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NURS71000 > Week 4: Mental Status/Neurological Assessment > Flashcards

Week 4: Mental Status/Neurological Assessment Flashcards

1
Q

Mental Status Definition: Abstract Reasoning

A

Represents as person’s ability to solve problems, identify patterns, and work with logical systems.

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2
Q

Mental Status Definition: Affect

A

The displaying of emotions

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3
Q

Mental Status Definition: Appearance

A

Overall visual appearance including how they are dressed, their body movements and posture, their facial expressions, and their overall hygiene

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4
Q

Mental Status Definition: Attention

A

Notice take of someone or something, giving focus to something in particular

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5
Q

Mental Status Definition: Behaviour

A

The way one acts or conducts themselves

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6
Q

Mental Status Definition: Cognition

A

Level of thinking and understanding through thought, experience, and senses

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7
Q

Mental Status Definition: Consciousness

A

The state of being awake and aware of one’s surroundings

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8
Q

Mental Status Definition: Judgement

A

The ability to make considered decisions or come to sensible conclusions

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9
Q

Mental Status Definition: Memory

A

The ability to recall events that have occurred/are going to happen or recall information from various time frames (immediate, recent/24 hours, remote)

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10
Q

Mental Status Definition: Mood

A

The displaying of various emotions/feelings often influenced by events or surrounding environment

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11
Q

Mental Status Definition: Orientation

A

Knowing the relative position of something or someone, direction or physical position

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12
Q

Mental Status Definition: Perception

A

The ability to see, hear, or become aware of something through senses

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13
Q

Mental Status Definition: Thinking

A

The process of using one’s mind to consider or reason about something

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14
Q

Mental Status Definition: Thought Process

A

The accepting, processing, and analyzing of information and thoughts

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15
Q

Neurological Assessment Definition: Aphasia

A

A language disorder that affects how you communicate

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16
Q

Mental Status Definition: Ataxia

A

Poor muscle control that causes clumsy movements, balance, walking, hand coordination, speech, and swallowing.

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17
Q

Mental Status Definition: Atrophy

A

The partial or complete shrinking of a body part, organ, cell, or tissue

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18
Q

Mental Status Definition: Dysarthria

A

Difficulty forming words/slurred or slow speech

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19
Q

Mental Status Definition: Dysphagia

A

Difficulty swallowing

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20
Q

Mental Status Definition: Glascow Coma Scale

A

The scale used to describe the extent of impaired consciousness in all types of acute medical and trauma patients, ranging 3 -15, 3 being unconscious, and 15 being fully awake

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21
Q

Mental Status Definition: Muscle Paresis

A

A condition in which muscle movement has become weakened or impaired

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22
Q

Mental Status Definition: Neurological Recheck Canadian Neurological Scale

A

A simple and validated score to assess stroke severity

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23
Q

Mental Status Definition: Nystagmus

A

Back-and-forth oscillation of the eyes

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24
Q

Mental Status Definition: Paraestheia

A

Abnormal sensation such as tingling, burning

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25
Q

Mental Status Definition: Paralysis

A

Loss of motor function as a result of a lesion

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26
Q

Mental Status Definition: Paresis

A

Partial loss of muscle control or weakness in voluntary movement

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27
Q

Mental Status Definition: Ptosis

A

The drooping of the upper eyelid

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28
Q

Mental Status Definition: Romberg Sign

A

A physical exam that assesses a patient’s balance and proprioception or sense of body position and movement

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29
Q

Mental Status Definition: Seizures

A

A burst of uncontrolled electrical activity between brain cells (neurons/nerve cells) that causes temporary abnormalities in muscle tone/movements (stiffness, twitching, or limpness), behaviours, sensations, or states of awareness

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30
Q

Mental Status Definition: Strabismus

A

A condition in which your eyes don’t line up with one another

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31
Q

Mental Status Definition: Syncope

A

Fainting (lack of cerebral blood flow)

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32
Q

Mental Status Definition: Tone

A

The amount of tension in a muscle at rest or how much a muscle resists stretching; complex system involving the brain, spinal cord, and muscles

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33
Q

Mental Status Definition: Tremor

A

A neurological condition that causes shaking or trembling in the body

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34
Q

Mental Status Definition: Vertigo

A

A type of dizziness that can be caused by issues in the inner ear or brain

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35
Q

What are the 2 forms of Vertigo?

A

Subjective and Objective

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36
Q

Mental Status Definition: Subjective Vertigo

A

Feels as though self is spinning

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37
Q

Mental Status Definition: Objective Vertigo

A

Feels as though the room is spinning

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38
Q

What are the 4 domains included in the mental status assessment used to observe and describe a person’s current state of mind?

A

Appearance
Behaviour
Cognition
Thought processes and perception

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39
Q

What is Mental Status?

A

A person’s emotional and cognitive functioning

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40
Q

What do you ask for during a Mental Health Assessment regarding a health history?

A
  • Biographical information
  • Reason for seeking care
  • Past health (ex. “Have you ever experienced or witnessed anything that threatened your life or safety or the life and safety of a loved one?”)
  • Chronic illness (may contribute to mental health)
  • Family Health History (genetics)
  • Current Health
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41
Q

When do you do a Mental Status Exam?

A
  • General survey, intuition, noticing something is ‘not quite right’.
  • Subjective assessment (patient shares a change or concern with cognition or mood).
  • Changes that you or the family notices in mood, behaviour, or speech.
    Brain lesions (ex. from trauma, seizure or stroke).
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42
Q

Which of the following should be tested first in an assessment of mental status?

a) Behaviour
b) Consciousness
c) Judgement
d) Language

A

b) Consciousness

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43
Q

What sections are included in a Mental Status Exam?

A

ABCT

Appearance
Behaviour
Cognition
Thought processes and perception

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44
Q

What falls under Appearance?

A
  • Posture
  • Body movements
  • Dress
  • Grooming and Hygiene
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45
Q

What falls under Behaviour?

A
  • Level of consciousness
  • Facial expressions
  • Speech
  • Mood and Affect
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46
Q

What falls under Cognition?

A
  • Orientation (person, place, time)
  • Gnosis (common objects and uses)
  • Attention span (completion of thoughts, distractibility)
  • Immediate recall (recall what you just said)
  • Recent memory (recall last 24 hours)
  • Remote memory (recall events/the past)
  • New learning (4 unrelated words test)
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47
Q

What is Immediate Recall?

A

Repeating what you just said or recalling what just happened

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48
Q

What is Recent Memory?

A

Recalling what just happened in the last 24 hours

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49
Q

What is Remote Memory?

A

Recalling a specific moment or historical event

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50
Q

What are the steps of the Glasgow Coma Scale?

A

Check
Observe
Stimulate
Rate

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50
Q
A
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51
Q

What is the 4 new words test?

A

Telling the patient 4 unrelated words and having them recall and repeat them back to you.

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52
Q

What are Thought Processes?

A

Complete thoughts that are logical, coherent and relevant

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53
Q

What are some abnormalities in Thought Processes?

A
  • Blocking related to emotion (e.g. “I forgot what I was going to say).
  • Confabulation (fabricating events to fill memory gaps).
  • Loose associations or flight of ideas (switching from one topic to another).
  • Circumstantiality (excessive detail).
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54
Q

What is Thought Content?

A

“Is what they say consistent and logical?”

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55
Q

What are some abnormalities in Thought Content?

A
  • Phobias
  • Hyperchondria
  • Obsession (e.g. violence or contamination)
  • Compulsion (e.g. counting, handwashing, checking and rechecking)
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56
Q

What are Perceptions?

A

Is the patient aware of reality?
Is the patient’s perceptions consistent with yours?
Does the patient have any hallucinations?

57
Q

What is the Neurological System made up of?

A

Central Nervous System (CNS) and the Peripheral Nervous System (PNS)

58
Q

What makes up the CNS?

A

The brain and spinal cord

59
Q

What makes up the PNS?

A

12 pairs of cranial nerves
31 pairs of spinal nerves and their branches

60
Q

What does the PNS do?

A

Carries sensory (afferent) messages to the central nervous system (CNS).

61
Q

What are Afferent messages?

A

Messages being carried to the brain

62
Q

What does the CNS do?

A

Send messages out to the muscles and glands, and autonomic messages that direct the internal organs and blood vessels

63
Q

What are Efferent messages?

A

Messages being carried from the brain to the muscles/body

64
Q

What protects the CNS?

A

The 3 meninges (dura mater, arachnoid mater, pia mater) and cerebral spinal fluid (CSF)

65
Q

What are the 3 meninges?

A

Dura mater
Arachnoid mater
Pia mater

66
Q

hat lobe is responsible for personality, behaviour, emotion and intellectual functions?

A

Frontal lobe

67
Q

What lobe is responsible for hearing, taste, and smell?

A

Temporal lobe

68
Q

What lobe is responsible for visual reception?

A

Occipital lobe

69
Q

What lobe is responsible primarily for sensation?

A

Parietal lobe

70
Q

If someone has RECEPTIVE aphasia, what does it mean?

A

They can hear sound but it has no meaning, like a foreign language

71
Q

With RECEPTIVE aphasia there is a problem with what area?

A

Wernicke’s Area

72
Q

If someone has EXPRESSIVE aphasia, what does it mean?

A

Person can understand, hear, and knows what they want to say but can’t speak (only garbled response)

73
Q

With EXPRESSIVE aphasia, there is a problem with what area?

A

Broca’s Area

74
Q

What 3 vital signs are the Hypothalamus responsible for?

A

Heart Rate (HR)
Temperature (T)
Blood Pressure (BP)

75
Q

What is responsible for motor coordination, equilibrium and muscle tone?

A

Cerebellum

76
Q

What are the 3 areas of the brainstem (nerve fibres)?

A

Midbrain
Pons
Medulla

77
Q

Which cranial nerve is responsible for talking and swallowing?

A

Vagus nerve (X)

78
Q

Which cranial nerve is responsible for hearing and equilibrium?

A

Acoustic (VIII)

79
Q

In a Neurological Assessment, what do we want to include in a screening assessment?

A
  1. Subjective assessment
  2. LOC/orientation (cognition)
  3. Cranial nerves
  4. Brief motor inspection
  5. Cerebellum: balance, coordination, skilled movement
  6. Canadian Neurological Assessment (specific to stroke)
80
Q

What is Syncope?

A

Fainting (lack of cerebral blood flow)

81
Q

What is Dysphagia?

A

Difficulty swallowing

82
Q

What is Paraesthesia?

A

Abnormal sensation such as tingling, burning

83
Q

What is Paralysis?

A

Loss of motor function as a result of a lesion

84
Q

What is Subjective Vertigo?

A

Feels as though self is spinning

85
Q

What is Nystagmus?

A

Back-and-forth oscillation of the eyes.

86
Q

What is Objective Vertigo?

A

Feels as though the room is spinning

87
Q

What is Paresis?

A

Partial loss of muscle control or weakness in voluntary movement

88
Q

What is Dysarthria?

A

Difficulty forming words/slurred or slow speech

89
Q

What is Postictal State?

A

Period following a seizure

90
Q

What is Dysphasia?

A

Difficulty with language comprehension and/or expression

91
Q

What is Aura?

A

Sensation that comes before a seizure

92
Q

What is Neurogenic Anosmia?

A

Neurologically cause loss of smell

93
Q

What is Dysmetria?

A

Lack of coordination of movements

94
Q

What is the acronym for the 12 cranial nerves?

A

OOOTTAFVGVAH

On
Occasion
Our
Trusty
Truck
Acts
Funny
Very
Good
Vehicle
Any
How

95
Q

What is the acronym for the FUNCTION of the 12 cranial nerves?

A

S = Sensory
M = Motor
B = Both

OOOTTAFVGVAH
SSMBMBSBBMM

Some
Say
Marry
Money
But
My
Brother
Says
Big
Brains
Matter
More

96
Q

What is Cranial Nerve (I)?

97
Q

What is Cranial Nerve (II)?

98
Q

What is Cranial Nerve (III, IV, & VI)?

A

Oclulomotor
Trochlear
Abducens

99
Q

What is Cranial Nerve (V)?

A

Trigeminal

100
Q

What is Cranial Nerve (VII)?

101
Q

What is Cranial Nerve (VIII)?

A

Acoustic (vestibulocochlear)

102
Q

What is Cranial Nerve (IX & X)?

A

Glossopharyngeal
Vagus

103
Q

What is Cranial Nerve (XI)?

A

Spinal accessory

104
Q

What is Cranial Nerve (XII)?

A

Hypoglossal

105
Q

How do you test Cranial Nerve:
Olfactory (I)?

A
  • Use familiar smells on both sides of nose
106
Q

How do you test Cranial Nerve:
Optic (II)?

A
  • Test visual acuity and test visual fields
  • Can use Snellen Eye Chart
  • Recognition of objects
  • Confrontation Test- to test peripheral visual fields
107
Q

How do you test Cranial Nerves:
Oculomotor (III), Trochlear (IV), & Abducens (VI)?

A
  • Check pupils for size, equality, consensual light reaction and accommodation
  • Assess extra ocular movements (changing positions of gaze) ex. Follow my finger
  • 6 Cardinal positions of gaze – client holds head still and follows an object such as finger or pen through several directions (ie. H pattern)
108
Q

How do you test Cranial Nerve:
Trigeminal Nerve (V)?

A
  • Palpate muscles of mastication (temporal and mastoid muscles)
  • Lightly touch patients face (sensation in face to light touch in three branches- forehead, cheeks and jaw). “Say Now”
  • Push down on chin, try to separate jaws
109
Q

How do you test Cranial Nerve:
Facial Nerve (VII)?

A
  • Ask them to smile, frown, note symmetry
  • Ask to show teeth, puff cheeks
  • Ask to clench teeth
110
Q

How do you test Cranial Nerve:
Acoustic Nerve (VIII)?

A

Whispered voice or quiet noise (whisper 2-syllable words behind the patient)

111
Q

How do you test Cranial Nerves:
Glossopharyngeal (IX) & Vagus Nerves (X)?

A
  • Use tongue depressor and note pharyngeal movement as patient says “ahh“
  • Observes talking and swallowing
112
Q

How do you test Cranial Nerve:
Spinal Accessory Nerve (XI)?

A
  • Examine sternomastoid and trapezius muscles, apply resistance when rotating head
  • Ask patient to shrug shoulders against resistance
113
Q

How do you test Cranial Nerve:
Hypoglossal Nerve (XII)?

A
  • Inspect the tongue
  • Ask the patient to say “light, tight, dynamite”
114
Q

How do you test the Cerebellar Function?

A
  • Balance tests such as gait, Tandem walking, Romberg test, and Shallow Knee bend.
  • Coordination and skilled movements such as rapid alternating movements, finger-finger, finger-nose, heel-shin tests.
114
Q

How do you test the Motor System?

A

Inspect and palpate muscles for size, strength, tone, and involuntary movements

115
Q

How do you test Gait?

A

Observe as patient walks 3 to 6m and turns and returns to starting point

116
Q

What is Tandem walking?

A

Walk a straight line in a heel-to-toe manner

117
Q

What would be abnormal findings in Gait?

A

Stiffness, ataxia (unsteadiness), lack of arm swing, unequal rhythm, wide base of support

118
Q

What is the Romberg Test?

A

Ask patient to stand up with feet together and arms at sides and ask pt to close eyes and hold the position (20-30 sec)

119
Q

Canadian Neurological Scale:
What is included in Mentation?

A

LOC
Orientation
Speech

120
Q

Canadian Neurological Scale:
What is included in Motor Functions for Weakness?

A

*Weakness
Face
Arms (proximal and distal)
Legs (proximal and distal)

121
Q

Canadian Neurological Scale:
What is included in Motor Function for Response?

A

*Response
Face
Arms
Legs

122
Q

What are the three neurological functions assessed by the Glasgow coma scale?

A

Eye response
Best motor response
Best verbal response

123
Q

What is the scaling of the Glasgow Coma Scale?

A

3 (severe brain injury) to 15 (normal brain activity)

124
Q

At what score on the Glasgow Coma Scale do you intubate?

A

Score of 8
“If its 8, intubate”

125
Q

The Glasgow Coma Scale (GCS) measures the level of consciousness in clients who are at high risk for rapid deterioration of the nervous system. A score of 13 indicates:

a) Deep coma
b) Severe impairment
c) No verbal response
d) Mild impairment

A

d) Mild impairment

126
Q

What does PERRLA stand for?

A

Pupils
Equal
Round
Reactive
Light Accommodation

127
Q

What does Pupils mean in PERRLA?

A

Control how much light enters the eye by shrinking and widening.

128
Q

What does Equal mean in PERRLA?

A

Same size, shape

129
Q

What does Round mean in PERRLA?

A

Look for unusual shape or borders

130
Q

What does Reactive mean in PERRLA?

A

Direct and consensual

131
Q

What does Light Accommodation mean in PERRLA?

A

Eyes adjust according to distance of object

132
Q

True or False: Increased Intracranial Pressure (IICP) presents with symptoms opposite to shock.

133
Q

What are signs of IICP?

A

Increased BP
Decreased HR
Decreased RR

** Also known as the Cushings Triad

134
Q

What are the signs of Shock?

A

Decreased BP
Increased HR
Increased RR

135
Q

What is the Trigeminal Nerve (V) responsible for in infants?

A

Rooting, sucking reflex

136
Q

What is the Facial Nerve (VII) responsible for in infants?

A

Wrinkling forehead when crying

137
Q

What is the Acoustic Nerve (VIII) responsible for in infants?

A

Eyes follow direction of sound

138
Q

What is the Glossopharyngeal & Vagus Nerves (IV & X) responsible for in infants?

A

Infant’s nose pinched, mouth opens, tongue rises in midline

139
Q

What is the Hypoglossal Nerve (XII) responsible for in infants?

A

Gag reflex

NURS71000 (5 decks)

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