Unit IV (Neurological Assessment)

Question 1

What does LOC stand for?

Answer 1

Level of Conciousness

Question 2

What does LOC measure?

Answer 2

degree of wakefulness or ability to arouse a person.

Question 3

The patient has suffered a head injury and is unresponsive to all stimuli. What tool is used to predict recovery?

Answer 3

Glasgow Coma Scale

Question 4

The patient is sitting in bed conversing with visitors. The LOC is assessed as:

Answer 4

Awake and Alert.

Question 5

The patient responds when asked questions, but quickly drifts back to sleep. The LOC is assessed as:

Answer 5

Lethargic.

Question 6

The patient is sleeping in bed, and does not arouse to being prodded with a sharp instrument. The LOC is assessed as:

Answer 6

Comatose

Question 7

A defect in or loss of power to express oneself by speech, writing or signs is termed:

Answer 7

Aphasia.

Question 8

The patient is able to understand the nurses instructions to turn their head. However, when asked to repeat words the patient does not repeat the appropriate word. The nurse identifies this as:

Answer 8

Expressive/motor aphasia.

Question 9

The nurse asks the patient raise their feet off the bed. The patient does not understand the nurses instructions. The nurse identified this type of aphasia as:

Answer 9

Receptive/sensory aphasia.

Question 10

What is a normal range for adult attention span?

Answer 10

15-20 minutes.

Question 11

What four items are assessed in regards to orientation?

Answer 11

Person
Place
Time
Situation

Question 12

What level of orientation is lost first?

Answer 12

Time (When & Where they are)

Question 13

The nurse asks the patient to repeat the numbers 2, 6, 24, 60. What type of memory is the nurse assessing?

Answer 13

Immediate Recall

Question 14

The nurse asks the patient what they had for breakfast. What type of memory is the nurse assessing?

Answer 14

Recent Memory/Short Term

Question 15

The nurse asks the patient for their date of birth and their mothers maiden name. What type of memory is the nurse assessing?

Answer 15

Remote/Long Term Memory

Question 16

What three sensory functions does the nurse assess?

Answer 16

Touch
Pain
Temperature

Question 17

When is it acceptable to not assess temperature sensory function?

Answer 17

If pain sensation is normal, temperature does not need to be assessed.

Question 18

How does the nurse assess for motor function?

Answer 18

• Watch gait of pt.
• Hold index finger in front of patient, and ask them to touch it with their index finger.
• Ask the patient to close their eyes and touch their nose with index fingers.

Question 19

How is grip measured?

Answer 19

-Have patient grip your fingers. Grip should be equal and strong.

Question 20

How should pupils appear? Normal measurement?

Answer 20

Equal in size and round, 3-7mm

Question 21

How do pupils respond to light?

Answer 21

Constrict rapidly.

Question 22

The nurse asks the patient to look at an object held 4” from their nose. While looking at the pupils, the nurse then asks the patient to look at an object across the room. What is the nurse measuring? What should the nurse see in regard to pupil diameter?

Answer 22

Accommodation-
Close- Constricted pupils.
Far- Dialated Pupils.

Question 23

What is PERLA/PERRLA?

Answer 23

Pupils
Equal
Round
Reactive to
Light and
Accommodation.

Question 24

The nurse asks the patient to look at the tip of their pen, and watches the pupils as the pen moves closer to the patients nose. What is being assessed?

Answer 24

Convergence.

Question 25

What diagnostic test records the brains activity in the form of electrical waves?

Answer 25

EEG (Electroencephalogram)

Question 26

What diagnostic test uses sound waves to assess blood flow through the carotid arteries?

Answer 26

Carotid Ultrasound

Question 27

What diagnostic procedure uses contrast to visualize the arteries of the brain?

Answer 27

Cerebral Angiography

Question 28

What diagnostic test is able to detect tumors, emboli, and aneurysms?

Answer 28

Cerebral Angiography