neurosensory exam 3

Question 1

who needs a focused neuro assessment?

Answer 1

neurological disorder or disease
neurologic change
neurological abnormal finding during basic assessment
trauma
known drug-induced mental status changes
any neurological complaints
4 HYPO’s - hypoxia, hypoglycemia, hypotension, hypoventilation

Question 2

lethargic (somnolent)

Answer 2

not fully alert
drifts off to sleep when not stimulated
drowsy
responds appropriately to questions

-what a normal person is when you wake them up in the middle of the night they awake to name may just be slow

Question 3

obtunded

Answer 3

sleeps most of the time
difficult to arouse-needs loud shout or vigorous shake
acts confused when aroused
speech mumbled or incoherent
requires constant stimulation to stay awake

• not ready to wake up from surgery
• took too many opioids

Question 4

stupor or semi-comatose

Answer 4

spontaneously unconscious
responds ONLY to vigorous shake or pain-has appropriate response
-groans, mumbles, gets angry
- DO NOT have appropriate speech patterns

this is when we start to worry about airway/breathing

Question 5

comatose

Answer 5

NO meaningful response to stimuli

light coma-no purposeful movement, some reflex activity
deep coma- no motor response

Question 6

what does the acronym BE FAST stand for and what does it signify?

Answer 6

SIGNS OF STROKE
Balance difficulties
Eyesight changes

Face weakness
Arm weakness
Speech difficulties
Time call 911

Question 7

propricopetion

Answer 7

recognizing where your limbs are in space

Question 8

how to assess for coordination

Answer 8

rapid alternating movements - touch thumb to each finger on same hand quickly

Question 9

what is an X-ray used for ?

Answer 9

to examine bones

Question 10

what is the nursing care for an X-ray?

Answer 10

explain procedure - painless
remove metal objects
avoid manipulation of head or back while obtaining
if spinal fracture suspected –> wear neck brace

Question 11

what is a CT scan?

Answer 11

uses x-rays to produce 3D images of organs, bones, & tissues
aids in determining what part of brain is affected
quickly detects hemorrhage, bone or vascular abnormalities, tumors, cysts
- when using IV contrast dye - looks at vascular - is there a problem with blood vessels in brain?

Question 12

what is an MRI

Answer 12

uses computer generated radio waves & powerful magnetic field to produce detailed images
computer creates a 3D image from a 2D slice

able to see brain, spinal cord, measure blood flow
used to detect stroke, tumors, infection, injury, epilepsy
NO EXPOSURE TO RADIATION

contrast - gadolinium

Question 13

nursing care for MRI

Answer 13

NO pace makers, NO metal
remove medicated patches

loud noises
can take up to 90 minutes to complete

Question 14

EEG (Electroencephalography)

Answer 14

monitor brain’s electrical activity
diagnose- seizures, metabolic disorders, inflammation, infection, sleep disorders
-can confirm brain dead

series of electrodes attached to skull using a special conducting paste
can be done sleeping, awake, or stimulated

Question 15

what are the three components of normal sensation

Answer 15

reception
perception
reaction

Question 16

what is reception

Answer 16

stimulation of a receptor such as a light, touch, or sound

Question 17

what is perception

Answer 17

integration of interpretation of stimuli

any factor affecting LOC impairs sensory perception

Question 18

what is reaction

Answer 18

only the most important stimuli will elicit a reaction

Question 19

what factors influence sensory function

Answer 19

age - being old causes risk for sensory alterations 
meaningful stimuli 
amount of stimuli
social interaction
environmental factors 
cultural factors

Question 20

what are the three sensory alterations

Answer 20

sensory deficits
sensory deprivation
sensory overload

Question 21

sensory deficits

Answer 21

deficit in the normal function of sensory reception and perception

EX. i have terrible vision without contact so at night i bump into things

Question 22

sensory deprivation

Answer 22

inadequate quality or quantity of stimulation

Question 23

sensory overload

Answer 23

reception of multiple sensory stimuli

Question 24

people at risk for sensory alterations

Answer 24

older adults
living in a confined environment
acutely ill

Question 25

what is aphasia

Answer 25

difficulty speaking or understanding

Question 26

what is expressive aphasia

Answer 26

inability to name common objects or express simple ideas in words or writing

THINK - they cannot EXPRESS themselves

EX. the patient understands your question but cannot express an answer

Question 27

what is receptive aphasia

Answer 27

inability to understand written or spoken language
patient can speak words but unable to understand language or communicate orally

commonly with stroke

Question 28

MRI absolute contraindications

Answer 28

implantable pediatric sternum device 
metallic foreign body in the eye 
"triggererfish" contact lens 
gastric reflux device 
insulin pump
temporary transvenous pacing leads