Unit IV (Neurological Assessment) Flashcards
What does LOC stand for?
Level of Conciousness
What does LOC measure?
degree of wakefulness or ability to arouse a person.
The patient has suffered a head injury and is unresponsive to all stimuli. What tool is used to predict recovery?
Glasgow Coma Scale
The patient is sitting in bed conversing with visitors. The LOC is assessed as:
Awake and Alert.
The patient responds when asked questions, but quickly drifts back to sleep. The LOC is assessed as:
Lethargic.
The patient is sleeping in bed, and does not arouse to being prodded with a sharp instrument. The LOC is assessed as:
Comatose
A defect in or loss of power to express oneself by speech, writing or signs is termed:
Aphasia.
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:
Expressive/motor aphasia.
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:
Receptive/sensory aphasia.
What is a normal range for adult attention span?
15-20 minutes.
What four items are assessed in regards to orientation?
Person
Place
Time
Situation
What level of orientation is lost first?
Time (When & Where they are)
The nurse asks the patient to repeat the numbers 2, 6, 24, 60. What type of memory is the nurse assessing?
Immediate Recall
The nurse asks the patient what they had for breakfast. What type of memory is the nurse assessing?
Recent Memory/Short Term
The nurse asks the patient for their date of birth and their mothers maiden name. What type of memory is the nurse assessing?
Remote/Long Term Memory
What three sensory functions does the nurse assess?
Touch
Pain
Temperature
When is it acceptable to not assess temperature sensory function?
If pain sensation is normal, temperature does not need to be assessed.
How does the nurse assess for motor function?
- 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.
How is grip measured?
-Have patient grip your fingers. Grip should be equal and strong.
How should pupils appear? Normal measurement?
Equal in size and round, 3-7mm
How do pupils respond to light?
Constrict rapidly.
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?
Accommodation-
Close- Constricted pupils.
Far- Dialated Pupils.
What is PERLA/PERRLA?
Pupils Equal Round Reactive to Light and Accommodation.
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?
Convergence.
What diagnostic test records the brains activity in the form of electrical waves?
EEG (Electroencephalogram)
What diagnostic test uses sound waves to assess blood flow through the carotid arteries?
Carotid Ultrasound
What diagnostic procedure uses contrast to visualize the arteries of the brain?
Cerebral Angiography
What diagnostic test is able to detect tumors, emboli, and aneurysms?
Cerebral Angiography
