Neuro Assessment

Question 1

The evaluation of the health status of a client with a neurologic disorder or dysfunction

Answer 1

Neurological System Assessment

Question 2

To obtain a _______ on the client’s neurological status abilities.
2. To _____, ___, and _____ data obtained in the nursing history.
3. To obtain data that will help _______ and plan of care.
4. To evaluate the ________ of health care and thus the progress of a client’s health.
5. To make ________about a client’s health status.
6. To identify areas for ______ and _____

Answer 2

To obtain a baseline data on the client’s neurological status abilities.
2. To supplement, confirm, or refute data obtained in the nursing history.
3. To obtain data that will help establish nursing diagnoses and plan of care.
4. To evaluate the physiologic outcomes of health care and thus the progress of a client’s health.
5. To make clinical judgments about a client’s health status.
6. To identify areas for health promotion and disease prevention.

Question 3

what are the equipments used in neuro assessment

Clue: ENTSPTT COPOSSR

Answer 3

Examination gloves
Newspaper
Tape Measure
Snellen Chart
Penlight
Tuning Fork
Tongue depressor
Cotton-tipped applicators
Ophthalmoscope
Paper clip
Objects to feel
Sterile cotton ball
Substances to smell
Reflex hammer

Question 4

Prior to performing the Neuro assessment Procedure, what should be done first and arrange in order

(Provide Client Privacy, Explain/ Discuss to client procedure, Introduce self, Perform Hand Hygiene, ask Client identity)

Answer 4

1. Introduce Self
2. Ask client Identity
   3.Explain/Discuss to client procedure
   4.Perform Hand hygiene and other prevention protocol
3. Provide Client Privacy

Question 5

2 Types of Assessing the Neurological System

Answer 5

1. Assess Level of Consciousness and Orientation
2. Assess CNs (Cranial Nerves)

Question 6

Type of Assessing Neuro System

“by asking client to identify name, location, day of the week, and year, note behavior and appearance.”

Answer 6

Assessing LOC and Orientation

Question 7

Rationale for assessing Loc and Orientation

Answer 7

To determine spontaneity of responses to questions

Question 8

For all assessments of the cranial nerves, have client ____ in a comfortable position at your ___ level.

Answer 8

sit, eye level

Question 9

What are the 12 Cranial Nerves

Answer 9

Olfactory, Optic Oculomotor, Trochlear, Abducens, Trigeminal, Facial, Acoustic/Vestibulocochlear, Glossopharyngeal, Vagus, Spinal Accessory, Hypoglossal

Question 10

What CNs Assessment and fill out the blank

To identify the ___ or ____ of the sense of smell

Answer 10

Olfactory (I)

absence & presence

Question 11

In Assessing Optic (II), what is used to assess the DISTANT VISION

Answer 11

Snellen Chart

Question 12

In assessing the visual fields in Optic, what should u do

Answer 12

Confrontation

Question 13

what should the Client Read during optic Assessment

Answer 13

Newspaper or Magazine

Question 14

Rationale for Optic (II)

Answer 14

To measure central (convergence) and peripheral vision

Question 15

In Oculomotor (III)/Trochlear (IV)/Abducens (VI)

A. Inspect margins of the ____
B. Assess ____ movements
C. Assess ______ response to light and ____ in both eyes

Answer 15

A. Inspect margins of the eyelids
B. Assess Extraocular Movements
C.Assess pupillary response to light and accommodation in both eyes

Question 16

Rationale for

Oculomotor (III)/Trochlear (IV)/Abducens (VI)
A. Inspect margins of eyelid
B. Assess extraocular movements

Answer 16

To determine parallel eye movement

Question 17

Two Test Function for Trigeminal (V)

Answer 17

Test Motor Function
Test Sensory Function

Question 18

In Trigeminal (V), what kind of Test Function and fill out the blank

ask client to clench teeth while you ___ the —- and ___ muscles for contraction

Answer 18

Test Motor Function

ask client to clench teeth while you palpate the temporal and masseter muscles for contraction

Question 19

in Trigeminal (V), Rationale for test motor Function

To determine_____ of muscles

Answer 19

To determine bilateral contraction of muscles

Question 20

What Equipment is used for Test Sensory Function in Assessing the Trigeminal Cranial Nerve?

Answer 20

Paper Clip

Question 21

What Cranial Nerve Assessment is this?

Ask client to smile, frown, wrinkle forehead, show teeth, puff out cheeks, purse lips, raise eyebrows, and close eyes tightly against resistance

Answer 21

Facial (VII)

Question 22

What is the Rationale of the test sensory function of the Trigeminal Cranial Nerve Assessment

• To determine ___ of the trigeminal nerve and ___ tract*

Answer 22

To determine lesions of the trigeminal nerve and spinothalamic tract

Question 23

Rationale for Facial (VII) Cranial Nerve Assessment

To determine for ___ facial movement and central —- on the upper ____ neurons

Answer 23

To determine for symmetric facial movement and central lesionon the upper motor neurons

Question 24

3 Kinds of test for Acoustic/Vestibulocochlear (VIII)

Answer 24

A. Testhearingability
B. PerformWebertest
C. Perform Rinne test

Question 25

Rationale for Acoustic/Vestibulocochlear (VIII) To determine g___ H___ A____

Answer 25

To determine **gross hearing acuity**

Question 26

What kind of Cranial Nerve Assessment and Fill out the Blank A. Test ___ function: ask client to open mouth wide and say “ah” while using ____ on client’s tongue B. Test ___ reflex C. Check ability to ____

Answer 26

Glossopharyngeal (IX), Vagus (X) A. Test motor function: ask client to open mouth wide and say “ah” while using tongue depressor on client’s tongue B. Test gag reflex C. Check ability to swallow

Question 27

Rationale for Acoustic/Vestibulocochlear To check for presence of protective reflexes such as -, -, or -

Answer 27

To check for presence of protective reflexes such as gagging, coughing, or swallowing

Question 28

What kind of Cranial Nerve Assessment and fill out blank A. _____ against resistance B.______ against resistance

Answer 28

Spinal Accesory (XI) A. Shrug shoulders against resistance B. Turn the head against resistance

Question 29

Rationale for Spinal Accessory (XI) Cranial Nerve Assessment Clue: (*fill out blank*) To check for ___ and ____ of contractions of ___ and ___ muscle

Answer 29

To check for *smoothness and strength* of contractions of **sternocleidomastoid** and **trapezius** muscle

Question 30

What Cranial Nerve is this? And fill out the blank Ask the client to ___ tongue, move it to side against resistance of a ____ and then put it back in the mouth

Answer 30

Hypoglossal XII Ask the client to protrude tongue, move it to side against resistance of a tongue depressor, and then put it back in the mouth

Question 31

Equipment used for Hypoglossal (XII) Assessment

Answer 31

Tongue Depressor

Question 32

Rationale for Hypoglossal (XII) To assess the ____ and ___ of the tongue

Answer 32

To assess the strength and mobility of the tongue

Question 33

In assessing the extremities for sensation a nurse must perform all sensory testing with client’s eyes _______ so he/she is unable to see when or where the stimulus strikes the skin. It is done through: _____, ______, ______

Answer 33

closed Pain, light touch, sensitivity to position

Question 34

a. Pain: Use the blunt and sharp ends of a ______ or _______ to skin surface. Apply in symmetrical areas of extremities.

Answer 34

safety pin paper clip

Question 35

b. Light touch: use a wisp of _______ to different points along a surface of skin in symmetrical areas of extremities.

Answer 35

cotton

Question 36

___________: Ask client to close both eyes. Then grasp finger or toe, holding it by its sides with your thumb and index finger. Move part alterately up and own. Ask client to tell you the direction it moved. Repeat with toes.

Answer 36

Sensitivity to position

Question 37

How to test the motor and cerebellar function

Answer 37

Gait Romberg’s test

Question 38

Have a client walk across, tum and comeback (e.g. heel to toe, on their toes, on their heels)

Answer 38

Gait:

Question 39

__________: have a client stand with feet together, arms at sides, both eyes open and eyes closed (for 20 - 30 sec). Protect client's safety by standing at the side; observed for swaying.

Answer 39

b. Romberg's test

Question 40

In Assessing **Deep tendon Reflex**, what is the **first** step you should do? A. Introduce Self B. Provide Privacy C. Obtain Equipment Needed D. Explain each test to your patient

Answer 40

C. Obtain Equipment Needed

Question 41

In assessing the superficial reflex of the Abdomen, patient must lie on the bed in________ position and legs should be ________ at the knees.

Answer 41

supine slightly flexed

Question 42

In abdominal superficial reflex assessment, Normally the umbilicus will _______ and toward the area being touched. If your patient has an upper or lower _______, his abdominal reflex may be absent.

Answer 42

move up neuron disturbance

Question 43

In **Assessing Deep Tendon Reflex** ***WHY*** should you explain each test to your patient and ***WHY*** should you *encourage* him to relax each part of his body as you test it?

Answer 43

For a **Valid Finding** , this include a ***Relaxed Patient*** proper use of reflex hammer, proper positioning of the extremity and a **relaxed** patient. **DO NOT** FORGET THE ***RELAXED*** PATIENT

Question 44

During the abdominal superficial reflex assessment, it is expected that the umbilicus will move _____

Answer 44

Down

Question 45

During the plantar reflex assessment, If everything is okay, his toes will curl ________.

Answer 45

downward

Question 46

Dorsiflexion of the _______ and fanning of the other toes (Babinski sign) is an abnormal response.

Answer 46

great toe

Question 47

If your patient is male, you will need to test the _______ Gently draw the stick down the upper portion of his right ______ thigh.

Answer 47

cremasteric reflex. inner

Question 48

Expect cremasteric muscle to ______ and the right testicle to _______ slightly.

Answer 48

contract rise

Question 49

what are the **five** reflexes in assessing the Deep Tendon Reflex

Answer 49

Bicep Reflex Tricep Reflex Brachioradialis Reflex Patellar Reflex Achilles Tendon Reflex

Question 50

Absence of cremasteric reflex may be present in upper and lower motor _______

Answer 50

neuron disturbance.

Question 51

In Corneal reflex It is tested carefully using a clean wisp of ______. Lightly touch the outer corner of each eye on the ______.

Answer 51

cotton sclera

Question 52

In Assessing your patient’s deep tendon reflexes: **Biceps Reflex** Why should you Slightly flex pt's right elbow?

Answer 52

To allow it to swing freely

Question 53

Condition such as _______ or ______ might result in loss of corneal reflex, either unilaterally or bilaterally

Answer 53

CVA coma

Question 54

What Equipment is used when assessing the deep tendon reflex?

Answer 54

Reflex Hammer

Question 55

e.__________ This is elicited by gently touching the back of the pharynx with a cotton-tipped applicator

Answer 55

Gag or Swallowing Reflex

Question 56

For the **Bicep Reflex** 2. Then, with your ____ pressed ____ against his biceps muscle tendon, hold your patient’s ___. 3. Keeping the reflex hammer held ____ between your ___ and ___, strike your ____. 4. Repeat the test on your patient’s left bicep

Answer 56

2. Then, with your **thumb** pressed **firmly** against his biceps muscle tendon, hold your patient’s **elbow.** 3. Keeping the reflex hammer held **loosely** between your **thumb and fingers** , **strike** your **thumb** 4. Repeat the test on your patient’s left bicep

Question 57

During gag reflex, a positive response is an equal elevation of the ______ and “gag” with _______. Absent response on one or both side can be seen following a CVA and requires careful evaluation

Answer 57

uvula stimulation

Question 58

In assessing the Bicep Reflex, what rationale is for this? Then, with your thumb pressed firmly against his biceps muscle tendon, hold your patient’s elbow. Keeping the reflex hammer held loosely between your thumb and fingers, strike your thumb. Repeat the test on your patient’ s left bicep

Answer 58

Expect your patient’s biceps muscle to contract, flexing his arms at the elbow

Question 59

For **Tricep Reflex**, To do this, have pt __ his arm at the elbow. Then, hold his arm at the wrist. With the reflex hammer, strike the triceps tendon ___ over his elbow. Repeat the test on the other elbow.

Answer 59

To do this, have pt **flex** his arm at the elbow. Then, hold his arm at the wrist. With the reflex hammer, strike the triceps tendon **directly** over his elbow. Repeat the test on the other elbow.

Question 60

Choose the Correct Letter A. Flexing or B. Extending In Bicep Reflex, Expect your patient’s Biceps muscle to contract, ___ his arms at the elbow In Tricep Reflex, Expect your patient’s Triceps muscle to contract, ___ his arms at the elbow

Answer 60

In Bicep Reflex, Expect your patient’s Biceps muscle to contract, **FLEXING** his arms at the elbow In Tricep Reflex, Expect your patient’s Triceps muscle to contract, **EXTENDING** his arms at the elbow

Question 61

In **Brachioradialis Reflex** 1. Have pt ___ his forearm on his ___. His palm should be facing ____.

Answer 61

rest, lap, down

Question 62

when assessing the brachioeadialis, when striking the **radius**, should the palm turn upward or downward?

Answer 62

upward

Question 63

the radius is located ____ the wrist

Answer 63

1”-2” above the wrist

Question 64

In Patellar Reflex, what should you expect to see to the knee when striking the patellar tendon?

Answer 64

Knee Extension, his knee to swing forward

Question 65

In the Patellar Reflex, where is the Patellar tendon Located? Below or Above the Patella?

Answer 65

Below the Patella

Question 66

In Achilles Tendon Reflex, if the Relaxation period is slowed, what should you suspect?

Answer 66

Hypothyroidism

Question 67

In achilles Tendon Reflex, Hold your patient’s Right foot with you__ (left or right) hand Gently Rotate his foot ___ (outward or inward)

Answer 67

Left, Outward

Question 68

When Striking the Achilless Tendon, what flexion should you watch on his ankle? What should you Observe after the contraction?

Answer 68

Plantar Flexion, Obserbe quickly the Muscle **relaxes** after contraction