Neurological System Flashcards by B -

Neurologic System

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STRUCTURE AND FUNCTION

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The central nervous system (CNS) includes the brain and spinal cord.
A)true
B)false

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The peripheral nervous system includes all the nerve fibers outside the brain and spinal cord: the 12 pairs of cranial nerves, the 31 pairs of spinal nerves, and all their branches.
A)true
B)false

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The peripheral nervous system carries sensory (afferent) messages to the CNS from sensory receptors, motor (efferent) messages from the CNS out to muscles and glands, as well as autonomic messages that govern the internal organs and blood vessels.
A)true
B)false

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THE CENTRAL NERVOUS SYSTEM {CNS)

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cerebral cortex is the cerebrum’s outer layer of nerve cell bodies, which looks like “gray matter” because it lacks myelin.
A)true
B)false

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Myelin is the white insulation on the axon that increases the conduction velocity of nerve impulses.
A)true
B)false

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The cerebral cortex is the center for human’s highest functions, governing thought, memory, reasoning, sensation, and voluntary movement
A)true
B)False

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The ________ is the center for human’s highest functions, governing thought, memory, reasoning, sensation, and voluntary movement

cerebral cortex

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Each hemisphere is divided into four lobes: frontal, parietal, temporal, and occipital
A)true
B)false

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The frontal lobe has areas concerned with personality, behavior, emotions, and intellectual function
A)true
B)false

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The parietal lobe’s postcentral gyrus is the primary center for sensation.
A)true
B)false

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• The occipital lobe is the primary visual receptor center.
A)true
B)false

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• The temporal lobe behind the ear has the primary auditory reception center with functions of hearing, taste, and smell.
A)true
B)false

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Wernicke’s area in the temporal lobe is associated with language comprehension. When damaged in the person’s dominant hemisphere, receptive aphasia results. The person hears sound, but it has no meaning, like hearing a foreign language.
A)true
B)false

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Wernicke’s area in the temporal lobe is associated with language comprehension and receptive aphasia results.
A)true
B)false

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receptive aphasia Means that The person hears sound, but it has no meaning, like hearing a foreign language.
A)true
B)false

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Broca’s area in the frontal lobe mediates motor speech. When injured in the dominant hemisphere, expressive aphasia results; the person cannot talk. The person can understand language and knows what he or she wants to say, but can produce only a garbled sound.
A)true
B)false

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Broca’s area in the frontal lobe mediates motor speech,and expressive aphasia results; the person cannot talk.
A)true
B)false

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expressive aphasia means that the person cannot talk. The person can understand language and knows what he or she wants to say, but can produce only a garbled sound.
A)true
B)false

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The basal ganglia are large bands of gray matter buried deep within the two cerebral hemispheres that form the subcortical associated motor system (the extrapyramidal system). They help to initiate and coordinate movement and control automatic associated movements of the body (e.g., the arm swing alternating with the legs during walking)
A)true
B)false

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The basal ganglia help to initiate and coordinate movement and control automatic associated movements of the body (e.g., the arm swing alternating with the legs during walking)
A)true
B)false

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The thalamus is the main relay station where the sensory pathways of the spinal cord, cerebellum, and brainstem form synapses (sites of contact between two neurons) on their way to the cerebral cortex.
A)true
B)false

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The hypothalamus is a major respiratory center with basic vital functions: temperature, appetite, sex drive, heart rate, and blood pressure (BP) control; sleep center; anterior and posterior pituitary gland regulator; and coordinator of autonomic nervous system activity and stress response. A)true B)false

The cerebellum is a coiled structure located under the occipital lobe that is concerned with motor coordination of voluntary movements, equilibrium, and muscle tone. It does not initiate movement but coordinates and smoothes it (e.g., the complex and quick coordination of many different muscles needed in playing the piano, swimming, or juggling). It is like the "automatic pilot" on an airplane in that it adjusts and corrects the voluntary movements but operates entirely below the conscious level. A)true B)false

The brainstem is the central core of the brain consisting of mostly nerve fibers. Cranial nerves III through XII originate from nuclei in the brainstem. A)true B)false

I. Midbrain-the most anterior part of the brainstem that still has the basic tubular structure of the spinal cord. It merges into the thalamus and hypothalamus. It contains many motor neurons and tracts. 2. Pons-the enlarged area containing ascending sensory and descending motor tracts. It has two respiratory centers (pneumotaxic and apneustic) tl1at coordinate with tl1e main respiratory center in the medulla. 3. Medulla-the continuation of the spinal cord in the brain that contains all ascending and descending fiber tracts. It has vital autonomic centers (respiration, heart, gastrointestinal function), as well as nuclei for cranial nerves VIII through XII. Pyramidal decussation (crossing of the motor fibers) occurs here (see p. 625).

Structures of the brainstem

The spinal cord is the long, cylindric structure of nervous tissue about as big around as the little finger. It occupies the upper two thirds of the vertebral canal from the medulla to lumbar vertebrae LI-L2. Its white matter is bundles of myelinated axons that form the main highway for ascending and descending fiber tracts that connect the brain to the spinal nerves. It mediates reflexes of posture control, urination, and pain response. Its nerve cell bodies, or gray matter, arc arranged in a butterfly shape with anterior and posterior "horns." A)true B)false

Pathways of the CNS

Crossed representation is a notable feature of the nerve tracts; the left cerebral cortex receives sensory information from and controls motor function to the right side of the body, whereas the right cerebral cortex likewise interacts with the left side of the body. Knowledge of where the fibers cross the midline will help you interpret clinical findings. A)true B)false

Sensory Pathways

Sensation travels in the afferent fibers in the peripheral nerve, then through the posterior (dorsal) root, and then into the spinal cord. A)true B)false

The spinothalamic tract contains sensory fibers that transmit the sensations of pain, temperature, and crude or light touch (i.e., not precisely localized) A)true B)false

Fibers carrying pain and temperature sensations ascend the lateral spinothalamic tract, whereas those of crude touch form the anterior spinothalamic tract. A)true B)false

Posterior (Dorsal) Columns. These fibers conduct the sensations of position, vibration, and finely localized touch. • Position (proprioception)-Without looking, you know where your body parts are in space and in relation to each other Vibration-Feeling vibrating objects Finely localized touch (stereognosis)-Without looking, you can identify familiar objects by touch

True

Pain in the right hand is perceived at its specific spot on the left cortex map. A)true B)false

Some organs are absent from the brain map, such as the heart, liver, or spleen. A)true B)false

Motor Pathways

Corticospinal fibers mediate voluntary movement, particularly very skilled, discrete, purposeful movements, such as writing. A)true B)false

The corticospinal tract is a newer, "higher," motor system that permits humans to have very skilled and purposeful movements. A)true B)false

The tract's origin in the motor cortex is arranged in a specific pattern called somatotopic organization. It is another body map, this one of a person, or homunculus, hanging "upside down" . A)true B)false

Extrapyramidal Tracts, These subcortical motor fibers maintain muscle tone and control body movements, especially gross automatic movements, such as walking. A)true B)false

Cerebellar System. This complex motor system coordinates movement, maintains equilibrium, and helps maintain posture. A)true B)false

The cerebellum receives information about the position of muscles and joints, the body's equilibrium, and what kind of motor messages are being sent from the cortex to the muscles. A)true B)false

Upper and Lower Motor Neurons

Upper motor neurons are a complex of all the descending motor fibers that can influence or modify the lower motor neurons. Upper motor neurons are located completely within the CNS. A)true B)false

Examples of upper motor neurons are corticospinal, corticobulbar, and extrapyramidal tracts. A)true B)false

Examples of upper motor neuron diseases are cerebrovascular accident, cerebral palsy, and multiple sclerosis. A)true B)false

Lower motor neurons are located mostly in the peripheral nervous system. The cell body of the lower motor neuron is located in the anterior gray column of the spinal cord, but the nerve fiber extends from here to the muscle A)true B)false

Examples of lower motor neurons are cranial nerves and spinal nerves of the peripheral nervous system. A)true B)false

Examples of lower motor neuron diseases are spinal cord lesions, poliomyelitis, and amyotrophic lateral sclerosis. A)true B)false

THE PERIPHERAL NERVOUS SYSTEM

nerve is a bundle of fibers outside the CNS. A)true B)false

Reflex Arc

They are involuntary, operating below the level of conscious control and permitting a quick reaction to potentially painful or damaging situations. _________?

Reflex arc

Reflexes also help the body maintain balance and appropriate muscle tone A)true B)false

There are four types of reflexes: (1) Deep tendon reflexes (myotatic), e.g., patellar [or knee jerk] (2) Superficial, e.g., corneal reflex, abdominal reflex; (3) Visceral (organic), e.g., pupillary response to light and accommodation; (4) Pathologic (abnormal), e.g., Babinski (or extensor plantar) reflex.

True

The deep tendon (myotatic, or stretch) reflex has five components: (1) an intact sensory nerve (afferent); (2) a functional synapse in the cord; (3) an intact motor nerve fiber (efferent); (4) the neuromuscular junction; and (5) a competent muscle.

True

Cranial Nerves

Cranial nerves enter and exit the brain rather than the spinal cord . A)true B)false

The 12 pairs of cranial nerves supply primarily the head and neck, except the vagus nerve, which travels to the heart, respiratory muscles, stomach, and gallbladder. A)true B)false

Spinal Nerves

The 31 pairs of spinal nerves arise from the length of the spinal cord and supply the rest of the body. They are named for the region of the spine from which they exit: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal. They are "mixed" nerves because they contain both sensory and motor fibers. A)true B)false

Dermal segmentation is the cutaneous distribution of the various spinal nerves. A)true B)false

dermatome is a circumscribed skin area that is supplied mainly from one spinal cord segment through a particular spinal nerve. The dermatomes overlap, which is a form of biologic insurance. A)true B)false

Autonomic Nervous System

The somatic fibers innervate the skeletal (voluntary) muscles; A)true B)false

the autonomic fibers innervate smooth (involuntary) muscles, cardiac muscle, and glands. The autonomic system mediates unconscious activity. A)true B)false

DEVELOPMENTAL COMPETENCE | Infants

The neurologic system is not completely developed at birth. A)true B)false

Motor activity in the newborn is under the control of the spinal cord and medulla. Very little cortical control exists, and the neurons are not yet myelinated. A)infants B)adults

Movements are directed primarily by primitive reflexes. A)infants B)adults

As the cerebral cortex develops during the first year, it inhibits these reflexes and they disappear at predictable times. Persistence of the primitive reflexes is an indication of CNS dysfunction. A)infants B)adults

The infant's sensory and motor development proceed along with the gradual acquisition of myelin, because myelin is needed to conduct most impulses. A)true B)false

The process of myelinization follows a cephalocaudal and proximodistal order (head, neck, trunk, and extremities). This is just the order in which we observe the infant gaining motor control (lifts head, lifts head and shoulders, rolls over, moves whole arm, uses hands, walks). A)infant B)adult

Sensation also is rudimentary at birth. A)true B)false

_____ needs a strong stimulus and then responds by crying and with whole body movements. As myelinization develops, the infant is able to localize the stimulus more precisely and to make a more accurate motor response. A)infant B)adult

DEVELOPMENTAL COMPETENCE | The Aging Adult

The aging process causes a general atrophy with a steady loss of neuron structure in the brain and spinal cord. This causes a decrease in weight and volume with a thinning of the cerebral cortex, reduced subcortical brain structures, and expansion of the ventricles. A)aging adult B)infant

Neuron loss leads many people older than 65 years to show signs that, in the younger adult, would be considered abnormal, such as general loss of muscle bulk; loss of muscle tone in the face, in the neck, and around the spine; decreased muscle strength; impaired fine coordination and agility; loss of vibratory sense at the ankle; decreased or absent Achilles reflex; loss of position sense at the big toe; pupillary miosis; irregular pupil shape; and decreased pupillary reflexes. A)aging adult B)infant

The velocity of nerve conduction decreases between 5% and 10% with aging, making the reaction time slower in some older persons. An increased delay at the synapse also occurs, so the impulse takes longer to travel. As a result, touch and pain sensation, taste, and smell may be diminished. A)aging adult B)infant

The motor system may show a general slowing down of movement. Muscle strength and agility decrease. A)aging adult B)infant

A generalized decrease occurs in muscle bulk, which is most apparent in the dorsal hand muscles. Muscle tremors may occur in the hands, head, and jaw, along with possible repetitive facial grimacing (dyskinesias). A)aging adult B)infant

Aging has a progressive decrease in cerebral blood flow and oxygen consumption. In some people, this causes dizziness and a loss of balance with position change. These people need to be taught to get up slowly. Otherwise they have an increased risk for falls and resulting injuries. In addition, older people may forget they fell, which makes it hard to diagnose the cause of the injury. A)aging adult B)infant

When they are in good health, aging people walk about as well as they did during their middle and younger years, except more slowly and more deliberately. Some survey the ground for obstacles or uneven terrain. Some show a hesitation and a slightly wayward path. A)true B)false

CULTURE AND GENETICS

There is racial/ethnic disparity here because 6% of American Indian/Alaska Natives have had a stroke, 4% of African Americans, 2.6% of Hispanics, 2.3% of whites, and only 1.6% of Asian/Pacific Islanders. A)true B)false

African Americans, American Indian/ Alaska Natives (AI/ AN), Asian/Pacific Islanders, and Hispanics die from stroke at younger ages than do whites. A)true B)false

There is geographic disparity; many states with high stroke mortality are concentrated in the U.S. southeast region, called the "stroke belt." This may occur because of the high proportion of people who live in this region who have two or more of the major modifiable risk factors for stroke (high BP, high cholesterol, diabetes, current smoking, physical inactivity, or obesity). A)true B)false

The AI/AN men have a higher prevalence of hypertension and high cholesterol than any other racial/ethnic group, A)true B)false

and AI/ AN women have the highest rate of obesity, current smoking, and diabetes. A)true B)false

African Americans also have high rates of stroke, and their risk factors are the following: higher prevalence of hypertension and diabetes than whites, and less likely to have BP controlled or diabetes treated than white A)true B)false

SUBJECTIVE DATA

1. Headache 2. Head injury 3. Dizziness/vertigo 4. Seizures 5. Tremors 6. Weakness 7. Incoordination 8. Numbness or tingling 9. Difficulty swallowing 10. Difficulty speaking 11. Significant past history 12. Environmental/occupational hazards

True

Headache. Any unusually frequent or severe headaches? A) assessing A patient who says "This is the worst headache of my life" needs emergency referral to screen cerebrovascular cause. B)false

Dizziness/vertigo. Ever feel light-headed, a swimming sensation, like feeling faint? A)assessing Syncope- is a sudden loss of strength, a temporary loss of consciousness (a faint) due to lack of cerebral blood flow (e.g., low BP). B)false

Syncope is a sudden loss of strength, a temporary loss of consciousness (a faint) due to lack of cerebral blood flow (e.g., low BP). A)true B)false

Do you ever feel a sensation called vertigo, a rotational spinning sensation? (Note: Distinguish vertigo from dizziness.) Do you feel as if the room spins (objective vertigo)? Or do you feel that you are spinning (subjective vertigo)? Did this come on suddenly or gradually? A)True vertigo is rotational spinning caused by neurologic disease in the vestibular apparatus in the ear or in the vestibular nuclei in the brainstem. B)false

True vertigo is rotational spinning caused by neurologic disease in the vestibular apparatus in the ear or in the vestibular nuclei in the brainstem. A)true B)false

Seizures. Ever had any convulsions? When did they start? How often do they occur? A)Seizures occur with epilepsy, a paroxysmal disease characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances. B)false

Seizures occur with epilepsy, a paroxysmal disease characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances. A)true B)false

Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor. A)true B)false

Any associated signs-Color change in face or lips, loss of consciousness, for how long, automatisms (eyelid fluttering, eye rolling, lip smacking), incontinence? A)assessing for seizures B)false

Postictal phase-After the seizure, are you told you spend time sleeping or have any confusion, weakness, headache, or muscle ache? A)assessing B)false

Tremors. Any shakes or tremors in the hands or face? When did these start? • Do they seem to grow worse with anxiety, intention, or rest? Are they relieved with rest, activity, alcohol? Do they affect daily activities? A)Tremor is an involuntary shaking, vibrating, or trembling B)false

Tremor is an involuntary shaking, vibrating, or trembling A)true B)false

Weakness. Any weakness or problem moving any body part? Is this generalized or local? Does weakness occur with any particular movement? (For example, with proximal or large muscle weakness, it is hard to get up out of a chair or reach for an object; with distal or small muscle weakness, it is hard to open a jar, write, use scissors, or walk without tripping.) A)assessing for Paresis is a partial or incomplete paralysis. B)Paralysis is a loss of motor function due to a lesion in the neurologic or muscular system or loss of sensory innervation. C)both a and b

Paralysis is a loss of motor function due to a lesion in the neurologic or muscular system or loss of sensory innervation. A)true B)false

Incoordination. Any problem with coordination? Any problem with balance when walking? Do you list to one side? Any falling? Which way? Do your legs seem to give way? Any clumsy movement? A)assessing for Dysmetria is the inability to control the distance, power, and speed of a muscular action. B)false

Dysmetria is the inability to control the distance, power, and speed of a muscular action. A)true B)false

Numbness or tingling. Any numbness or tingling in any body part? Does it feel like pins and needles? When did this start? Where do you feel it? Does it occur with activity? A)assessing for Paresthesia is an abnormal sensation (e.g., burning, tingling). B)false

Paresthesia is an abnormal sensation (e.g., burning, tingling). A)true B)false

Difficulty speaking. Any problem spealdng: with forming words or with saying what you intended to say? When did you first notice this? How long did it last? A)assessing for Dysarthria is difficulty forming words; dysphasia is difficulty with language comprehension or expression B)false

Dysarthria is difficulty forming words; A)true B)false

dysphasia is difficulty with language comprehension or expression A)true B)false

Significant past history. Past history of: stroke (cerebrovascular accident), spinal cord injury, meningitis or encephalitis, congenital defect, or alcoholism? A)assessing B)false

Are you taking any medications now? A)Review anticonvulsants; anti-tremor, anti-vertigo, pain medication B)false

Additional History for Infants and Children

``` Did you (the mother) have any health problems during the pregnancy: any infections or illnesses, medications taken, toxemia, hypertension, alcohol or drug use, diabetes? A)assessing Prenatal history may affect infant's neurologic development. B)false ```

Does the child seem to have any problem with balance? Have you noted any unexplained falling, clumsy or unsteady gait, progressive muscular weakness, problem with going up or down stairs, problem with getting up from lying position? A)assessing because If occurs, may not be noticed until starts to walk in late infancy. Screens for muscular dystrophy. B)false

Has this child had any seizures? Please describe. Did the seizure occur with a high fever? Did any loss of consciousness occur- how long? How many seizures occurred with this same illness (if occurred with high fever)? A) assessing for Seizures may occur with high fever in infants and toddlers. Or, seizures may be sign of neurologic disease B)false

Do you know if your child has had any environmental exposure to lead? A)assessing for Chronically elevated lead levels may cause a developmental delay or a loss of a newly acquired skill or be asymptomatic B)false

Any family history of seizure disorder, cerebral palsy, muscular dystrophy? A)assessing B)false

Additional History for the Aging Adult

Any problem with dizziness? Does this occur when you first sit or stand up, when you move your head, when you get up and walk just after eating? Does this occur with any of your medications? A)assessing Diminished cerebral blood flow and diminished vestibular response may produce staggering with position change, which increases risk for falls B)false

For men) Do you ever get up at night and then feel famt while standjng to urinate? A)assessing for Micturition syncope. B)false

Have you noticed any decrease in memory, change in mental function? Have you felt any confusion? Did this seem to come on suddenly or gradually? A)assessing Memory loss and cognitive decline are early inrucators of Alzheimer disease and can be mistaken for normal cognitive decline of aging B)false

Have you ever noticed any tremor? Is this in your hands or face? Is this worse with anxiety, activity, rest? Does the tremor seem to be relieved with alcohol, activity, rest? Does the tremor interfere with daily or social activities? A)assessing for Senile tremor is relieved by alcohol, but this is not a recommended treatment. Assess if the person is abusing alcohol in effort to relieve tremor. B)false

Have you ever had any sudden vision change, fleeting blindness? Did this occur along with weakness? Did you have any loss of consciousness? A)assessing to Screen symptoms of stroke. B)false

OBJECTIVE DATA

PREPARATION

Perform a complete neurologic examination on persons who have neurologic concerns (e.g., headache, weakness, loss of coordination) or who have shown signs of neurologic dysfunction. A)true B)false

test cranial nerves while assessing the head and neck A)true B)false

EQUIPMENT NEEDED

Penlight Tongue blade Cotton swab Cotton ball Tuning fork (128 Hz or 256 Hz) Percussion hammer (Possibly} familiar aromatic substances (e.g., peppermint, coffee, vanilla}

True

TEST CRANIAL NERVES

Cranial Nerve 1-Olfactory Nerve

Do not test routinely. Test the sense of smell in those who report loss of smell, those with head trauma, and those with abnormal mental status, and when the presence of an intracranial lesion is suspected A)true B)false

First, assess patency by occluding one nostril at a time and asking the person to sniff. Then, with the person's eyes closed, occlude one nostril and present an aromatic substance. A)true B)false

Use familiar, conveniently obtainable, and non-noxious smells, such as coffee, toothpaste, orange, vanilla, soap, or peppermint. Alcohol wipes smell familiar and are easy to find but are irritating. A)true B)false

One cannot test smell when air passages are occluded with upper respiratory infection or with sinusitis. A)true B)false

Anosmia-decrease or loss of smell occurs bilaterally with tobacco smoking, allergic rhinitis, and cocaine use A)true B)false

Smell normally is decreased bilaterally with aging. Any asymmetry in the sense of smell is important. A)true B)false

Unilateral loss of smell in the absence of nasal disease is neurogenic anosmia A)true B)false

Cranial Nerve 2-Optic Nerve

Test visual acuity and test visual fields by confrontation A)true B)false

Using the ophthalmoscope, examine the ocular fundus to determine the color, size, and shape of the optic disc A)true B)false

Visual field loss and Papilledema with increased intracranial pressure; optic atrophy are all abnormal findings of optic nerve 2 A)true B)false

Cranial Nerves Ill, IV, and VI-Oculomotor, IV, , Trochlear, and Abducens Nerves

Palpebral fissures are usually equal in width or nearly so A)true B)false

Ptosis (drooping) occurs with myasthenia gravis, dysfunction of cranial nerve Ill, or Horner syndrome A)abnormal finding B)false

Check pupils for size, regularity, equality, direct and consensual light reaction, and accommodation A)true B)false

Increasing intracranial pressure causes a sudden, unilateral, dilated and nonreactive pupil. A)abnormal finding B)false

Assess extraocular movements by the cardinal positions of gaze A)true B)false

Strabismus (deviated gaze) or limited movement A)abnormal finding B)false

Nystagmus is a back-and-forth oscillation of the eyes. End-point nystagmus, a few beats of horizontal nystagmus at extreme lateral gaze, occurs normally. A)true B)false

Assess any other nystagmus carefully, noting: Presence of nystagmus in one or both eyes. Pendular movement (oscillations move equally left to right) or jerk (a quick phase in one direction, then a slow phase in the other). Classify the jerk nystagmus in the direction of the quick phase. Amplitude. Judge whether the degree of movement is fine, medium, or coarse. Frequency. Is it constant, or does it fade after a few beats? Plane of movement. Horizontal, vertical, rotary, or a combination?

True

Nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem. A)true B)false

Cranial Nerve V-Trigeminal Nerve

Motor Function. Assess the muscles of mastication by palpating the temporal and masseter muscles as the person clenches the teeth. Muscles should feel equally strong on both sides. Next, try to separate the jaws by pushing down on the chin; normally you cannot. A)true B)false

Decreased strength on one or both sides. Asymmetry in jaw movement. Pain with clenching of teeth. Abnormal finding in motor function A)true B)false

Sensory Function. With the person's eyes closed, test light touch sensation by touching a cotton wisp to these designated areas on person's face: forehead, cheeks, and chin. Ask the person to say "Now," whenever the touch is felt. This tests all three divisions of the nerve: (1) ophthalmic, {2) maxillary, and {3) mandibular. A)true B)false

Decreased or unequal sensation. With a stroke, sensation of face and body is lost on the opposite side of the lesion. Abnormal finding of sensory function A)true B)false

Corneal Reflex. This test of cranial nerves V and VII was usually omitted unless the person had unilateral sensorineural hearing loss. It involves bringing a wisp of cotton in from the side, lightly touching the cornea, and noting a bilateral blink reflex. However, the corneal reflex may be decreased or absent normally in contact lens wearers and in aging persons. Evidence does not support the usefulness of this test. A)true B)false

The test is limited clinically because an absent blink occurs in only one third of the cases of acoustic neuroma and only then when the tumor has grown quite large. For cornea reflex A)true B)false

Cranial Nerve VII-Facial Nerve

Motor Function. Note mobility and facial symmetry as the person responds to these requests: smile, frown, close eyes tightly (against your attempt to open them), lift eyebrows, show teeth, and puff cheeks. Then, press the person's puffed cheeks in, and note that the air should escape equally from both sides. A)true B)false

Muscle weakness is shown by flattening of the nasolabial fold, drooping of one side of the face, lower eyelid sagging, and escape of air from only one cheek that is pressed in. Abnormal finding of motor function A)true B)false

Loss of movement and asymmetry of movement occur with both central nervous system lesions (e.g., brain attack or stroke that affects the lower face on one side) and peripheral nervous system lesions (e.g., Bell's palsy that affects the upper and lower face on one side). Abnormal finding of motor function A)true B)false

Sensory Function. Do not test routinely. Test only when you suspect facial nerve injury. When indicated, test sense of taste by applying to the tongue a cotton applicator covered with a solution of sugar, salt, or lemon juice (sour). Ask the person to identify the taste. A)true B)false

Cranial Nerve VIII-Acoustic (Vestibulocochlear) Nerve

Test hearing acuity by the ability to hear normal conversation and by the whispered voice test A)true B)false

Cranial Nerves IX and X-Giossopharyngeal and Vagus Nerves

Motor Function. Depress the tongue with a tongue blade, and note pharyngeal movement as the person says "ahhh" or yawns; the uvula and soft palate should rise in the midline, and the tonsillar pillars should move medially. A)true B)false

Absence or asymmetry of soft palate movement or tonsillar pillar movement. Following a stroke, dysfunction in swallowing may increase risk for aspiration. A)abnormal finding B)false

Touch the posterior pharyngeal wall with a tongue blade, and note the gag reflex. Also note that the voice sounds smooth and not strained. A)true B)false

Hoarse or brassy voice occurs with vocal cord dysfunction; nasal twang occurs with weakness of soft palate. Abnormal finding A)true B)false

Sensory Function. Cranial nerve IX does mediate taste on the posterior one third of the tongue, but technically, this sensation is too difficult to test. A)true B)false

Cranial Nerve XI-Spinal Accessory Nerve

Examine the sternomastoid and trapezius muscles for equal size. Check equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the chin. Then ask the person to shrug the shoulders against resistance. These movements should feel equally strong on both sides. A)true B)false

Atrophy. Muscle weakness or paralysis occurs with a stroke or following injury to the peripheral nerve (e.g., surgical removal of lymph nodes) are abnormal findings A)true B)false

Cranial Nerve XII-Hypoglossal Nerve

Inspect the tongue. No wasting or tremors should be present. Note the forward thrust in the midline as the person protrudes the tongue. Also ask the person to say "light, tight, dynamite," and note that lingual speech (sounds of letters I, t, d, n) is clear and distinct. A)true B)false

Atrophy. Fasciculations. Tongue deviates to side with lesions of the hypoglossal nerve (when this occurs, deviation is toward the paralyzed side). Abnormal finding A)true B)false

INSPECT AND PALPATE THE MOTOR SYSTEM

Muscles

Size. As you proceed through the examination, inspect all muscle groups for size. Compare the right side with the left. Muscle groups should be within the normal size limits for age and should be symmetric bilaterally. When muscles in the extremities look asymmetric, measure each in centimeters and record the difference. A difference of 1 cm or less is not significant. Note that it is difficult to assess muscle mass in very obese people. A)true B)false

Atrophy-abnormally small muscle with a wasted appearance; occurs with disuse, injury, lower motor neuron disease such as polio, diabetic neuropathy A)true B)false

Hypertrophy-increased size and strength; occurs with isometric exercise. A)true B)fallen

Strength.Test the power of homologous(same) muscles simultaneously. Test muscle groups of the extremities, neck, and trunk. A)true B)false

Tone. Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows as a mild resistance to passive stretch. To test muscle tone, move the extremities through a passive range of motion. First, persuade the person to relflx completely, to "go loose like a rag doll." Move each extremity smoothly through a full range of motion. Support the arm at the elbow and the leg at the knee. Normally, you will note a mild, even resistance to movement. A)true B)false

Limited range of motion. Pain with motion. Flaccidity-decreased resistance, hypotonia occur with peripheral weakness. A)abnormal findings B)false

Spasticity and rigidity- types of increased resistance that occur with central weakness A)abnormal B)false

Involuntary Movements. Normally, no involuntary movements occur. If they are present, note their location, frequency, rate, and amplitude. Note if the movements can be controlled at will. A)true B)false

Tic, tremor, fasciculation, myoclonus, chorea, and athetosis abnormal findings A)true B)false

Cerebellar Function

Balance Tests

Gait. Observe as the person walks 10 to 20 feet, turns, and returns to the starting point. Normally, the person moves with a sense of freedom. The gait is smooth, rhythmic, and effortless; the opposing arm swing is coordinated; the turns are smooth. The step length is about IS inches from heel to heel. A)true B)false

Stiff, immobile posture. Staggering or reeling. Wide base of support. Lack of arm swing or rigid arms. Abnormal findings in gait A)true B)false

Unequal rhythm of steps. Slapping of foot. Scraping of toe of shoe.abnormal finding in gait A)true B)false

Ataxia-uncoordinated or unsteady gait A)true B)false

Ask the person to walk a straight line in a heel-to-toe fashion (tandem walking) . This decreases the base of support and will accentuate any problem with coordination. Normally, the person can walk straight and stay balanced. A)true B)false

Crooked line of walk. Widens base to maintain balance. Staggering, reeling, loss of balance.abnormal findings of walking A)true B)false

An ataxia that did not appear with regular gait may appear now. Inability to tandem walk is sensitive for an upper motor neuron lesion, such as multiple sclerosis, and for acute cerebellar dysfunction, such as alcohol intoxication A)true B)false

You may also test for balance by asking the person to walk on his or her toes, then on the heels for a few steps. Normally, plantar flexion and dorsiflexion are strong enough to permit this. A)true B)false

Muscle weakness in the legs prevents heel walking and toe walking A)true B)false

The Romberg Test. Ask the person to stand up with feet together and arms at the sides. Once in a stable position, ask the person to close the eyes and to hold the position. Wait about 20 seconds. Normally, a person can maintain posture and balance even with the visual orienting information blocked, although slight swaying may occur. (Stand close to catch the person in case he or she falls.) A)true B)false

Sways, falls, widens base of feet to avoid falling is a positive Romberg test A)true B)false

Positive Romberg sign is loss of balance that occurs when closing the eyes. You eliminate the advantage of orientation with the eyes, which had compensated for sensory loss. A positive Romberg sign occurs with cerebellar ataxia {multiple sclerosis, alcohol intoxication), loss of proprioception, and loss of vestibular function. A)true B)false

. A positive Romberg sign occurs with cerebellar ataxia {multiple sclerosis, alcohol intoxication), loss of proprioception, and loss of vestibular function. A)true B)false

Ask the person to perform a shallow knee bend or to hop in place, first on one leg, then the other. This demonstrates normal position sense, muscle strength, and cerebellar function. Note that some individuals cannot hop because of aging or obesity. Alternatively, you can ask them to rise from a chair without using the armrests for support. A)true B)false

Unable to perform knee bend because of weakness in quadriceps muscle or hip extensors. A)abnormal finding B)false

Coordination and Skilled Movements

Rapid Alternating Movements (RAM). Ask the person to pat the knees with both hands, lift up, turn hands over, and pat the knees with the backs of the hands. Then ask the person to do this faster. Normally, this is done with equal turning and a quick, rhythmic pace. A)true B)false

Lack of coordination. Slow, clumsy, and sloppy response is termed dysdiadochokinesia and occurs with cerebellar disease. A)true B)false

Alternatively, ask the person to touch the thumb to each finger on the same hand, starting with the index finger, then reverse direction. Normally, this can be done quickly and accurately. A)true B)false

Lack of coordination. Dysmetria is clumsy movement with overshooting the mark and occurs with cerebellar disorders or acute alcohol intoxication. A)true B)false

Dysmetria is clumsy movement with overshooting the mark and occurs with cerebellar disorders or acute alcohol intoxication. A)true B)false

Past-pointing is a constant deviation to one side. . A)abnormal finding B)false

Intention tremor when reaching to a visually directed object. A)abnormal finding B)false

Finger-to-Finger Test. With the person's eyes open, ask that he or she use the index finger to touch your finger, then his or her own nose. After a few times, move your finger to a different spot. The person's movement should be smooth and accurate. A)true B)false

Finger-to-Nose Test. Ask the person to close the eyes and to stretch out the arms. Ask the person to touch the tip of his or her nose with each index finger, alternating hands and increasing speed. Normally, this is done with accurate and smooth movement. A)true B)false

Misses nose. Worsening of coordination when the eyes are closed occurs with cerebellar disease or alcohol intoxication A)abnormal B)normal

Heel-to-Shin Test. Test lower extremity coordination by asking the person, who is in a supine position, to place the heel on the opposite knee and run it down the shin from the knee to the ankle. Normally, the person moves the heel in a straight line down the shin. A)true B)false

Lack of coordination, heel falls off shin, occurs with cerebellar disease. A)abnormal B)normal

ASSESS THE SENSORY SYSTEM

Ensure validity of sensory system testing by making sure the person is alert, cooperative, and comfortable and has an adequate attention span. Otherwise, you may get misleadjng and invalid results. Testing of the sensory system can be fatiguing. You may need to repeat the examination later or to break it into parts when the person is tired. A)true B)false

You do not need to test the entire skin surface for every sensation. Routine screening procedures include testing superficial pain, light touch, and vibration in a few distal locations and testing stereognosis. This will suffice for all who have not demonstrated any neurologic symptoms or signs. Complete testing of the sensory system is warranted in those with neurologic symptoms (e.g., localized pain, numbness, and tingling) or when you discover abnormalities (e.g., motor deficit). Then, test all sensory modalities and cover most derma tomes of the body A)true B)false

Note if the topographic pattern of sensory loss is distal (i.e., over the hands and feet in a "glove and stocking" distribution) or if it is over a specific dermatome. A)abnormal B)normal

Avoid asking leading questions such as "Can you feel this pinprick?" This creates an expectation of how the person should feel the sensation, which is called suggestion. Instead, use unbiased directions. A)true B)false

The person's eyes should be closed during each of the tests. Take time to explain what will be happening and exactly how you expect the person to respond. A)true B)false

Spinothalamic Tract

Pain. Pain is tested by the person's ability to perceive a pinprick. Break a tongue blade lengthwise, forming a sharp point at the fractured end and a dull spot at the rounded end. Lightly apply the sharp point or the dull end to the person's body in a random, unpredictable order. Ask the person to say "sharp" or "dull," depending on the sensation felt. (Note that the sharp edge is used to test for pain; the dull edge is used as a general test of the person's responses.) A)true B)false

Hypoalgesia-decreased pain sensation. A)true B)false

Analgesia-absent pain sensation. A)true B)false

Hyperalgesia-increased pain sensation. A)true B)false

Let at least 2 seconds elapse between each stimulus to avoid summation. With summation, frequent consecutive stimuli are perceived as one strong stimulus. Discard tongue blade to prevent transmitting any possible infection. A)true B)falseness

Temperature. Test temperature sensation only when pain sensation is abnormal; otherwise, you may omit it because the fiber tracts are much the same. Place the flat side of the tuning fork on the skin; its metal always feels cool. This can alternate with the warmth of your hand. A)true B)false

Light Touch. Apply a wisp of cotton to the skin. Stretch a cotton ball to make a long end, and brush it over the skin in a random order of sites and at irregular intervals. This prevents the person from responding just from repetition. Include the arms, forearms, hands, chest, thighs, and legs. Ask the person to say "now" or "yes" when touch is felt. Compare symmetric points. A)true B)false

Hypoesthesia-decreased touch sensation. A)true B)false

Anesthesia-absent touch sensation. A)true B)false

Hyperesthesia-increased sensation. A)true B)false

Posterior Column Tract

Vibration. Test the person's ability to feel vibrations of a tuning fork over bony prominences. Use a low-pitch tuning fork ( 128 Hz or 256 Hz) because its vibration has a slower decay. Strike the tuning fork on the heel of your hand, and hold the base on a bony surface of the fingers and great toe. Ask the person to indicate when the vibration starts and stops. If the person feels the normal vibration or buzzing sensation on these distal areas, you may assume proximal spots are normal and proceed no further. If no vibrations are felt, move proximally and test ulnar processes and ankles, patellae, and iliac crests. Compare the right side with the left side. If you· find a deficit, note whether it is gradual or abrupt. A)true B)false

Unable to feel vibration. Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Often, this is the first sensation lost. A)true B)false

Peripheral neuropathy is worse at the feet and gradually improves as you move up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome A)abnormal B)normal

Position (Kinesthesia). Test the person's ability to perceive passive movements of the extremities. Move a finger or the big toe up and down, and ask the person to tell you which way it is moved. The test is done with the eyes closed, but to be sure it is understood, have the person watch a few trials first. Vary the order of movement up or down. Hold the digit by the sides, since upward or downward pressure on the skin may provide a clue as to how it has been moved. Normally, a person can detect movement of a few millimeters. A)true B)false

Loss of position sense. Is an abnormal finding A)true B)falsse

Tactile Discrimination {Fine Touch). The following tests also measure the discrimination ability of the sensory cortex. As a prerequisite, the person needs a normal or near-normal sense of touch and position sense. A)true B)false

Problems with tactile discrimination occur with lesions of the sensory cortex or posterior column. A)true B)false

Stereognosis. Test the person's ability to recognize objects by feeling their forms, sizes, and weights. With the person's eyes closed, place a familiar object (paper clip, key, coin, cotton ball, or pencil) in his or her hand and ask the person to identify it. Normally, a person will explore it with the fingers and correctly name it. Test a different object in each hand; testing the left hand assesses right parietal lobe functioning. A)true B)false

Astereognosis-inability to identify object correctly. Occurs in sensory cortex lesions (e.g., brain attack [stroke]). A)true B)false

Graphesthesia. Graphesthesia is the ability to "read" a number by having it traced on the skin. With the person's eyes closed, use a blunt instrument to trace a single digit number or a letter on the palm. Ask the person to tell you what it is. Graphesthesia is a good measure of sensory loss if the person cannot make the hand movements needed for stereognosis, as occurs in arthritis. A)true B)false

Inability to distinguish number occurs with lesions of the sensory cortex. A)abnormal B)normal

Two-Point Discrimination. Test the person's ability to distinguish the separation of two simultaneous pin points on the skin. Apply the two points of an opened paper clip lightly to the skin in ever-closing distances. Note the distance at which the person no longer perceives two separate points. The level of perception varies considerably with the region tested; it is most sensitive in the fingertips (2 to 8 mm) and least sensitive on the upper arms, thighs, and back (40 to 75 mm) A)true B)false

An increase in the distance it normally takes to identify two separate points occurs with sensory cortex lesions. A)true B)false

Extinction. Simultaneously touch both sides of the body at the same point. Ask the person to state how many sensations are felt and where they arc. Normally, both sensations are felt. A)true B)false

The ability to recognize only one of the stimuli occurs with sensory cortex lesion; the stimulus is extinguished on the side opposite the cortex lesion. A)abnormal B)false

Point Location. Touch the skin, and withdraw the stimulus promptly. Tell the person, "Put your finger where I touched you." You can perform this test simultaneously with light touch sensation. A)true B)false

With a sensory cortex lesion, the person cannot localize the sensation accurately, even though light touch sensation may be retained. A)true abnormal finding B)false

TEST THE REFLEXES

Stretch, or Deep Tendon Reflexes (DTRs) ,

Measurement of the stretch reflexes reveals the intactness of the reflex arc at specific spinal levels as well as the normal override on the reflex of the higher cortical levels. A)true B)false

For an adequate response, the limb should be relaxed and the muscle partially stretched. Stimulate the reflex by directing a short, snappy blow of the reflex hammer onto the muscle's insertion tendon. Use a relaxed hold on the hammer. A)true B)false

Use the pointed end of the reflex hammer when aiming at a smaller target such as your thumb on the tendon site A)true B)false

use the flat end when the target is wider or to diffuse the impact and prevent pain. A)true B)false

The reflex response is graded on a 4-point scale: 4+ Very brisk, hyperactive with clonus, indicative of disease 3+ Brisker than average, may indicate disease, probably normal 2+ Average, normal I+ Diminished, low normal, or occurs only with reinforcement 0 No response

True

Clonus is a set of rapid, rhythmic contractions of the same muscle. A)true B)false

Hyperreflexia is the exaggerated reflex seen when the monosynaptic reflex arc is released from the usually inhibiting influence of higher cortical levels. This occurs with upper motor neuron lesions (e.g., a brain attack) A)true B)false

Hyporeflexia, which is the absence of a reflex, is a lower motor neuron problem. It occurs with interruption of sensory afferents or destruction of motor efferents and anterior horn cells (e.g., spinal cord injury). A)true B)false

Reinforcement is another technique to relax the muscles and enhance the response. Ask the person to perform an isometric exercise in a muscle group somewhat away from the one being tested. For example, to enhance a patellar reflex, ask the person to lock the fingers together and "pull as hard as you can." Then strike the tendon. To enhance a biceps response, ask the person to clench the teeth or to grasp the thigh with the opposite hand. A)true B)false

``` Biceps Reflex (C5 to C6). Support the person's forearm on yours; this position relaxes as well as partially flexes the person's arm. Place your thumb on the biceps tendon and strike a blow on your thumb. You can feel as well as see the normal response, which is contraction of the biceps muscle and flexion of the forearm. A)true B)false ```

``` Triceps Reflex (C7 to C8). Tell the person to let the arm "just go dead" as you suspend it by holding the upper arm. Strike the triceps tendon directly just above the elbow. The normal response is extension of the forearm. Alternately, hold the person's wrist across the chest to flex the arm at the elbow, and tap the tendon. A)true B)false ```

``` Brachioradialis Reflex (C5 to C6). Hold the person's thumbs to suspend the forearms in relaxation. Strike the forearm directly, about 2 to 3 cm above the radial styloid process. The normal response is flexion and supination of the forearm. A)true B)false ```

``` Quadriceps Reflex ("Knee Jerk") (L2 to L4). Let the lower legs dangle freely to flex the knee and stretch the tendons. Strike the tendon directly just below the patella. Extension of the lower leg is the expected response. You also will palpate contraction of the quadriceps. A)true B)false ```

For the person in tl1e supine position, use your own arm as a lever to support the weight of one leg against the other leg. This maneuver also flexes the knee. A)true B)false

``` Achilles Reflex ("Ankle Jerk") (L5 to S2). Position the person with the knee flexed and the hip externally rotated. Hold the foot in dorsiflexion, and strike the Achilles tendon directly. Feel the normal response as the foot plantar flexes against your hand. A)true B)false ```

For the person in the supine position, flex one knee and support that lower leg against the other leg so that it falls "open." Dorsiflex the foot, and tap the tendon A)Achilles tendon reflex B)false

Clonus. Test for clonus, particularly when the reflexes are hyperactive. Support the lower leg in one hand. With your other hand, move the foot up and down a few times to relax the muscle. Then stretch the muscle by briskly dorsiflexing the foot. Hold the stretch. With a normal response, you feel no further movement. When clonus is present, you will feel and see rapid, rhythmic contractions of the calf muscle and movement of the foot. A)true B)false

Clonus is repeated reflex muscular movements. A hyperactive reflex with sustained clonus {lasting as long as the stretch is held) occurs with upper motor neuron disease. A)true B)false

Superficial (Cutaneous) Reflexes

The motor response is a localized muscle contraction.

Cutaneous reflex

Abdominal Reflexes-Upper {T8 to T1 0), Lower {T1 0 to T12). Have the person assume a supine position, with the knees slightly bent. Use the handle end of the reflex hammer, a wood applicator tip, or the end of a split tongue blade to stroke the skin. Move from each corner of the abdomen toward the midline at both the upper and lower abdominal levels. The normal response is ipsilateral contraction of the abdominal muscle with an observed deviation of the umbilicus toward the stroke. When the abdominal wall is very obese, pull the skin to the opposite side and feel it contract toward the stimulus. A)true B)false

Superficial reflexes are absent with diseases of the pyramidal tract (e.g., they are absent on the contralateral side with brain attack) A)true B)false

``` Cremasteric Reflex (L 1 to L2). This is not routinely done. On the male, lightly stroke the inner aspect of the thigh with the reflex hammer or tongue blade. Note elevation of the ipsilateral testicle. A)true B)false ```

Absent in both upper motor neuron (UMN) and lower motor neuron (LMN) lesions. Abnormal finding in Cremasteric reflex. A)true B)false

``` Plantar Reflex (L4 to S2). Position the thigh in slight external rotation. With the reflex hammer, draw a light stroke up the lateral side of the sole of the foot and inward across the ball of the foot, like an upside-down J. The normal response is plantar flexion of the toes and inversion and flexion of the forefoot. A)true B)false ```

Except in infancy, the abnormal response is dorsiflexion of the big toe and fanning of all toes, which is a positive Babinski sign, also called "upgoing toes". This occurs with UMN disease of the corticospinal (or pyramidal) tract. Abnormal finding of plantar reflex A)true B)false

DEVELOPMENTAL COMPETENCE | Infants (Birth to 12 Months)

Failure to attain a skill by expected time. Persistence of reflex behavior beyond the normal time. Are abnormal findings of infant to 12 months A)true B)false

At birth, the newborn is very alert, with the eyes open, and demonstrates strong, urgent suckjng. The normal cry is loud, lusty, and even angry. The next 2 or 3 days may be spent mostly sleeping as the baby recovers from the birth process. After that, the pattern of sleep and waking activity is highly variable; it depends on the baby's individual body rhythm as well as external stimuli. A)true B)false

A high-pitched, shrill cry or catsounding screech occurs with CNS damage. A)infant B)adult

A weak, groaning cry or expiratory grunt occurs with respiratory distress A)infant B)false

The behavioral assessment should include your observations of the infant's spontaneous waking activity, responses to environmental stimuli, and social interaction with the parents and others A)true B)false

Lethargy, hyporeactivity, hyperirritability, and parent's report of significant change in behavior all warrant referral. A)infant B)adult

By 2 months of age, the baby smiles responsively and recognizes the parent's face. Babbling occurs at 4 months, and one or two words (mama, dada) are used nonspecifically after 9 months. A)true B)falseness

Testing Cranial Nerve Function of Infants

Cranial nerve 5 testing infant Rooting reflex, sucking reflex. A)true B)false

Cranial nerve 8 testing infant for Loud noise yields Moro reflex (until 4 mo) Acoustic blink reflex-infant blinks in response to a loud hand clap 30 em (12 inches) from head (avoid making air current) Eyes follow direction of sound. A)true B)false

Cranial nerve 9&10 testing infant Swallowing, gag reflex Coordinated sucking and swallowing A)true B)false

Smoothness of movement suggests proper cerebellar function, as does the coordination involved in sucking and swallowing. A)infant B)adult

To screen gross and fine motor coordination, use the Denver ll test with its age-specific developmental milestones. You also can assess movement by testing the reflexes listed in the following section. Note their smoothness of response and symmetry. Also, note whether their presence or absence is appropriate for the infant's age. A)true B)false

Delay in motor activity occurs with brain damage, mental disability, peripheral neuromuscular damage, prolonged illness, and parental neglect A)infant abnormal findings B)false

Assess muscle tone by first observing resting posture. The newborn favors a flexed position; extremities are symmetrically folded inward, the hips are slightly abducted, and the fists are tightly flexed. Infants born by breech delivery, however, do not have flexion in the lower extremities. A)true B)false

Frog position-hips abducted and almost flat against the table, externally rotated (normal only after breech delivery). A)true B)false

Opisthotonos-head arched back, stiffness of neck, and extension of arms and legs; occurs with meningeal or brainstem irritation and kernicterus abnormal finding of the A)infant B)aging adult

Extension of limbs may occur with intracranial hemorrhage. Any type of continual asymmetry (e.g., asymmetry of upper limbs) occurs with brachial plexus palsy. A)abnormal findings of infant B)false

After 2 months of age, flexion gives way to gradual extension, beginning with the head and continuing in a cephalocaudal direction. Now is the time to check for spasticity; none should be present. Test for spasticity by flexing the infant's knees onto the abdomen and then quickly releasing them. They will unfold but not too quickly. Also, gently push the head forward- the baby should comply. A)true B)false

Spasticity is an early sign of cerebral palsy. After releasing flexed knees, legs will quickly extend and adduct, even to a "scissoring" motion when spasticity is present. Also, the baby often resists head flexion and extends back against your hand when spasticity is present. A)abnormal finding B)false

The fists normally are held in tight flexion for the first 3 months. Then the fists open for part of the time. A)true B)false

A purposeful reach for an object with both hands occurs around 4 months of age, a transfer of an object from hand to hand at 7 months of age, a grasp using fingers and opposing thumb at 9 months of age, and a purposeful release at 10 months of age. Babies are normally ambidextrous for the first 18 months A)true B)false

Note persistent one-hand preference in baby younger than 18 months of age, which may indicate a motor deficit on the opposite side. A)true abnormal finding B)false abnormal finding

First, with the baby supine, pull to a sit holding the wrists and note head control. The newborn will hold the head almost in the same plane as the body, and it will balance briefly when the baby reaches a sitting position and then flop forward. (Even a premature infant shows some head flexion.) At 4 months of age, the head stays in line with the body and does not flop. A)true B)false

Because development progresses in a cephalocaudal direction, head lag is an early sign of brain damage. A)true B)false

After 6 months of age, refer any baby with failure to hold head in midline when sitting. A)true B)false

Second, lift up the baby in a prone position, with one hand supporting the chest. The term newborn holds the head at an angle of 45 degrees or less from horizontal, the back is straight or slightly arched, and the elbows and knees are partly flexed. A)true B)false

At 3 months of age, the baby raises the head and arches the back, as in a swan dive. This is the Landau reflex, which persists until 1 1/2 years of age. A)true B)false

Head lag, a limp, floppy trunk, and dangling arms and legs. Absence of the Landau reflex indicates motor weakness, upper motor neuron disease, or mental disability. A)true, infant B)false

Assess muscle strength by noting the strength of sucking and of spontaneous motor activity A)infant B)false

You will perform very little sensory testing with infants and toddlers. The newborn normally has hypoesthesia and requires a strong stimulus to elicit a response. The baby responds to pain by crying and a general reflex withdrawal of all limbs. By 7 to 9 months of age, the infant can localize the stimulus and shows more specific signs of withdrawal. Other sensory modalities are not tested. A)true B)false

Unusually rapid withdrawal is hyperesthesia, which occurs with spinal cord lesions, CNS infections, increased intracranial pressure, peritonitis. A)abnormal finding in a infant of a stimulus B)false

No withdrawal is decreased sensation, which occurs with decreased consciousness, mental deficiency, spinal cord or peripheral nerve lesions. A)abnormal. Finding In a infant from a stimulus B)false

Infantile automatisms are reflexes that have a predictable timetable of appearance and departure. The reflexes most commonly tested are listed in the following section. For the screening examination, you can just check the rooting, grasp, tonic neck, and Moro reflexes A)true B)false

Rooting Reflex. Brush the infant's cheek near the mouth. Note whether the infant turns the head toward that side and opens the mouth. Appears at birth and disappears at 3 to 4 months. A)true B)false

Sucking Reflex. Touch the lips and offer your gloved little finger to suck. Note strong sucking reflex. The reflex is present at birth and disappears at 10 to 12 months. A)true B)false

Palmar Grasp. Place the baby's head midline to ensure symmetric response. Offer your finger from the baby's ulnar side, away from the thumb. Note tight grasp of all the baby's fingers. Sucking enhances grasp. Often, you can pull baby to a sit from grasp. The reflex is present at birth, is strongest at 1 to 2 months, and disappears at 3 to 4 months. A)true B)false

The palmar grasp reflex is absent with brain damage and with local muscle or nerve injury. A)true B)false

Persistence of palmar grasp reflex after 4 months of age occurs with frontal lobe lesion. A)true B)false

Plantar Grasp. Touch your thumb at the ball of the baby's foot. Note that the toes curl down tightly. The reflex is present at birth and disappears at 8 to 10 months A)true B)false

Babinski Reflex. Stroke your finger up the lateral edge and across the ball of the infant's foot. Note fanning of toes (positive Babinski reflex). The reflex is present at birth and disappears (changes to the adult response) by 24 months of age (variable). A)true B)false

Positive Babinski reflex after 2 or 2 1/2 years of age occurs with pyramidal tract disease. A)true B)false

Tonic Neck Reflex. With the baby supine, relaxed, or sleeping, turn the head to one side with the chin over shoulder. Note ipsilateral extension of the arm and leg and flexion of the opposite arm and leg; this is the "fencing" position. If you turn the infant's head to the opposite side, positions will reverse. The reflex appears by 2 to 3 months, decreases at 3 to 4 months, and disappears by 4 to 6 months. A)true B)false

Persistence later in infancy occurs with brain damage. A)true B)false

A Tonic neck

Moro Reflex. Startle the infant by jarring the crib, making a loud noise, or supporting the head and back in a semi-sitting position and quickly lowering the infant to 30 degrees. The baby looks as if he or she is hugging a tree. That is, symmetric abduction and extension of the arms and legs, fanning fingers, and curling of the index finger and thumb to C-position occur. The infant then brings in both arms and legs. The reflex is present at birth and disappears at 1 to 4 months. A)true B)false

Absence of the Moro reflex in the newborn or persistence after 5 months of age indicates severe CNS injury. A)true B)false

Absence of movement in just one arm occurs with fracture of the humerus or clavicle and with brachial nerve palsy A)true B)false

Absence in one leg occurs with a lower spinal cord problem or a dislocated hip A)true B)false

A hyperactive Moro reflex occurs with tetany or CNS infection. A)true B)false

Placing Reflex. Hold the infant upright under the arms, close to a table. Let the dorsal "top" of foot touch the underside of table. Note flexing of hip and knee, followed by extension at the hip, to place foot on table. Reflex appears at 4 days after birth. A)true B)false

Stepping Reflex. Hold the infant upright under the arms, with the feet on a flat surface. Note regular alternating steps. The reflex disappears before voluntary walking. A)true B)false

Extensor thrust, or "scissoring"; crossing of lower extremities are abnormal findings in stepping reflex A)true B)false

DEVELOPMENTAL COMPETENCE | Preschool- and School-Age Children

Smell and taste are almost never tested, but if you need to test the child's sense of smell (cranial nerve I), use a scent familiar to the child such as peanut butter or orange peel. A)true B)false

When testing visual fields (cranial nerve II) and cardinal positions of gaze (cranial nerves III, IV, VI), you often need to gently immobilize the head or the child will track with the whole head. A)true B)false

Make a game out of asking the child to imitate your funny "faces" (cranial nerve VII); thus the child has fun and you win a friend. A)true B)false

Use the Denver II to screen gross and fine motor skills that are appropriate for the child's specific age. Be familiar with developmental milestones for each age. A)true B)false

Muscle hypertrophy or atrophy occurs with muscular dystrophy. Muscle weakness. Incoordination. Abnormal findings A)true B)false

Note the child's gait during both walking and running. Allow for the normal wide-based gate of the toddler and the normal knock-kneed walk of the preschooler. Normally, the child can balance on one foot for about 5 seconds by 4 years of age, can balance for 8 to 10 seconds at 5 years of age, and can hop at 4 years. Children enjoy performing these tests. A)true B)false

Staggering, falling.Weakness climbing up or down stairs occurs with muscular dystrophy. Broad-based gait beyond toddlerhood, scissor gait.Failure to hop after 5 years of age indicates incoordination of gross motor skill. Are all abnormal findings A)true B)false

Observe the child as he or she rises from a supine position on the floor to a sitting position, and then to a stand. Note the muscles of the neck, abdomen, arms, and legs. Normally, the child curls up in the midline to sit up, then pushes off with both hands against the floor to stand A)true B)fallen

Weak pelvic muscles are a sign of muscular dystrophy; from the supine position, the child will roll to one side, bend forward to all four extremities, plant hands on legs, and literally "climb" up himself or herself. This is Gower's sign A)true B)false

Fine coordination is not fully developed until the child has reached 4 to 6 years of age. Consider it normal if a younger child can bring the finger to within 2 to 5 em ( l to 2 inches) of the nose. A)true B)false

Failure of the finger-to-nose test with the eyes open indicates gross incoordination; failure of the test with the eyes closed indicates minor incoordination or lack of position sense. A)true B)false

Testing sensation is very unreliable in toddlers and preschoolers. You may test light touch by asking the child to close the eyes and then to point to the spot where you touch or tickle. A)true B)false.

Testing of vibration, position, stereognosis, graphesthesia, or two-point discrimination usually is not done on a child younger than 6 years. Also, do not test for perception of superficial pain. A)true B)false

In children older than 6 years, you may perform sensory testing as with adults. Use a fractured tongue blade if you need to test superficial pain. A)true B)false

Sensory loss occurs with decreased consciousness, mental deficiency, or spinal cord or peripheral nerve dysfunction. A)true B)false

The DTRs usually are not tested in children younger than 5 years due to lack of cooperation in relaxation. A)true B)false

When you need to test DTRs in a young child, use your finger to percuss the tendon. Use a reflex hammer only with an older child. Coax the child to relax, or distract and percuss discreetly when the child is not paying attention. A)true B)false

The knee jerk is present at birth, then the ankle jerk and brachial reflex appear, and the triceps reflex is present at 6 months. A)true B)false

Hyperactivity of DTRs occurs with upper motor neuron lesion, hypocalcemia, and hyperthyroidism and with muscle spasm associated with early poliomyelitis. A)true B)false

Decreased or absent reflexes occur with a lower motor neuron lesion, muscular dystrophy, and flaccidity or flaccid paralysis A)true B)false

Clonus may occur with fatigue, but it usually indicates hyperreflexia. A)true B)false

DEVELOPMENTAL COMPETENCE | The Aging Adult

Any decrease in muscle bulk is most apparent in the hand, as seen by guttering between the metacarpals. These dorsal hand muscles often look wasted, even with no apparent arthropathy. The grip strength remains relatively good A)aging adult B)false

Hand muscle atrophy is worsened with disuse and degenerative arthropathy A)true B)false

Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying "yes" or "no"), and tongue protrusion. A)aging adult B)false

Dyskinesias are the repetitive stereotyped movements in the jaw, lips, or tongue that may accompany senile tremors. No associated rigidity is present. A)aging adult B)infant

Distinguish senile tremors from tremors of parkinsonism. The latter includes rigidity and slowness and weakness of voluntary movement. A)true B)false

Absence of a rhythmic reciprocal gait pattern is seen in parkinsonism and hemiparesis . A)true B)false

The rapid alternating movements (e.g., pronating and supinating the hands on the thigh) may be more difficult to perform by the aging adult. A)true B)false

After 65 years of age, loss of the sensation of vibration at the ankle malleolus is common and is usually accompanied by loss of the ankle jerk. Position sense in the big toe may be lost, although this is less common than vibration loss. Tactile sensation may be impaired. The aging person may need stronger stimuli for light touch and especially for pain. A)true B)false

Note any difference in sensation between right and left sides, which may indicate a neurologic deficit. A)true B)false

The DTRs are less brisk. Those in the upper extremities are usually present, but the ankle jerks are commonly lost. Knee jerks may be lost, but this occurs less often. Because aging people find it difficult to relax their limbs, always use reinforcement when eliciting the DTRs. A)true B)false

The plantar reflex may be absent or difficult to interpret. Often, you will not see a definite normal flexor response. However, you still should consider a definite extensor response to be abnormal A)aging adult B)false

The superficial abdominal reflexes may be absent, probably because of stretching of the musculature through pregnancy or obesity. A)true, aging adult B)false

NEUROLOGIC RECHECK

Signs of increasing intracranial pressure signal impending cerebral disaster and death and require early and prompt intervention. A)true B)false

Use an abbreviation of the neurologic examination in the following sequence: l. Level of consciousness 2. Motor function 3. Pupillary response 4. Vital signs

True

Level of Consciousness. A change in the level of consciousness is the single most important factor in this examination. It is the earliest and most sensitive index of change in neurologic status. Note the ease of arousal and the state of awareness, or orientation. A)true B)false

A change in consciousness may be subtle. Note any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. A)true B)false

If the person is not fully alert, increase the amount of stimulus used in this order: l. Name called 2. Light touch on person's arm 3. Vigorous shake of shoulder 4. Pain applied (pinch nail bed, pinch trapezius muscle, rub your knuckles on the person's sternum) Record the stimulus used as well as the person's response to it.

True

Motor Function. Ask the person to lift the eyebrows, frown, bare teeth. Note symmetric facial movements and bilateral nasolabial folds (cranial nerve VII). A)true B)false

A weak grip occurs with UMN and LMN disease and with local hand problems (arthritis, carpal tunnel syndrome). A)true B)false

Alternatively, ask the person to lift each hand or to hold up one finger. You also can check upper extremity strength by palmar drift. Ask the person to extend both arms forward or halfway up, palms up, eyes closed, and hold for 10 to 20 seconds. Normally, the arms stay steady with no downward drift. A)true B)false

Pronator drift is a downward unilateral drift and turning in of the forearm that occurs with mild hemiparesis. A)true abnormal finding B)false

Full strength allows the leg to be lifted 90 degrees. If multiple trauma, pain, or equipment precludes this motion, ask the person to push one foot at a time against your hand's resistance, "like putting your foot on the gas pedal of your car A)true B)false

For the person with decreased level of consciousness, note if movement occurs spontaneously and as a result of noxious stimuli such as pain or suctioning. An attempt to push away your hand after such stimuli is called localizing and is characterized as purposeful movement. A)true B)false

Any abnormal posturing, decorticate rigidity, or decerebrate rigidity indicates diffuse brain injury. A)true B)false

Pupillary Response. Note the size, shape, and symmetry of both pupils. Shine a light into each pupil and note the direct and consensual light reflex. Both pupils should constrict briskly. (Allow for the effects of any medication that could affect pupil size and reactivity.) When recording, pupil size is best expressed in millimeters. Tape a millimeter scale onto a tongue blade and hold it next: to the person's eyes for the most accurate measurement A)true B)false

In a brain-injured person, a sudden unilateral dilated and nonreactive pupil is ominous. A)true B)false

Cranial nerve Ill runs parallel to the brainstem. When increasing intracranial pressure pushes the brainstem down (uncal herniation), it puts pressure on cranial nerve Ill, causing pupil dilation. A)true B)false

Measure the temperature, pulse, respiration, and blood pressure as often as the person's condition warrants. Although they are vital to the overall assessment of the critically ill person, pulse and blood pressure are notoriously unreliable parameters of CNS deficit. Any changes are late consequences of rising intracranial pressure A)true B)false

The Cushing reflex shows signs of increasing intracranial pressure: blood pressure-sudden elevation with widening pulse pressure; pulse-decreased rate, slow and bounding A)true B)false

Glasgow Coma Scale was developed as an accurate and reliable quantitative tool. The GCS is a standardized, objective assessment that defines the level of consciousness by giving it a numeric value. A)true B)false

The scale is divided into three areas: eye opening, verbal response, and motor response. Each area is rated separately, and a number is given for the person's best response. The three numbers are added; the total score reflects the brain's functional level. A fully alert, normal person has a score of 15, whereas a score of 7 or less reflects coma. Serial assessments can be plotted on a graph to illustrate visually whether the person is stable, improving, or deteriorating. A)true B)false

The GCS assesses the fu nctional state of the brain as a whole, not of any particular site in the brain. A)true B)false

PROMOTING A HEAL THY LIFESTYLE: STROKE PREVENTION Symptoms and Non-Modifiable and Well-Documented Modifiable Risk Factors for Stroke

stroke, or cerebrovascular accident (CVA), occurs when the blood flow is interrupted to a part of the brain, which is why it is often referred to as a "brain attack." The most common type is an ischemic stroke, occurring when a blood clot blocks a blood vessel in the brain. Less common is a hemorrhagic stroke, which occurs when a blood vessel in the brain ruptures and causes bleeding. A)true B)false

Stroke symptoms usually do not hurt, which is why many people ignore them or delay seeking medical attention. Common symptoms of stroke include: 1 . Sudden weakness or numbness in the face, arms, or legs, especially when it is on one side of the body 2. Sudden confusion, trouble speaking or understanding 3. Sudden changes in vision, such as blurry vision or partial or complete loss of vision in one or both eyes 4. Sudden trouble walking, dizziness, loss of balance or coordination 5. Sudden severe headache with no reason or explanation

True

Sometimes people can have a "mini-stroke" or transient ischemic attack (TIA) A)true B)false

``` Modifiable Risk Factors 1.History of cardiovascular disease 2. Hypertension 3. Cigarette smoking/smoke 4. Diabetes 5. Atrial fibrillation 6. Other cardiac conditions 7. Dyslipidemia 8. Asymptomatic carotid stenosis 9. Sickle-cell disease 10. Postmenopausal hormone therapy 11 . Diet and nutrition 12. Physical inactivity 13. Obesity and fat distribution 14. History of transient ischemic attack (TIA) ```

ABNORMAL FINDINGS

10 Warning Signs of Alzheimer Disease (Alzheimer's Association, 2006) MEMORY Loss LOSING TRACK FoRGETTING WORDS GETTING LOST PooR JUDGMENT ABSTRACT FAILING LOSING THINGS Mood SWINGS PERSONALITY CHANGE GROWING PASSIVE

True

Abnormalities in Cranial Nerves

Olfactory abnormal finding would Anosmia A)true B)false

II: Optic nerve abnormal finding Defect or absent central vision, Defect in peripheral vision, hemianopsia, Absent light reflex, Papilledema, Optic atrophy, Retinal lesions. A)true B)false

III: Oculomotor nerve abnormal finding Dilated pupil, ptosis, eye turns out and slightly down Failure to move eye up, in, down Absent light reflex. A)true B)false

IV: Trochlear nerve abnormal finding Failure to turn eye down or out. A)true B)false

V: Trigeminal nerve abnormal finding Absent touch and pain, pares thesias No blink Weakness of masseter o r tempo ralis muscles A)true B)false

VI: Abducens nerve abnormal finding Failure to move laterally, diplopia on lateral gaze A)true B)false

VII: Facial nerve abnormal finding Absent or asymmetric facial movement Loss of taste A)true B)false

VI II: Acoustic nerve abnormal finding Decrease or loss of hearing. A)true B)false

X: Vagus nerve abnormal finding Uvul a deviates to side No gag reflex Hoarse or brassy Nasal twang Husky Dysphagia, fluids regurgitate through nose A)true B)false

XI: Spinal accessory abnormal finding Absent movement of sternomastoid or trapezius muscles. A)true B)false

XII: Hypoglossal nerve abnormal finding Deviates to side Slowed rate of movement A)true B)false

Abnormalities in Muscle Tone

Decreased muscle tone or hypotonia; muscle feels limp, soft, and flabby; muscle is weak and easily fatigued; limb feels like a rag doll A)Flaccidity B) spacdidy

Increased tone or hypertonia; increased resistance to passive lengthening; then may suddenly give way (clasp-kn ife phenomenon) like a pocket knife sprung open A)Spasticity B)rigid

Constant state of resistance (lead-pipe rigidity); resists passive movem ent in any di recti on; dystonia. A)Rigidity B)false

Type of rigidity in wh ich the increased tone is released by degrees during passive range of motion so it feels like small, regular jerks. Associated with parksonism A)Cogwheel rigidity B)false

Abnormalities in Muscle Movement

Decreased or loss of motor power due to problem with motor nerve or muscle fibers. Causes: acute-trauma, spinal cord injury, brain attack, poliomyelitis, polyneuritis, Bell's palsy; chronic- muscular dystrophy, d iabetic neuropathy, multiple sclerosis; episodic-myasthenia gravis. A)Paralysis B)flase

Patterns of paralysis: hemiplegia-spastic or flaccid paralysis of one side (right o r left) of body and extremities; para- plegia-symmetric paralysis of both lower extremities; quadriplegia-paralysis in all four extremities. Paresis- weakness of muscles rather than paralysis.

True

Rapid, continuous twitching of resting muscle or part of muscle, without movement of limb, that can be seen by clinicians or felt by patients. Types: fine-occurs with lower motor neuron disease, associated with atrophy and weak- ness; coarse-occurs with cold exposure or fatigue and is not significant A)Fasciculation B)Myoclonus

Rapid, sudden jerk or a short series of jerks at fairly regular intervals. A hiccup is a myoclonus of diaphragm. Single myoclonic arm or leg jerk is normal when the person is falling asleep; myoclonic jerks are severe with grand mal seizures. A)Myoclonus B)Tic

involuntary, compulsive, repetitive twitching of a muscle group (e.g., wink, grim ace, head moveme nt, shoulder shrug); due to a neurologic cause (e.g., tard ive dyskinesias, Tourette syndrome) or a psychogenic cause (habit tic). A)Tic B)Seizures

A _______ is a time-limited event due to excessive, hypersynchronous discharge of neurons in the brain. This may be due to a clear provocation such as cerebral trauma, structural lesions (tumor, blood clot, infection), hyponatremia, acute alcohol withdrawal, or medication overdose. Also, the condition of epilepsy has unprovoked recurrent seizures due to cerebrovascular disease or in 70% of patients of unknown cause. Generalized seizures involve the entire brain, such as the tonic-clonic or grand mal seizure. This type of _____ has distinct phases: (I) loss of consciousness; (2) tonic phase with muscular rigidity, opening of mouth and eyes, tongue biting, and high-pitched cry; (3) clonic phase wi th violent muscular contractions, facial grimacing, and increased heart rate; and (4) postictal phase with deep sleeping, disorientation, and confusion. A)Seizure Disorder B)tremor

Involuntary contraction of opposing muscle groups. Results in rhythmic, back-and-forth movement of one or more joints. May occur at rest or with voluntary movement. All ______ disappear while sleeping. Tremors may be slow (3 to 6 per second) or rapid (10 to 20 per second ). A)Tremor B)Rest Tremor

This occurs when muscles are quiet and supported against gravity (hand in the lap). Coarse and slow (3 to 6 per second); partly or completely disappears with voluntary movement (e.g., " pill rolling" tremor of parkinsonism , with thumb and opposing fingers). A)Rest Tremor B)none

Rate varies; worse with voluntary movement as in reaching toward a visually guided target. Occurs with cerebellar disease and multiple sclerosis. A)Intention Tremor B)tic

``` Essential tremor (familial)-a type of intention tremor; most common trem or with older people. Benign (no associated disease) but causes emotional stress in business or social situations. Improves with the administration of sedatives, propranolol, or alcohol, but do discourage alcohol because of the risk for addiction. A)true B)false ```

Sudden, rapid, jerky, purposeless movement involving limbs, trunk, or face. Occurs at irregular intervals, not rhythmic or repetitive, more convulsive than a tic. Some a re sponta neo us, and some a re initiated; all a re accentuated by voluntary acts. Disappears with sleep. Common with Sydenham's chorea and Huntington's disease. A)Chorea B)tic

Slow, twisting, writhing, continuous movement, resembling a snake or worm. Involves the distal part of the limb more than the proximal part. Occurs with cerebral palsy. Disappears with sleep. "Athetoid" hand-some fingers are flexed and some are extended. A)Athetosis B)tic

ABNORMAL FINDINGS -------------------------------------------------------------- FOR ADVANCED PRACTICE

Arm is immobile against the body, with flexion of the shoulder, elbow, wrist, and fingers and adduction of shoulder, does not swing freely. The leg is stiff and extended and circumducts with each step (drags toe in a semicircle). A)Spastic Hemiparesis B)Cerebellar Ataxia

Staggering, wide-based gait; difficulty with turns; uncoordinated movement with positive Romberg sign. A)Spastic Hemiparesis B)Cerebellar Ataxia

Posture is stooped; trunk is pitched forward; elbows, hips, and knees are flexed. Steps are short and shuffling. Hesitation to begin walking, and difficult to stop suddenly. The person holds the body rigid. Walks and turns body as one fixed unit. Difficulty with any change in direction. A)Parkinsonian (Festinating) B)Scissors

Knees cross or are in contact, like holding an orange between the thighs. The person uses short steps, and walking requires effort. A)Parkinsonian (Festinating) B)Scissors

Slapping quality-looks as if walking up stairs and finds no stair there. Lifts knee and foot high and slaps it down hard and Aat to compensate for footdrop. A)Steppage or Footdrop B)Waddling

Weak hip muscles-when the person takes a step, the opposite hip drops, which allows compensatory lateral movement of pelvis. Often, the person also has marked lumbar lordosis and a protruding abdomen A)Steppage or Footdrop B)Waddling

Leg length discrepancy >2.5 em ( I inch). Vertical telescoping of affected side, which dips as the person walks. Appearance of gait varies depending on amount of accompanying muscle dysfunction. A)Short Leg B)false

Characteristics of Upper and Lower Motor Neuron Lesions

Upper Motor Neuron Lesion In m uscles corresponding to distribution of damage in pyramidal tract lesion ; usually in hand grip, arm extensors, leg flexors Descending motor pathways that originate in the motor areas of cerebral cortex and carry impulses to the anterior horn cells of the spinal cord Brain attack or cerebrovascular accident Increased tone; spasticity May have some atrophy from disuse; otherwise normal Hyperreflexia, ankle clonus; diminished or absent superficial abdominal reflexes; positive Babinski sign Risk for contractures; Impaired Physical Mobility A)UMN B)LMN

True

Lower Motor Neuron Lesion In specific muscles served by damaged spinal segment, ventral root, or peripheral nerve Nerve cells that originate in the anterior horn of spinal cord or in brainstem and carry impulses by the spinal nerves or cranial nerves to the muscles, the "final common pathway" Poliomyelitis, herniated intervertebral disk Loss of tone, flaccidity Atrophy (wasting), may be marked Fasciculations Hyporeflexia or areflexia; no Babinski sign, no pathologic reflexes Impaired Physical Mobility A)LMN B)UMN

Patterns of Motor System Dysfunction

. Mixed group of paralytic neuromotor disorders of infancy and childhood; due to damage to cerebral cortex caused by a developmental defect, intrauterine meningitis or encephalitis, birth trauma, anoxia, or kerni cterus. A)Cerebral palsy B)cellubar

. Chronic, progressive wasting of skeletal musculature, which produces weakness, contractures a nd, in severe cases, respiratory dysfunction and death. Onset of symptoms occurs in childhood. Many types exist; the most severe is Duchenne dystrophy, characterized by the waddling ga it described in Table 23-6. A)Muscular dystrophy B)hemiplagia

. Damage to corticospi nal tract (e.g., CVA, or st roke). Upper motor neuron damage occurs above the pyramidal decussation crossover, so motor impairment is on contralateral (o pposite) side. Initially flaccid when the lesion is acute; later, the muscles become spastic and abnormal reflexes appear. Characteristic posture: arm-shoulder adducted, elbow flexed, wrist pronated, leg extended; face-weakness only in lower muscles. Hyperreflexia a nd possible clonus occur on the involved side; loss of corneal, abdominal, and crem asteric reflexes; positive Babinski and Hoffman reflexes. A)Hemiplegia B)cellubar

. Defect of extrapyramidal tracts, in the basal ganglia, with loss of the neuro transmitter dopamine. Classic triad of symptoms: tremor, rigidity, bradykinesia. Also slower, monotonous speech and diminutive writing. Body tends to stay immobile; facial expression is flat, staring, expressionless; excessive salivation occurs; reduced eye blinking. Posture is stooped; equilibrium is impaired; loses bala nce easily; ga it is described in Table 23-6. Parkinsonian tremor; cogwheel rigidi ty on passive range of motion. A)Parkinsonism B)Cellubuar

. A lesion in one hemisphere produces motor abnormalities on the ipsilateral side. Characterized by ataxia, lurching forward of affected side while walking, rapid altern ating movements are slow and arrhythmic, finger-to- nose test reveals ataxia and tremor with overshoot or undershoot, and eyes display coarse nystagmus. A)Cerebellar B)Paraplegia.

. Lower motor neuron damage caused by spinal cord injury. A severe injury or complete transection initially produces "spinal shock," which is defined as no movement or reflex activity below the level of the lesion. Gradually, deep tendon reflexes reappear and become increased; flexor spasms of legs occur; and finally, extensor spasms of legs occur; these spasms lead to prevailing extensor tone. A)Paraplegia B)MS

. Chronic, progressive, immune- mediated disease in which axons experience inflammation, demyelination , degeneration and, finally, sclerosis. Structures most frequently involved are the optic nerve, oculomotor nerve, corticospinal tract, posterior column tract, and cerebellum. Thus symptoms are varied but include blurred vision, diplopia, extreme fatigue, weakness, spasticity, numbness and tingling, and loss of balance. A)Multiple Sclerosis B)false

Patterns of Sensory Loss

Diabetes, chronic alcoholism, nutritional deficiency caused by A)Peripheral Neuropathy B)trauma

Loss of pain and temperature, contralateral side, starting one to two segments below the level of the lesion. Loss of vibration and position djscrimination on the ipsilateral sid e, below the level of the lesion. Meningioma, neurofibroma, cervical spondylosis, multiple sclerosis A)Spinal Cord Hemisection (Brown-Sequard Syndrome) B)Complete Transection of the Spinal Cord

Complete loss of all sensory modalities below the level of the lesion. Co ndi tion is associa ted with motor paralysis and loss of sphincter control. Spinal cord trauma, demyelinating disorders, tumor. A)Spinal Cord Hemisection (Brown-Sequard Syndrome) B)Complete Transection of the Spinal Cord

Loss of nil sensory modalities on the face, arm , and leg on th e side contralateral to the lesion. Vascular occlusion A)thalamus B)cortex

Because pain, vibration, and crude touch arc mediated by thalamus, little loss of these sensory functions occurs with a cortex lesion. Loss of discrimination occurs on the contralateral side. Loss of graphesthesia, stereognosis, recognition of shapes and weights, finger finding. Cerebral cortex, parietal lobe lesion (e.g., CVA, or stroke) A)cortex B)none

Abnormal Postures

Upper extre mities-flexion of arm , wrist, and fingers; adduction of arm (i.e., tight aga inst th o rax). Lower extremities-extensio n, interna l rotation, plantar flexion. This indicates hemi spheric lesion of cerebra l cortex. A)Decorticate Rigidity B)flaccid

Upper extremities sti ffly ex tended, adducted, in ternal rotation, palms pronated. Lower extrem ities stiffly extended, plantar fl exion; teeth clenched; hyperextended back. More om ino us than decorticate rigidity; indicates les ion in brain- stem at midbrain or upper pons. A)Decerebrate Rigidity B)falccid

Complete loss of muscle tone and para lys is of a ll four ex- trem ities, indicating completely nonfunctional brainstem. A)Flaccid Quadriplegia B)none

Prolonged arching of the back, with head and heels bent backward. This indicates meningeal irritation. A)Opisthotonos B)false

Pathologic Reflexes

``` Extension of great toe, fanning of toes A)Babinski reflex B)Oppenheim reflex C)Gordon reflex D) all the above ```

Clawing of fingers and thumb A)Hoffmann reflex B)false

Resistance to straighten ing (beca use of hamstring spasm), pain down posterior thigh A)Kernig reflex B)false

Resistance and pain in neck, with Flexion of hips and knees A)Brudzinski reflex B)false

Frontal Release Signs

Method of Testing Gently percuss oral region Abnormal Response (Reflex is Present) Puckers lips Indications Frontal lobe disease, cerebral degenerative disease (Alzheimer), amyo trophic sclerosis, corticobulbar lesions A)snout B)sucking

Method of Testirrg Touch oral region Abnormal Response (Reflex is Present) Sucking movement of lips, tongue, jaw, swallowing Indications Same as for snout reflex A)snout B)sucking

Method of Testirrg Touch palm with your finger Abnormal Response (Reflex is Present) Uncontrolled, forced grasping (grasp is usually last of these signs to appear, so its presence indicates severe disease) Indications When unilateral, frontal lobe lesion on contralateral side; when bilateral, diffuse bifrontal lobe disease A)grasp B)snout

Summary Checklist: Neurologic Examination

Neurologic Screening Examination 1. Mental status 2. Cranial nerves II: Optic Ill, IV, VI: Extraocular muscles V: Trigeminal VII: Facial mobility 3. Motor function Gait and balance Knee flexio n- hop or shallow knee bend 4. Sensory function Superficial pain and light touch- arms and legs Vibration-arms and legs 5. Reflexes Biceps Triceps Patellar Achilles

True

Neurologic Complete Examination 1. Mental status 2. Cranial nerves II through XII 3. Motor system Muscle size, strength, tone Gait and balance Rapid alternating movements 4. Sensory function Superficial pain and light touch Vibration Position sense Stereognosis, graphesthesia, two- point discrimination 5. Reflexes DTRs: biceps, triceps, brachioradialis, patellar, Achilles Superficial: abdominal, plantar

True

EXTRA INFORMATION

the extrapyramidal system is located in the A)basal ganglia B)cerebellum

automatic associated movements of the body are under the control and regulation of A)basal ganglia B)hypothalamus

involuntary muscle movements A)athetosis B)flaccidity

clonus is a set of rapid, rhythmic contractions of the same muscle A)true B)Falsee

clonus that may be seen when testing DTR is characterizeed by A)set of rapid,rhymtric contractions of the same muscle B)false

cerebellar function is tested by A)performance of rapid alternating movements B)false

Which area of the brain integrates the understanding of spoken and written words? ``` Choose one of the following A Basal ganglia B Wernicke's area C Broca's area D Cerebrum ```

Broca's area regulates verbal expression and writing ability. A)true B)false

To evaluate for Kernig's sign, the patient is supine, and the nurse raises the patient's leg straight up (or flexes the thigh on the abdomen) and extends the knee. The sign is present if there is resistance to straightening or pain radiating down the posterior leg. A)true B)false

Females are almost twice as likely as males to sustain traumatic brain or spinal cord injuries. ``` Choose one of the following A True B False ```

The nurse walks into a patient's room and finds that the patient is disoriented to time and place but is awake and responsive. What term best describes this patient? ``` Choose one of the following A Lethargic B Comatose C Confused D Alert ```

The lethargic or drowsy patient responds to some or all stimuli appropriately but with delay and slowness. A)true B)false

The comatose patient is unresponsive and can be aroused only briefly by vigorous, repeated stimulation. A)true B)false

An ambulance brings a 76-year-old man to the ED. His daughter found him on the floor of his house; he is almost unresponsive. It is unknown how long he was on the floor. When performing an acute assessment on this man, which of the following may the health care team omit? ``` Choose one of the following A Pupillary reaction B Glasgow coma scale C Health history D Level of consciousness ```

The nurse is going to a patient's room to assess the level of consciousness. What is the order of applying stimulation in performing this task? Choose one of the following A Normal voice; spontaneous, loud voice; tactile (touch); noxious stimulation B Spontaneous; normal voice; loud voice; noxious stimulation; tactile (touch) C Spontaneous; normal voice; loud voice; tactile (touch); noxious stimulation D Noxious stimulation; spontaneous; loud voice; tactile (touch); normal voice

The nurse is doing a brainstem assessment on an unconscious patient. Which of the following will the nurse examine during this part of the acute assessment? Select all that apply. ``` Select all that apply: A Corneal reflex B Oculocephalic reflex (doll's eye maneuver) C Pupillary assessment D Level of consciousness assessment via the Glasgow coma scale E Gag reflex ```

A B E

Brainstem assessment includes gaze, facial symmetry, corneal reflex, gag reflex, cough, and oculocephalic reflex (doll's eye maneuver) if cervical spine injury has been ruled out A)true B)false

Which of the following is usually the first sign of neurological deterioration? ``` Choose one of the following A Altered mentation and decreasing level of consciousness B Posturing C Dilating pupil D No response to painful stimulation ```

Altered mentation and decreasing level of consciousness are usually the first signs of neurological deterioration A)true B)false

After performing an acute assessment and gathering baseline information, it is often not practical or necessary to perform a complete neurological examination. ``` Choose one of the following A True B False ```

A nurse is teaching a small group of older adults about the early warning signs of stroke. Which of the following would not be included in teaching as a warning sign? Choose one of the following A Sudden trouble seeing in one or both eyes B Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body C Pain in the left arm radiating to the neck and jaw D Sudden trouble walking, dizziness, or loss of balance or coordination

Various tests and methods of imaging are used to diagnose neurological problems. Which test continues to be the staple of neurodiagnostic imaging? ``` Choose one of the following A Angiogram B MRI C x-ray D Computerized tomography (CT) ```

Lifestyle can play a big part in developing risk factors for stroke. Which of the following can greatly reduce a patient's risk for stroke? Select all that apply. ``` Select all that apply: A Quitting smoking B Eating a high-sodium diet C Following a sedentary lifestyle D Regularly exercising E Maintaining a healthy weight ```

A D E

A stiff neck (nuchal rigidity) is associated with meningitis and intracranial hemorrhage from irritation of the meninges. With the patient supine, the nurse slides a hand under and raises the patient's head gently, flexing the neck. Pain and resistance to movement are associated with nuchal rigidity. A)true B)false

The Brudzinski's sign is positive if there is resistance or pain in the neck and flexion in the hips or knees. A)true B)false

Agnosia .. . loss of ability to recognize importance of sensory impressions A)true B)false

Agraphia .. . . . .. .. . . . . .. . .. .loss of ability to express thoughts in writing A)true B)false

Amnesia . . .. . ... . . . . ...... . . loss of memory A)true B)false

Apraxia.... .. .. . . .. .. . . .. ... loss of ability to perform purposeful movements in the absence of sensory or motor damage (e.g., inability to use objects correctly) A)true B)false

Athetosis ................... bizarre, slow, twisting, writhing movement, resembling a snake or worm A)true B)false

Chorea ..................... sudden, rapid, jerky, purposeless movement involving limbs, trunk, or face A)true B)false

Coma ...................... state of profound unconsciousness from which person cannot be aroused A)true B)false

Decerebrate rigidity. . . . . . . . . . arms stiffly extended, adducted, internally rotated; legs stiffly extended, plantar flexed A)true B)false

Decorticate rigidity . . . . . . . . . . arms adducted and flexed, wrists and fingers flexed; legs extended, inter- nally rotated, plantar flexed A)true B)false

Dysarthria..................imperfect articulation of speech due to problems of muscular control resulting from central or peripheral nervous system damage A)true B)false

Extinction .................. disappearance of conditioned response A)true B)false

Fasciculation................ rapid continuous twitching of resting muscle without movement of limb A)true B)false

Myoclonus . . . . . . . . . . . . . . . . . . rapid sudden jerk of a muscle A)true B)false

Nuchal rigidity .............. stiffness in cervical neck area A)true B)false

Tic. ... . .. . . .... .. . ..... .. . . repetitive twitching of a muscle group at inappropriate times (e.g., wink,grimace) A)true B)false

Posterior (dorsal) columns: sensations of position, vibration, and finely localized touch. A)true B)false

Cerebellar system: coordinates movement, maintains equilibrium, and helps maintain posture. It functions at the subconscious level A)true B)false

* Biceps reflex: C5 to C6. * Brachioradialis reflex: C5 to C6. • Triceps reflex: C7 to C8. * Quadriceps reflex: L2 to L4. * Achilles reflex: L5 to S2.

True

Glasgow Coma Scale: eye opening, verbal response, motor response. A)true B)false

The medical record indicates that a person has an injury to Broca's area. When meeting this person you expect: a. difficulty speaking. b. receptive aphasia. c. visual disturbances. d. emotional lability.

2. The control of body temperature is located: a. Wernicke's area. b. the thalamus. c. the cerebellum. d. the hypothalamus.

3. To test for stereognosis, you would: a. have the person close his or her eyes, and then raise the person's arm and ask the person to describe its location. b. touch the person with a tuning fork. c. place a coin in the person's hand and ask him or her to identify it. d. touch the person with a cold object.

4. During the examination of an infant, use a cotton-tipped applicator to stimulate the anal sphincter. The absence of a response suggests a lesion of: a. L2. b. Tl2. c. S2. d. cs.

5. During a neurologic examination, the tendon reflex fails to appear. Before striking the tendon again, the examiner might use the technique of: a. two-point discrimination. b. reinforcement. c. vibration. d. graphesthesia.

Cerebellar function is assessed by which of the following tests? a. muscle size and strength b. cranial nerve examination c. coordination-hop on one foot d. spinothalamic test

7. To elicit a Babinski reflex: a. gently tap the Achilles tendon. b. stroke the lateral aspect of the sole of the foot from heel to the ball. c. present a noxious odor to the person. d. observe the person walking heel to toe.

8. A positive Babinski sign is: a. dorsiflexion of the big toe and fanning of all toes. b. plantar flexion of the big toe with a fanningofall toes. c. the expected response in healtl1y adults. d. withdrawal of the stimulated extremityfrom the stimulus

The cremasteric response: A)is positive when the ipsilateral testicle elevates upon stroking of the inner aspect of the thigh. B)false

To examine for the function of the trigeminal nerve in an infant, you would A)offer the baby a bottle B)false

Senile tremors may resemble parkinsonism, except that senile tremors do not include: A)rigidity and weakness of voluntary movement. B)tongue protrusion.

People who have Parkinson disease usually have which of the following characteristic styles of speech? A)slow, monotonous B)word confusion

The Glasgow Coma Scale (GCS) is divided into three areas. They include: a. pupillary response, a reflex test, and assessing pain. b. eye opening, motor response to stimuli, and verbal response. c. response to fine touch, stereognosis, and sense of position. d. orientation, rapid alternating movements, and the Romberg test.

14. The Landau reflex in the infant is seen when: a. the head is held and then flops forward as the baby is pulled to a sitting position by holding the wrists. b. the toes curl down tightly in response to touch on the ball of the baby's foot. c. the infant attempts to place his foot on the table while being held with the top of the foot touching the underside of the table. d. the baby raises the head and arches the back, as in a swan dive.

mastication and sensation of face, scalp, cornea A)trigeminal B)abducens

talking, swallowing, and sensory information from pharynx and carotid sinus A)vagus B)false

CVA has hyperactive reflexes A)true B)false

Hyporeflexia shows an herniated intervertebral disk A)true B)false

A person that is oriented to his surroundings the nurse is assessing the cerebrum A)true B)false

Kinesthsina is position sense A)true B)false