Neurological Assessment

Question 1

a. Onset

It’s important to determine what ?

Answer 1

When the symptoms started

Question 2

a. Onset

Ask: ?

Answer 2

When was the onset and what symptoms did the client have initially

Question 3

b. Description of symptoms

What do you want to have the client describe ?

Answer 3

• Location
• How long the symptoms have persisted (Duration)
• How severe

(Ex: a Headache)

Question 4

c. Associated factors

What do you want to determine ?

Answer 4

If there were any triggers or aggravating factors associated with the symptoms

Question 5

c. Associated factors

Ask: ?

Answer 5

Did anything help relieve the symptoms ?

Question 6

d. Overall appearance

What do you want to note ?

Answer 6

The clients general appearance and behavior

Question 7

d. Overall apperance

What do you want to observe for ?

Answer 7

Any obvious signs of neurological deficit

Ex: slurred speech

Question 8

What is the most important aspect of a Neuro exam ?

Answer 8

Assessment of the client’s mental status, including LOC

Question 9

What makes up a persons Mental status ?

Answer 9

• Awareness of surroundings and alertness
• Orientation to person, place, and time
• Memory: both short and long term

Question 10

What is the most sensitive indicator of neuro status ?

Answer 10

LOC

Question 11

What may be the first sign that there is a problem ?

Answer 11

A change in LOC

Question 12

What is the Glasgow Coma Scale used for ?

Answer 12

Used to assess the LOC in a client who already has altered consciousness or has the potential of altered consciousness

(from trauma)

Question 13

Where is the Glasgow Coma Scale primarily used ?

Answer 13

In the ED or ICU

Question 14

What is the Glasgow Coma Scale Definition ?

Answer 14

A scale that measures the degree of LOC

Question 15

What are the 3 responses of the Glasgow Coma Scale ?

Answer 15

• Eye opening
• Motor response
• Verbal response

Question 16

What numbers do we like to see on the Glasgow Coma Scale ?

Answer 16

High numbers! (ranging from 13 to 15)

Question 17

What is the best score on the Glasgow Coma Scale ?

Answer 17

15

Question 18

________ is always #1 with neurological assessment ?

Answer 18

LOC

Question 19

What are the responses on the Glasgow Coma Scale for Eye Opening ?

Answer 19

• Spontaneous (4)
• To verbal command (3)
• To pain (2)
• No response (1)

Question 20

What are the responses on the Glasgow Coma Scale for Motor Response ?

Answer 20

• To verbal command (6)
• To localized pain (5)
• Flexed/withdraws (4)
• Flexes abnormally (3)
• Extends abnormally (2)
• No response (1)

Question 21

What are the responses on the Glasgow Coma Scale for Verbal Response ?

Answer 21

• Oriented/talks (5)
• Disoriented/talks (4)
• Inappropriate words (3)
• Incomprehensible sounds (2)
• No response (1)

Question 22

What is normal pupil size ?

Answer 22

2-6mm

Question 23

What does PERRLA stand for ?

Answer 23

Pupils
Equal
Round
Reactive
Light
Accomidating

Question 24

What do you want to assess for regarding hand grips, leg lifts, and pushing strength of the feet ?

Answer 24

Assess for strength and equality & if the client will follow command

Question 25

The Babinski reflex is normal in who ?

• when should it not longer be present ?

Answer 25

Normal in an Infant up to 1 year

• When babies begin walking

Question 26

The Babinski reflex should be abnormal in who ?

Answer 26

Adults

Question 27

The adult or child greater than 1 year should have a normal curling reflex or ?

Answer 27

Curling of the toes when the bottom of the foot is stroked (plantar reflex)

Question 28

What does it mean if the adult has a Babinski reflex or fanning of the toes when you stroke the bottom of the foot ?

• Possible causes ?

Answer 28

There is a severe problem in the Central Nervous system that is affecting the upper motor neuron

• Tumor or lesion on the brain or spinal cord, meningitis, MS, Lou Gehrig’s disease