 - nasal mucosa should be paler than other mucosa - nasal septum - turbinates

Question 31

how to assess nostril patency?

Answer 31

- block 1 nare and do that on both sides and they should be able to breath

Question 32

how to assess sinuses

Answer 32

- take thumbs and feel - don't do if not necessary

Question 33

what nerves control the tounge?

Answer 33

- 9 & 10 = open and say ahhh and the uvula moves - 11 = when they can stick their tongue out say "light, tight, dolomite"

Question 34

what do nurses assess the neck?

Answer 34

- inspect and palpate: - lymph nodes - trachea - thyroid - range of motion - carinal nerve 11

Question 35

how do nurses to examine lymph nodes

Answer 35

- using gentle circular motion of fingers to palpate lymph nodes - beginning w/ preauricular lymph nodes in front of ear, palpate the 10 groups of lymph nodes - Many nodes are closely packed so you must be systematic and thorough in the exam - Do not very sequence or you may miss the small nodes