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Nursing Assessment > Sheet 1-NURS 314 Study Guide Exam #2 > Flashcards

Sheet 1-NURS 314 Study Guide Exam #2 Flashcards

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1
Q

Concept/Question

A

Explanation/Answer

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2
Q

Valves on left side of heart

A

Mitral (bicuspid) and aortic

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3
Q

Valves on right side of heart

A

Tricuspid and pulmonic

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4
Q

What is the direction of blood flow in the heart?

A

Deoxgenated blood flows from venous system and liver through the Vena cava into the Right Atrium through the Tricuspid valve into the Right Ventricle which pumps blood (systole) through the Pulmonic valve into the Pulmonic arteries to the lungs for oxygenation. From the lungs, oxygenated blood returns via the Pulmonary veins into the Left Atrium through the Mitral valve into the Left Ventricle (diastole) which pumps oxygenated blood (systole) through the Aortic valve into the Aorta for circulation through the arteries to body tissues

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5
Q

When do the AV valves open?

A

During the heart’s filling phase (diastole) to allow ventricles to fill with blood

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6
Q

When do the AV valves close?

A

During systole (pumping phase), the valves close to prevent backflow of blood into the atria

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7
Q

What is S1?

A

Closure of mitral and tricuspid valves close; beginning of systole and ventricular contraction
Coincides with carotid pulse
Coincides with R wave
Heard over entire precordium

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8
Q

What is S2?

A

Closure of pulmonic and aortic valves; end of systole (opening of mitral and tricuspid valves during to initiate ventricular filling, diastole)

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9
Q

What is betweeen S2 and next S1

A

Diastole - blood is refilling into ventricles

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10
Q

Electrical conduction of the heart

A

1 Sinoatrial node (Pacemaker) - 80-100
2 Atrioventricular node - 
3 Atrioventricular Bundle (Bundle of His)
4 Left & Right Bundle branches (which fire separately)
5 Bundle Branches

SA node: cells can depolarize on their own (i.e. automaticity; e.g. w/o having a neighboring cell do it first) (pacemaker); specialized band of tissue, highway for depolarization wave; coordinated way evenly through right and left; via internodal tracts to AV node only connection between atria and ventricles, creates a delay between contraction of atria and contraction of ventricles; important because simultaneous contraction would squeeze blood against each other, allows time for blood to move through to ventricles, to ensure blood moves in coordinated way (0.1s); then to the bundle of His down to bottom of both ventricles (right bundle and left bundle); left splits again to Perkinje fibers, electrical signal disperses to involve all the muscle cells of the myocardial cells;

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11
Q

What is a heart murmur?

A

An abnormal blowing, swooshing sound heard during S1 and S2 due to turbulent blood flow
Systolic - can be normal or with heart dz
Diastolic - always indicates heart dz

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12
Q

What causes a heart murmur?

A
  1. velocity of blood increases (e.g. flow murmur)
2. Viscosity of blood decreases (e.g. anemia)
3. Structural defects in valves (e.g. narrowed valve, incompetent valve) or unusual openings in the chambers (e.g. dilated chamber, wall defect)
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13
Q

Heart murmur grading - Grade 1

A

Barely audible in a quiet room

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14
Q

Heart murmur grading - Grade 2

A

Clearly audible, but faint (most common)

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15
Q

Heart murmur grading - Grade 3

A

Moderately loud, easy to hear

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16
Q

Heart murmur grading - Grade 4

A

Loud; associated w/ palpable thrill

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17
Q

Heart murmur grading - Grade 5

A

Very loud, heard w/ one edge of stethoscope off chest

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18
Q

Heart murmur grading - Grade 6

A

Loudest, heard w entire stethoscope lifted off chest

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19
Q

What are the extra heart sounds?

A

S3 and S4
Midsystolic click
Ejection click

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20
Q

What is S3?

A

Ventricular gallop; Sound heard during diastole from vibrations from ventricular filling. Ventricular walls are resistant to filling during early rapid filling phase (protodiastole).
Occurs immediately after S2, when AV valves open and blood first enters ventricles 
Occurs with heart failure and volume overload

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21
Q

What is S4?

A

Atrial gallop; Occurs at the end of diastole, at pre systole, when the ventricle is resistant to filling. Atria contract and push blood into noncompliant ventricle which creates vibrations 
occurs with CAD

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22
Q

Midsystolic click

A

Heart sounds associated with mitral valve prolapse

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23
Q

Ejection click

A

occurs early in systole with the opening of the semilunar valves

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24
Q

Components of an ECG (electrocardiograph)

A

P wave
PR interval
QRS complex
T wave

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25
Q

P wave

A

depolarization of atria

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26
Q

PR interval

A

the time necessary for atrial depolarization plus time for the impulse to travel through the AV node to the ventricles) beginning of P wave to beginning of QRS complex

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27
Q

QRS

A

depolarization of ventricles

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28
Q

T wave

A

repolarization of ventricles

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29
Q

What is cardiac output

A

volume of blood in each systole (stroke volume) x beats per minute

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30
Q

What is preload?

A

venous return that builds during diastole; the length to which the ventricular muscle is stretched at end of diastole just before contraction

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31
Q

Ausculation of heart sounds

A

Aortic opening: Right sternal border 2nd ICS (S2 louder than S1)
Pulmonic opening: Left sternal border 2nd ICS (S2 louder than S1)
Erb’s Point: Left sternal border 3rd ICS (S1 and S2 even)
Tricuspid valve: Left sternal border, 5th ICS
Mitral valve: (APEX) 5th ICS MCL

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32
Q

Pulse deficit

A

Apical rate - radial rate

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33
Q

Auscultating the carotid arteries

A

For middle-aged or older, or patients who show signs of CVD assess for bruits

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34
Q

Bruits

A

Blowing, swooshing sound indicating blood flow turbulence; normally none is present; usually due to a local vascular cause such as atherosclerosis

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35
Q

What degree of artery narrowing causes a bruit?

A

When the artery is occluded by 1/2 -2/3, a bruit is audible and up to 2/3 increasing loudness indicates worsening atherosclerosis. After 2/3 bruit loudness decreases. No bruit is audible if artery is completely occluded. Absence of bruit does not indicate absence of carotid lesion

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36
Q

Where do we assess for bruits?

A

Carotid arteries
Abdominal aorta

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37
Q

Risk factors for heart disease and stroke

A

High blood pressure
abnormal lipids
smoking
high cholesterol
Abdominal obesity
Type 2 diabetes
Age
Genetics
Alcohol intake
Sedntary lifestyle
Blood thinners

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38
Q

Subjective data in assessment of heart

A

Chest pain, dyspnea, orthopnea; cough; fatigue; cyanosis or pallor; edema; nocturia; past or family hx of cardiac disease

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39
Q

Objective data in assessment of heart

A
  1. Neck vessels: assess carotid for bruits; jugular venous pulse and estimate JVP as needed
2. Precordium: Inspection and palpation to assess apical pulse and detect heaves or lifts
3. Precordium: Ausculate heart APETM for heart sounds, murmurs,
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40
Q

Cardiac changes in older adults

A

Increase in systolic BP, disrhythmias, and the ability of the heart to augment cardiac output with exercise is decreased (max. HR decreased)

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41
Q

Symptoms of angina or chest pain

A

Chest/back/jaw/L. shoulder/L.arm pain
Dypnea
Pallor
Diaphoresis
Fatigue
Palpitations/tachycardia
Anxiety/denial or sleep disturbance
N&V
Dizziness
Silent MIs

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42
Q

Are pulsations at the apex of heart considered normal?

A

No, would be called a heave and they indicate ventricular hypertrophy or hyper dynamic/fluid overload

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43
Q

Which position helps facilitate the auscultation or murmurs or additional heart sounds?

A

To the left, side-lying

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44
Q

What are the abdominal borders?

A

From the diaphragm to the brim of the pelvis; all internal organs are called viscera

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45
Q

Organs in the RUQ

A

liver, gallbladder, duodenum, head of pancreas, right kidney, right adrenal gland, hepatic flexure of colon, part of ascending and transverse colon

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46
Q

Organs in the LUQ

A

Stomach, spleen, left lobe of liver, body of pancreas, left kidney and adrenal gland, splenic flexure of colon, part of transverse and descending colon

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47
Q

Organs in the RLQ

A

cecum, appendix, right ureter, right ovary and fallopian tube, or right spermatic cord

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48
Q

Organs in the LLQ

A

Portions of descending colon, sigmoid colon, left ureter, left ovary and fallopian tube or spermatic cord

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49
Q

Organs in the midline of abdomen

A

Aorta, bladder, uterus

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50
Q

Changes in abdomen in older adults

A

Abdominal obesity, pernicious anemia, iron def. anemia, calcium malabsoprtion, increase in gallstones, delay in gastric emptying, decreased liver size (by 25%) and hepatic blood flow (33%), delayed metabolism of drugs, constipation, decreased salivation and taste

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51
Q

Subject assessment of abdomen

A

Appetite
Early satiety (feeling of fullness)
Weight change (unintentional gain or loss of 5lb in one month)
Dysphagia 
Chronic indigestion
N&V
food intolerances
Bowel habits
Abdominal hx
Diet recall
Nicotine (increase incidence of peptic ulcers and cancers)
Medications 
Abdominal pain

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52
Q

Assessment of abdominal pain

A

Visceral 
Parietal
Referred

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53
Q

Abdominal pain - visceral

A

When hollow abdominal organs - intestines- become distended or contract forcefully or when the capsule of solid organs such as liver and spleen are stretched. Poorly defined or localized and intermittently timed, 
Dully, achy, bruning, cramping or colicky

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54
Q

Abdominal pain - parietal

A

Parietal peritoneum becomes inflamed (e.g. appendicitis or peritonitis); tends to localize to source
Characterized as sever, steady pain

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55
Q

Abdominal pain - referred

A

occurs at distant sites that are innervated at approximately the same levels as the disrupted abdominal organ; pain travels from source and becomes highly localized at distant site


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56
Q

Constipation

A

Less than 3 BM/wk OR
Straining, lumpy or hard stools, feeling of incomplete evacuation, feeling of anorectal blockage, use of manual maneuvers

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57
Q

Diarrhea

A

More than 3-4 stools/day
Liquid, conforms to container; bloody or mucus; medications can cause

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58
Q

Physical exam of abdomen

A
  1. inspection
2. Auscultation
3. Percussion
4. Palpation
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59
Q

Physical exam of abdomen - complete sequence

A
  1. Inspect the abdomen 
Contour (flat, rounded, scaphoid, distended), symmetry, umbilicus, skin (textrure, color, veins, arteries, hydration, lesions), pulsation, movement, hair distribution, demeanor
2. Auscultation - all four quadrants for BS (hypoactive, normal, hyperactive)
3. Percussion - for tympany and dullness (predominating sound should be tympany b/c majority of organs are air-filled; liver and spleen will be dull)
Percuss for liver span
Percuss for spleen
CVA tenderness
4. Palpation - light to deep
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60
Q

Inspection of abdomen

A

Contour (flat, rounded, scaphoid, distended or protuberant indicating ascites), symmetry, umbilical hernia or inflamation, skin (texture, color, veins and arteries, scars or lesions), pulsation (aneurysm) or movement (flatus); hair distribution; demeanor

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61
Q

Why do we auscultate BS before percussion and palpation?

A

Actions can increase peristalsis, which may cause misinterpretation of BS

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62
Q

Auscultation of BS

A

Assess character and frequency of BS; any vascular sounds or bruits
High-pitched, gurgling cascading sounds occurring irregularly anywhere from 5-30 times per minute

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63
Q

Hypoactive BS

A

Absent BS; following abdominal surgery or inflammation of the peritoneum

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64
Q

Hyperactive BS

A

loud, high-pitched, rushing, tinkling sounds that indicate increased motility (due to diarrhea, gas, irritation)

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65
Q

What is borborygmus?

A

A hyperactive BS from hyper-peristalsis “stomach growling”

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66
Q

Percussion of the abdomen

A

Liver span
Spleen
General tympany

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67
Q

Percussion - general tympany

A

Tympany should predominate because air in the intestines rises to the surface when person is lying supine

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68
Q

When would dullness occur during percussion of the abdomen?

A

Distended bladder, adipose tissue, fluid, or mass

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69
Q

When does hyper resonance with percussion occur?

A

Gaseous distention

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70
Q

What is the purpose of liver span estimation?

A

Screens for hepatomegaly and monitors changes in liver size; however, its a gross estimation b/c inaccurate detection of upper border

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71
Q

What is the normal adult liver span?

A

6-12cm; correlates with height; avg.10.5cm for males and 7.5cm for females
In chronic emphysema, liver is displaced downward by hyper inflated lungs

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72
Q

What is hepatomegaly?

A

Enlarged liver indicated by enlarged liver span; misdiagnosed due to dullness percussed in 5th ICS that is actually due to lung disease (pleural effusion or consolidation) and at the lower border by ascites or pregnancy or gas distention of colon

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73
Q

What is a normal finding during percussion of the spleen?

A

dullness around 9th and 11th ICS at LML; 7 cm, should not encroach on normal tympany over gastric air bubble

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74
Q

What indications lead to an enlarged spleen?

A

Mononucleosis, trauma, infection

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75
Q

What is the technique for spleen percussion?

A

Percuss in the lowest ICS at LAAL; tympany should result; ask person to inhale deeply; tympani should remain
Positive Spleen Percussion Sign: results when dull note is heard when patient inhales during splenic percussion; indicates moderate splenomegaly before spleen becomes palpable i.e. mono, malaria, hepatic cirrhosis

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76
Q

What is ascites?

A

Free fluid in the peritoneal space that occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer

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77
Q

Purpose of light palpation of abdomen?

A

To form an overall impression of the skin surface and superficial musculature
Note: Any muscle guarding, rigidity, large masses, tenderness

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78
Q

Normally palpable organs

A

muscles, liver, abdominal aorta, small and large intestines, kidneys, partially or full bladder, pregnant uterus, femoral arteries, feces (LLQ)

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79
Q

Normally non-palpable organs

A

Stomach, gallbladder, spleen, pancreas, adrenal glands, renal arteris, iliac arteries, appendix, ovaries, non-preg uterus, empty bladder, prostate

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80
Q

Common abnormal findings:

A

Enlarged liver
Enlarged Spleen
Abdominal aortic aneurysm
Masses
Ascites
Excess air (distention)
Adhesions
Hernias

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81
Q

Abdominal assessment developmental changes - older adults

A
  1. Increased deposits of sub-q fat abdomen and hips
2. Abdominal muscles thinner, more relaxed; organs more easily palpated liver, kidneys
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82
Q

Function of the vascular and lymphatic system

A

Delivery and transport of oxygen and nutrients and elimination of waste products from cellular metabolism; immune function

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83
Q

Structure and function of arteries

A

Heart makes high-pressure system
Arteries are strong, tough and tense to withstand pressure demands
Contain elastic fibers to allow walls to stretch w systole and recoil w diastole
Controlled by VSM (vascular smooth muscle) which controls amount of blood delivered to tissues
Supply oxygen and essential nutrients to tissues

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84
Q

What is a pulse? Where are they found in the body?

A

Pressure wave created by each heartbeat is felt at certain arterial sites clos to the skin or over a bone:
- Temporal 
- Carotid
- Brachial (major artery in arm)
- Radial
- Ulnar (deeper and harder to feel)
- Abdominal aorta
- Femoral artery (major leg)
- Popliteal
- Posterior tibialis
- Dorsalis pedis


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85
Q

What is ischemia?

A

Deficient supply of oxygenated arterial blood to tissue caused by obstruction of blood vessel
Complete blockage: leads to death of distal tissue
Partial blockage: insufficient supply; may only be apparent at exercise when oxygen needs increase

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86
Q

Veins accesible to examination

A

Jugular veins
Veins in arms
Femoral and popliteal

87
Q

Three types of veins in the legs

A
  1. Deep veins 
2. Superficial veins
3. Perforators
88
Q

What are the deep veins?

A

Run alongside arteries; conduct most of venous return from legs (as long as these remain intact, superficial veins can be excised without harming circulation)
- femoral
- popliteal

89
Q

What are the superficial veins?

A
  • Great saphenous (inside leg, joins popliteal)
- Small saphenous (outside leg, joins popliteal)
90
Q

What are the perforating veins?

A

Connecting veins that join deep and superficial veins; one-way valves route blood from superficial into deep veins

91
Q

Structure and function of venous return

A

Veins drain deoxygenated blood and waste products from tissues and return to the heart
low-pressure
venous flow mechanism keeps blood moving:
- larger in diameter and more distensible than arteries; can expand and hold more blood when volume increases (compensatory mechanism to reduce stress on heart)
- ability to stretch is called capacitance vessels

92
Q

What is important for efficient venous return?

A
  • contracting skeletal muscles
- Competent valves in veins
- patent lumen
93
Q

What is the function of the lymphatic system?

A
  1. Conserve fluid and plasma proteins that leak out of capillaries (because veins cannot absorb all fluid that is pushed out; prevents fluid build up in interstitial spaces and edema)
2. Forms a major part of immune system 
3. Absorbs lipids from intestinal tract
94
Q

Describe the drainage of the lymph vessels

A

Lymph vessels converge and drain into two main lymphatic trunks which then empty into venous system at subclavian veins

95
Q

What areas does the right lymphatic vessel drain?

A

Right side of head and neck, right arm, right thorax, right lung, and pleura, right side of heart, right upper section of liver

96
Q

Cervical nodes drain:

A

Head and neck

97
Q

Axillary nodes drain:

A

Breast and upper arm

98
Q

Epitrochlear nodes drain:

A

Lower arm and hand

99
Q

Inguinal nodes:

A

lower extremity; external genitalia, anterior abdominal wall (normally small, nontender and movable)

100
Q

What areas does the thoracic duct vessel drain?

A

Rest of the body

101
Q

How is lymph fluid moved throughout the body?

A

Slow compared to blood;
1. contracting skeletal muscles
2. Pressure changes secondary to breathing
3. Contraction of vessel walls themselves

102
Q

What are lymph nodes? What is their purpose?

A

Small, oval clumps of lymphatic tissue located at intervals along vessels
Filter fluid before its returned to the bloos stream
Filter out microorganisms that could be harmful to the body: B and T lymphocytes in the lymph nodes mount an antigen-specific response to eliminate pathogens

103
Q

What do localized, swollen and tender nodes indicate?

A

Local inflammation


104
Q

What do enlarged epitrochlear nodes indicate?

A

Infection of hand or forearm;
Can also occur in generalized lymphadenopathy: lymphoma, leukemia, sarcodosis, infections, mono

105
Q

What is lymphadenopathy?

A

Enlargement of the lymph nodes
Indicate: infection, malignancy, immunologic diseases

106
Q

Organs related to lymphatic system

A

Spleen
Tonsils
Thymus (T cells develop here during childhood)

107
Q

What is the function of the spleen?

A
  1. Destroy old RBCs
2. Produce antibodies
3. Store RBCs
4. Filter microorganisms
108
Q

Name the tonsils

A

Pharyngeal (anterior to tragus)
Palatine
Lingual

109
Q

Developmental changes in peripheral vascular

A

Increased rigidity (arterosclerosis); yields rise in systolic BP
Enlargement of intramuscular calf veins
Prolonged bed rest and heart failure increase risk of DVT and pulmonary embolism
Thin shiny, skin; thick-ridged nails; loss of hair on lower legs

110
Q

What is DVT?

A

Occlusion of deep vein by thrombolism
Causing inflammation, blocked venous return, cyanosis, and edema
S: Sudden onset of intense, sharp, deep muscle pain; may increase w sharp dorsiflexion of foot
O: increased warmth, swelling, redness,

111
Q

Thrombogenesis

A
  1. stasis
2. Hypercoagulability
3. Endothelial dysfunction
112
Q

What is unique about a hard, fixed, nontender lymph node?

A

Considered cancerous until proven otherwise

113
Q

Arterial v Venous Leg Cramps

A

Arterial: Worse with exercise, better with rest or dangling; pain of ischemia, intermittent claudication; caused by arteriosclerosis; risk for infarcts, dry gangrene, amputations
Venous: Better with exercise, worse with dangling; pain of pressure, fatigue; caused by venous insufficiency (venous valve failure d/t immobility, diabetes); risk for ulcers, wet gangrene, amputations

114
Q

Pitting Edema Scale

A

Normal: Finger should leave no indentation (unless standing all day or pregnancy)
1+: Mild pitting: slight indentation, no perceptible swelling
2+: Moderate pitting, indentation subsides rapidly
3+: Deep pitting, indentation remains, leg looks swollen
4+: Very deep pitting, indentation last long time, leg very swollen

115
Q

What is lymphedema?

A

Swelling of a limb caused by an obstructed lymph channel or damage to nodes and vessels

116
Q

Ligament

A

Fibrous bands running from one bone to the other
Strengthen joint and prevent movement in undesirable directions

117
Q

Tendon

A

Attaches skeletal muscle to bone

118
Q

Cartilage

A

Covers the surface of opposing bones;
Avascular, receives nourishment from synovial fluid that circulates during joint movement; 
Cushions the bones and provides smooth surface to facilitate joint movement

119
Q

Bursa

A

Enclosed sac filled with synovial fluid; located in areas of increased frcition and help muscles and tendons glide smoothly over bone

120
Q

Inversion

A

moving sole of foot inward at ankle

121
Q

eversion

A

moving sole of foot outward at ankle

122
Q

rotation

A

moving head around central axis

123
Q

protraction

A

moving body part forward, parallel to the ground

124
Q

Retraction

A

moving body part backward parallel to ground

125
Q

Elevation

A

raising a body part

126
Q

Depression

A

lowering a body part

127
Q

Internal rotation

A

toward midline

128
Q

External rotation

A

away from midline

129
Q

Adduction

A

Move towards midline

130
Q

Abduction

A

Away from midline of body

131
Q

Flexion

A

beding; decreasing angle of joint

132
Q

Extension

A

straightening increasing angle of joint

133
Q

pronation

A

turn forearm w palm facing down

134
Q

supination

A

turn forearm with palm facing up

135
Q

Assessment of musculoskeletal system

A

Inspection: size and contour of joints and muscles; skin and tissue over joint
Palpation: Skin temperature, muscles, bony articulations, area of joint capsule; ROM and muscle/motor strngth testing

136
Q

Developmental changes in musculoskeletal - elderly

A

Loss of peripheral sub-q fat, muscle, and calcium in bones (osteopenia, osteoporosis)
Loss of ligament and tendon elasticity and flexibility (severe is contracture)
Flattening of vertebral disks
Enlargement and deformity of joint related to wear and destruction of articular cartilage (osteoarthritis); kyphosis, loss of lordotic curvatur, stooped appearance

137
Q

Number of cervical spine

A

7

138
Q

of thoracic

A

12

139
Q

lumbar

A

5

140
Q

sacral

A

5

141
Q

coccygeal

A

3 or 4

142
Q

Intervertebral disks

A

cushion the spine

143
Q

Herniated disc

A

Ruptured disk, nucleus pulposus herniates out of vertebral column; compresses on spinal nerve causing pain

144
Q

Osteoporosis

A

Disease in which bone demineralizes or loss of bone density
Bone becomes porous and fragile
Bone remodeling: cyclic process of bone deposition and resorption: deposition occurs up to age 40; bone resorption(loss of bone matrix) occurs more rapidly after 40
Women have more than men; increased risk 5 yrs post menopause due to lack of estrogen leads to increased bone loss
Uncontrollable Risk factors: gender, age, ethnicity, hx bone fractures
Controllable risk factors: exercise, calcium intake, anorexia, low estrogen levels, smoking, caffeine, alcohol, medication intake
Reduce risk: increase exercise, intake of calcium and vit D; ERP

145
Q

Temporalmandibular joint movement

A

1) hinge: open and close
2) gliding: protrusion and retraction
3) Gliding: side to side

146
Q

Vertebral column

A

1) Flexion: bending forward
2) Extension: bending backward
3) abduction
4) rotation

147
Q

Glenohumoral

A

ball and socket; full ROM

148
Q

Elbow

A

Hinge: flexion and extension

149
Q

Wrist and carpals:

A

radiocarpal: flexion and extension, side to side
midcarpal: flexion, extension and some rotation
metacarpophylangeall and interphalangeal: flexion and extension

150
Q

Hip

A

ball and socket

151
Q

Knee

A

Femur, tibia, patella
Hinge joint: flexion and extension

152
Q

Muscle strength rating scale

A

5- normal
4- movement against resistance but less than normal
3- movement against gravity, but not against resistance
2 - movement at the joint but not against gravity
1- visible muscle movement but no movement at the joint
0 - no muscular contraction

153
Q

Scoliosis

A

Lateral curvature and rotation

154
Q

Lordosis

A

exxagerated lumbar curve; pregnancy is normal, obesity

155
Q

Kyphosis

A

exaggerated thoracic curve; common with aging

156
Q

Tempormandibular joint

A

Vertical motion: hinge 3-6cm
Lateral motion: 1-2 cm
Protrusion

157
Q

Cervical spine

A

Flexion 45
hyperextension 55
lateral bending 40
rotation 70 (look right or left)

158
Q

Shoulder

A

Forward flexion up to 180 (raise arms above head)
Hyperextension 50 (arms behind you)
Internal rotation 90
External rotation
Abduction of 180 (above head and hands together)
Adduction 50: across midlin

159
Q

Elbow

A

Flexion 150 to 160
Extension 0
supination and pronation 90

160
Q

Wrist and hand

A

hyperextension 70 - bend hand up at wrist


161
Q

Frontal lobe

A

personality
behavior
emotion
intellectual functions

162
Q

Precentral gyrus

A

Primary motor area

163
Q

Broca’s area (frontal lobe)

A

Motor speech

164
Q

Wernicke’s area (temporal lobe)

A

Speech comprehension

165
Q

Temporal lobe

A

Hearing
Taste
Smell

166
Q

Parietal lobe

A

sensation

167
Q

Post central gyrus

A

primary sensory area

168
Q

Occipital lobe

A

visual reception

169
Q

Cerebellum

A

Motor coordination
equilibrium
balance

170
Q

Basal ganglia

A

Initiate and coordinate movement; control automatic associated movements of the body (e.g. arm swinging during walking)

171
Q

Thalamus

A

Main relay station where the sensory pathways of the spinal cord, cerebellum and brainstem synapses before going to cerebral cortex

172
Q

Hypothalamus

A

Major respiratory center, basic vital functions: temperature, appetite, sex drive, blood pressure; sleep; anterior and posterior pituitary gland regulator; coordinates autonomic nervous system response and stress response

173
Q

Cerebellum

A

Motor coordination of voluntary movements

174
Q

Brainstem

A

Midbrain: Motor neurons and tracts
Pons: Two respiratory centers
Medulla: Continuum of spinal cord with brain; autonomic centers (respiration, heart rate, GI) and controls cranial nerves VIII through XII

175
Q

Spinal cord

A

Mediates reflexes of posture control, urination and pain response; nerve cell bodies are arranged in butterfly shape with anterior and posterior horns

176
Q

Major sensory pathways of CNS

A

Spinothalamic tract: pain, temperature, and crude and light touch
Posterior (Dorsal) Columns: Fine touch, proprioception and vibrations

177
Q

Major motor pathways of CNS

A

Corticospinal crossed tract
Corticospinal uncrossed tract
Extrapyramidal Tract

178
Q

Components of PNS

A

Afferent nerve fibers: deliver sensory information to CNS
Efferent nerve fibers: carry information from the CNS 
Reflex arcs
Cranial nerves
Spinal nerves
Autonomic nervous system

179
Q

Function of autonomic nervous system

A

Innervates heart, glands, diaphragm
Mediates unconscious activity
Peripheral nervous system composed of cranial nerves and spinal nerves
Cranial nerves can be sensory or motor or both


180
Q

Presyncope

A

Lightheaded, swimming sensation, like feeling faint

181
Q

Vertigo

A

Rotational spinning

182
Q

Disequilibrium

A

Unsteady, like on a boat

183
Q

Sequence of neuro exam

A

Mental status
Cranial nerves
Motor system (including gait and coordination)
Sensory system
Reflexes

184
Q

DTR

A

Measure of intactness of reflex arc at specific spinal intervals

185
Q

DTR assessment scale

A

4+ - very brisk, hyperactive with clonus, indicative of dz
3+ - brisker than average, may indicate disease, probably normal
2+ - average, normal
1+ - diminished, low normal, occurs only with reinforcement
0 - no response

186
Q

Hyporeflexia

A

Absence of reflex, lower motor neuron problem; occurs with interruption of sensory afferents or destruction of motor efferents ad anterior horn cells (e.g. spinal cord injury

187
Q

Clonus

A

Set of rapid, rhythmic contractions of same muscle

188
Q

Hyperreflexia

A

Exaggerated reflex, upper motor neuron lesions (e.g. brain attack)

189
Q

Biceps reflex

A

C5-C6: Place thumb on biceps tendon and strike blow on your thumb; normal response is contraction of biceps and flexion

190
Q

Triceps reflex

A

C7-C8: Tell person to let arm go dead; strike just above elbow while holding it; normal response is extension of the forearm

191
Q

Brachioradialis reflex

A

C5-C6: Hold person’s thumb, strike forearm directly about 2-3cm above radial styloid process; normal response is flexion and supination of forearm

192
Q

Quadriceps reflex

A

L2-L4: Let lower legs dangle, strike just below patella; normal response is leg extension, palpate contraction of quad

193
Q

Achilles reflex

A

L5-S2: Position person with knee flexed and hip externally rotated, hold foot in dorsiflexion, strike achilles tendon directly; normal response is plantar flexion against hand

194
Q

Plantar reflex

A

L4-S2: with hip slightly externally rotated, draw upside-down J towards ball of foot; normal response is plantar flexion and inversion and flexion of forefoot
Positive Babinski sign: abnormal in adulthood dorsiflexion of big toe and fanning of toes (normal in infancy); indicates dz of spinal tract

195
Q

Sensory tests for posterior column tract

A

Vibration
Position (kinesthesia) (proprioception): tests person ability to perceive passive movements of toes and fingers
Tactile discrimination (fine touch): stereognosis, graphesthesia


196
Q

Aphasia

A

Loss of power of expression of expression by power of speech, writing or signs, loss of comprehension of spoken word or written language

197
Q

Dysphagia

A

Difficulty swallowing

198
Q

Dysphasia

A

Difficulty speaking consisting of lack of coordination and inabiity to arrange words in their proper order

199
Q

Signs of stroke

A

Sudden weakness or numbness of face, arm and leg on one side of body
Loss of speech, difficulty talking
Dimness or loss of vision, double vision
Unexplained dizziness
Unsteadiness or sudden falls
Headache
Confusion

200
Q

What is a stroke?

A

Caused by sudden or gradual interruption of blood supply
Infarct: Cerebral vessels prone to atherosclerosis and arteriosclerosis, with narrowing of vessels; thrombus/embolus formation; also cardiogenic thrombus/embolus
Hemorrhage: Secondary to HTN, DM, vascular malformation, aneurysm, tumor invasion

201
Q

CN I

A

Olfactory: Smell

202
Q

CN II

A

Optic: Vision

203
Q

CN III

A

Oculomotor: motor-most EOM movement, opening of eyelids; parasympathetic- pupil constriction, lens shape

204
Q

CN IV

A

Trochlear: Downward and inward movement of eye

205
Q

CN V

A

Trigeminal: Motor- mastication; sensory - sensation of face, scalp, cornea, mucous membranes of mouth and nose

206
Q

CN VI

A

Abducens: Lateral movement of eye

207
Q

CN VII

A

Facial: motor- facial muscles, close eye, labial speech, close mouth; sensory - tast on anterior two-thirds of tongue; parasympathetic - saliva and tear secretion

208
Q

CN VIII

A

Acoustic: hearing and equilibrium

209
Q

CN IX

A

Glossopharyngeal: motor- pharynx (phonation and swallowing); sensory - taste on posterior one third of tongue, pharynx (gag reflex); para- parotid gland, carotid reflex

210
Q

CN X

A

Vagus: motor-pharynx and larynx (talking and swallowing); sensory-general sensation from carotid body, carotid sinus, pharynx and viscera; para-carotid reflex

211
Q

CN XI

A

Spinal: movement of traps and sternomastoid muscles

212
Q

CN XII

A

Hypoglossal: movement of tongue

213
Q

Stress incontinence

A

Involuntary urine loss with physical strain, sneezing, coughing

214
Q

Urge incontinence

A

involuntary urine loss from overactive detrusor muscle in bladder; it contracts and creates urgent need to void

Nursing Assessment (2 decks)

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