Week #9: Neuro Flashcards
A client’s patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding?
a) Right knee +4; left knee +3
b) Right knee +1; left knee +3
c) Right knee +2; left knee +1
d) Right knee +3; left knee +2
c) Right knee +2; left knee +1
A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. What would the nurse do?
a) Perform the Weber test
b) Use a Snellen chart to test visual acuity
c) Ask a client to identify scents
d) Test extraocular eye movements
c) Ask a client to identify scents
A client says that an object placed in the hand is a pair of scissors when the object is a paper clip. Which aspect of the client’s neurologic system should the nurse identify as being compromised?
a) Responsiveness
b) Sensory
c) Motor
d) Position sense
b) Sensory
When assessing cranial nerves IX and X, which of the following would the nurse consider as an abnormal finding?
a) Contraction of the pharyngeal muscle
b) Upward movement of the palate
c) Asymmetrical tongue movement
d) Impaired swallowing
d) Impaired swallowing
When evaluating a client’s risk for cerebrovascular accident, which client would the nurse identify as being at highest risk?
a) 68-year old African American male with hypertension
b) 35-year old African American who has sleep apnea
c) 55-year old Caucasian male who has 2 beers a week
d) 42-year old Caucasian woman who smokes
a) 68-year old African American male with hypertension
A nurse is preparing to assess a client’s cerebellar function. What aspect of neurological function should the nurse address?
a) Sensation
b) Remote memory
c) Mental status exam
d) Balance
d) Balance
As people age, several neurological changes occur. Neurons, brain size, and neurotransmitters decrease. What are some of the results of aging on the neurological system? Select all that apply.
a) Delayed reflexes
b) Reduced response to stimuli
c) Inability to process nutrients
d) More frequent seizures
e) Slower thought processing
a) Delayed reflexes
b) Reduced response to stimuli
e) Slower thought processing
Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve?
a) Have the client smile, frown, and wrinkle the forehead
b) Ask the client to differentiate sharp and dull sensations on the face
c) Palpate the temporal and masseter muscles while the client clenches teeth
d) Assess dilation of pupils with direct light
c) Palpate the temporal and masseter muscles while the client clenches teeth
Lifestyle can play a big part in developing risk factors for stroke. Which of the following can greatly reduce a client’s risk for stroke? Select all that apply.
a) Quitting smoking
b) Regularly exercising
c) Following a sedentary lifestyle
d) Maintaining a healthy weight
e) Eating a high-sodium diet
a) Quitting smoking
b) Regularly exercising
d) Maintaining a health weight
The nurse enters a client’s room to administer a prescribed anticoagulant for atrial fibrillation. The client exhibits new onset facial drooping and slurred speech. What is the nurse’s priority action?
a) Assess the client’s bleeding time before medication administration
b) Administer the PO anticoagulant immediately
c) Assess the client’s vital signs and cranial nerves
d) Ask the client to raise both arms in front of the client’s body
d) Ask the client to raise both arms in front of the client’s body
Extraocular movements (EOMs) down & in
Cranial Nerve IV (Trochlear)
Provides most parasympathetic innervation to a large region; effects include digestion, defecation, slowed heart rate, and reduced contraction strength
Cranial Nerve X (Vagus)
Extraocular movements (EOMs) lateral
Cranial Nerve VI (Abducens)
Taste and sensation for the anterior 2/3 of the tongue and soft palate; serves as the primary motor nerve for facial expression
Cranial Nerve VII (Facial)
Pharyngeal muscle elevation for swallowing & speech; parotid gland secretion; general sensory (pain, touch, temperature) function
Cranial Nerve IX (Glossopharyngeal)
Tongue movement
Cranial Nerve XII (Hypoglossal)
Extraocular movements (EOMs) upward, medial, downward, up and in; eyelid raising and pupil constriction
Cranial Nerve III (Oculomotor)
Swallowing and speaking; innervates the muscles that turn the head and elevates the shoulders (shoulder shrug)
Cranial Nerve XI (Spinal Accessory)
Smell and smell interpretation, including peristalsis, salivation, and sexual stimulation
Cranial Nerve I (Olfactory)
Ophthalmic branch: sensation to the cornea, conjunctiva, nasal mucosa, forehead, and nose
Maxillary branch: sensation to the skin of the cheek and nose, lower eyelid, upper jaw, teeth, and oral mucosa
Mandibular branch: sensation to the lower jaw and motor function to muscles of mastication
Cranial Nerve V (Trigeminal)
Hearing & equilibrium
Cranial Nerve VIII (Acoustic)
Vision, including visual acuity and peripheral vision
Cranial Nerve II (Optic)
Fibers connect the CNS with organs (including the heart and kidneys), smooth muscle, and glands in the voluntary division of the nervous system.
a) True
b) False
a) True
Increases in CSF pressure can lead to herniation of the brain and compression of the brainstem; such compression may alter respiratory function and reduce consciousness.
a) True
b) False
a) True
A patient with an injury at the thoracic area would have arm movement and sensation but no leg movement or sensation.
a) True
b) False
a) True
The 2 components of the autonomic nervous system are the parasympathetic (fight or flight) and sympathetic (rest and digest).
a) True
b) False
b) False
A patient who has a cerebrovascular accident (stroke) in the right side of the brain will have motor & sensory deficits on the ________ side of the body.
Left
Damage to Broca area causes problems with speaking or finding words. This is called ____________ aphasia.
Expressive
Clinical situations that require urgent communication of neurological assessment findings include a change in ________________, _____________ reaction, and verbal or motor response.
Consciousness; Pupillary
Please list the 12 cranial nerves (in order) and if they are sensory, motor, or both:
I. Olfactory (S)
II. Optic (S)
III. Oculomotor (M)
IV. Trochlear (M)
V. Trigeminal (B)
VI. Abducens (M)
VII. Facial (B)
VIII. Acoustic (S)
IX. Glossopharyngeal (B)
X. Vagus (B)
XI. Spinal accessory (M)
XII. Hypoglossal (M)
When muscles have absolutely no resistance to movement
Flaccid/atonic
If the tone of the muscle seems to be only decreased or “flabby”
Hypotonia
The increased resistance of the muscles to passive stretch
Hypertonia
The steady, persistent resistance to passive stretch in both flexor and extensor muscle groups
Rigidity
Unsteady, wavering movement with inability to touch the target
Ataxia
Heterogenous syndrome due to variations in the location and extent of brain damage; results in attention diversion and eye movements towards the right side
Neglect
- assess patency of nostrils
- have Pt identify scent placed near open nostril w/ other closed off
CN I (Olfactory, S)
- ask Pt to identify how many fingers you’re holding up
- use Snellen chart for far vision & near vision w/ small print
- test visual fields using confrontation
CN II (Optic, S)
- assess PERRLA, 6 cardinal positions of gaze, and observe for nystagmus
CN III (Oculomotor, M), CN IV (Trochlear, M), & CN VI (Abducens, M)
Sensory: have Pt identify sharp or dull sensations on all 3 divisions of nerve at scalp (ophthalmic), cheek (maxillary), and chin (mandibular)
Motor: Have Pt tightly clench teeth; palpate over jaw for masseter muscle symmetry; ask Pt to open jaw against resistance
CN V (Trigeminal, B)
Sensory: evaluate taste (sweet, sour, salty, bitter)
Motor: observe facial movements during conversation; ask Pt to raise eyebrows, squeeze eyes shut, wrinkle forehead, frown, smile, show teeth, purse lips, and puff out cheeks
CN VII (Facial, B)
- assess w/ whisper test
CN VIII (Acoustic, S)
Sensory: w/ CN VII
Motor: with CN X upon swallowing
CN IX (Glossopharyngeal, B)
Motor: have Pt stick tongue out and say “ah”
Sensory: stimulate gag reflex (only if problem is suspected)
CN X (Vagus, B)
- ask Pt to press against resistance on opposite side of the chin & to shrug shoulders against resistance
CN XI (Spinal accessory, M)
- evaluate w/ CN X and ask Pt to stick out tongue (observe for symmetry) & have them say “light, tight, dynamite”
CN XII (Hypoglossopharyngeal, M)
Describe the grading scale of reflexes:
4+: very brisk, hyperactive responses
3+: brisker than average
2+: normal, average, expected
1+: diminished
0: no response
The Glasgow Coma Scale (GCS) is used to assess ___, and scores on 3 categories:
- scores range from _ (deep coma) to __ (normal).
- LOC
1. verbal response
2. eye opening
3. motor function - 3; 15
the max you can score on verbal response on the GSC scale is _
5
the max you can score on eye opening on the GSC scale is _
4
the max you can score on motor function on the GSC scale is _
6
enter room & observe arousal
spontaneous (LOC)
state Pt’s name; ask them to open eyes
normal voice (LOC)
use ___ voice if no response to normal voice
loud voice (LOC)
touch patient’s shoulder or arm lightly
tactile (LOC)
apply nail bed pressure to elicit pain response, telling Pt you will be applying pressure
noxious stimulation [pain] (LOC)
involves senses (smell, hearing, touch)
sensory innervation
involves movement & function of muscles or glands
motor innervation
consists of 3 components of the brain (cerebrum, cerebellum, and brainstem) as well as the spinal cord
- controls how we think, learn, and move & feel and carries messages back & forth between the brain and nerves throughout the body
- protected by blood-brain barrier
CNS
includes all of the nerves outside the brain & spinal cord; relays messages to the rest of the body
peripheral (somatic) nervous system
maintains involuntary functions of cardiac & smooth muscles & glands
- consists of sympathetic (fight-or-flight) & parasympathetic (rest-and-digest)
ANS
