Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

NUR1114 Nursing > 📝 Neurological Assessment > Flashcards

📝 Neurological Assessment Flashcards

1
Q

What are key focus areas in a neurological health history interview?

A

Headache, head injury, dizziness and vertigo, seizures, muscle control, senses, speech, memory, and cognition.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What three large areas of the brain are involved in regulating consciousness?

A

The reticular formation, the thalamus, and the cortex.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are some causes of altered levels of consciousness?

A

Coma, substance abuse, confusion, certain medications, delirium, epilepsy, disorientation, low blood sugar, lethargy, stroke, and hypoxaemia.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the most widely recognised assessment tool of the level of consciousness?

A

The Glasgow Coma Scale (GCS).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are the components of the Glasgow Coma Scale?

A

Eye opening, best verbal response, and best motor response.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

How do you assess peripheral pain using the Glasgow Coma Scale?

A

Options include nail bed pressure and inter-phalangeal joint pressure.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What indicates normal pupillary function?

A

Pupils should be round, central, equal in size, and reactive to light.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are some preparatory steps before commencing a neurological assessment?

A

Understanding the patient’s condition, considering personal preferences, ensuring gender appropriateness, cultural and linguistic considerations, family involvement, using functional equipment, and correct documentation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What physiological parameters might be impacted by neurological injury?

A

Hypotension, hypertension, dysrhythmias, tachypnoea, temperature alterations, and hypoxia.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is the purpose of a FAST assessment?

A

To quickly identify signs of a stroke: Facial drooping, Arm weakness, Speech difficulties, and Time to call emergency services.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are the fundamental processes involved in the physiology of pain?

A

Transduction, transmission, perception, and modulation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

How does the body modulate pain?

A

Through the activation of descending neural pathways that inhibit pain transmission, using substances like endogenous opioids.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What distinguishes nociceptive pain from other types of pain?

A

It is the pain sensed by the nociceptors after tissue injury or inflammation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

How is acute pain different from chronic pain?

A

Acute pain has a sudden onset and is short-term, while chronic pain is constant, lasting for more than 3 to 6 months.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What myths about pain in adults and children should nurses and midwives be aware of?

A

For example, the myth that people with severe tissue damage always experience significant pain, or the misconception that infants and children do not feel pain.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are the components of a comprehensive pain assessment?

A

Verbalisation, duration, location, frequency, intensity, type, alleviating factors, physiological and behavioural responses, and referred pain.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are some physiological indicators of acute pain?

A

Elevated blood pressure, increased pulse rate, high respiratory rate, pallor, perspiration, and dilated pupils.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are common behavioral responses indicating pain?

A

Grimacing, clenched teeth, muscle tension, restlessness, and protection of the injured part.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is referred pain, and how is it significant in assessment?

A

Pain perceived at a location other than the site of the painful stimulus, significant for diagnosing underlying conditions.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are barriers to effective pain assessment and management?

A

Nurse and midwife beliefs, prescriber practices, patient and family influences, cost, legal concerns, tolerance, physical dependence, and fear of addiction.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What mnemonic can be used for pain assessment and what does it stand for?

A

SOCRATES: Site, Onset, Character, Radiation, Alleviating factors, Timing, Exacerbating factors, Severity.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is the significance of the Glasgow Coma Scale (GCS) score in neurological assessment?

A

The GCS score helps in quantifying the level of consciousness and guiding clinical decision-making for patients with neurological injuries.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

How can nurses assess cranial nerve function as part of the neurological assessment?

A

Through specific tests for each of the 12 cranial nerves, evaluating functions such as smell, vision, eye movement, facial sensation, facial expression, hearing, and swallowing.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What respiratory patterns may indicate brainstem dysfunction or injury?

A

Abnormal patterns such as Cheyne-Stokes respiration, central neurogenic hyperventilation, apneusis, cluster breathing, ataxic breathing, bradypnoea, and tachypnoea.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Why is monitoring pupillary function important in neurological assessment?
Changes in pupil size, shape, or reactivity can indicate changes in intracranial pressure or damage to neurological pathways.
26
How does altered level of consciousness affect vital signs?
It can lead to hypertension or hypotension, dysrhythmias, irregular respirations, temperature regulation issues, and hypoxia, signaling neurological deterioration.
27
What does the AVPU scale stand for, and how is it used?
Alert, Voice responsive, Pain responsive, Unresponsive. It's a quick way to assess a patient's level of consciousness.
28
In what ways do nurses and midwives assess pain in different contexts, such as in nursing and midwifery?
By understanding the subjective nature of pain, using validated assessment tools, considering the physiological and behavioral signs of pain, and accounting for individual differences in pain perception and expression.
29
What role does the family play in the assessment of pain and neurological status?
Families can provide valuable information about the patient's normal status, changes in behavior, and responses to pain, especially in patients who cannot communicate effectively.
30
How can neurological injuries impact a patient's respiratory patterns, and what are the implications for nursing care?
Neurological injuries can lead to abnormal respiratory patterns, indicating the level of brainstem function or injury. Nurses must monitor these patterns to detect deterioration and manage airway and breathing effectively.
31
What are examples of central and peripheral methods to assess pain response in unconscious patients?
Central methods include sternal rub and trapezius squeeze; peripheral methods include nail bed pressure and inter-phalangeal joint pressure.
32
How does the concept of pain threshold and tolerance impact the assessment and management of pain?
Since individuals have varying thresholds for perceiving pain and different tolerances for enduring pain, personalized pain management strategies are necessary.
33
What are the implications of misconceptions about pain in clinical practice?
Misconceptions can lead to underassessment and undertreatment of pain, affecting patient recovery, satisfaction, and quality of life.
34
Why is it important to consider both physiological and behavioral indicators in pain assessment?
Because pain is a subjective experience, physiological indicators (like vital signs) and behavioral responses provide a more comprehensive understanding of the patient's pain level.
35
What challenges do nurses face in managing pain for patients with dementia or cognitive impairments?
Difficulties in communication make it challenging to accurately assess pain, requiring reliance on non-verbal cues and potentially leading to under-treatment of pain.
36
How do acute and chronic pain differ in their physiological and psychological impacts on patients?
Acute pain often has a clear physiological cause and resolves with healing, while chronic pain persists beyond normal healing, leading to long-term physical and psychological impacts.
37
What strategies can be employed to overcome barriers to effective pain management?
Education of healthcare professionals and patients, development of institutional policies supporting pain management, and use of multidisciplinary approaches can help overcome barriers.
38
How does the assessment of pain in children differ from adults, and what considerations should be taken?
Children may express pain differently than adults, requiring age-appropriate assessment tools and attention to non-verbal cues for accurate pain assessment.
39
In the context of a neurological assessment, why is it critical to perform a systematic assessment including GCS, pupillary function, and limb strength?
A systematic approach ensures no aspect of neurological function is overlooked, allowing for early detection of deterioration or improvement, guiding treatment decisions.
40
Discuss the importance of cultural and linguistic considerations in conducting a neurological assessment.
Cultural and linguistic differences can significantly impact the neurological assessment process, including the interpretation of symptoms, pain expression, and responsiveness. Understanding and respecting these differences ensure accurate assessment and effective communication. Healthcare professionals must be aware of cultural nuances related to expressions of illness and pain, use interpreters when necessary, and adapt assessment tools to be culturally sensitive, ensuring that all patients receive equitable and effective care.
41
41. How does the nursing process facilitate a systematic approach to neurological assessment
- The nursing process—assessment, diagnosis, planning, implementation, and evaluation—provides a structured framework for nurses to conduct a comprehensive neurological assessment, develop care plans based on identified needs, implement interventions, and evaluate patient outcomes, allowing for adjustments as needed.
42
What role do physiological indicators play in the assessment of chronic pain, and how might they differ from acute pain indicators?
In chronic pain, physiological indicators such as blood pressure and heart rate may not show the same acute responses as seen in acute pain, due to the body's adaptation over time. Nurses must rely more on patient reports, behavior observations, and the impact of pain on daily activities to assess chronic pain.
43
Why is it essential to include both objective and subjective data in a neurological assessment?
Including both objective data (like vital signs, GCS scores, and neurological exam findings) and subjective data (patient-reported symptoms and pain levels) provides a comprehensive understanding of the patient's neurological status, enhancing the accuracy of the assessment and effectiveness of subsequent care.
44
What are the implications of not accurately assessing pain in the nursing and midwifery context?
Inaccurate pain assessment can lead to under-treatment or over-treatment of pain, affecting patient recovery, satisfaction, and overall well-being. In nursing and midwifery, this can impact maternal and neonatal outcomes, delay recovery, increase the risk of complications, and negatively affect the patient-care provider relationship.
45
How does the assessment of neurological status inform the care planning process for patients with neurological injuries?
The assessment of neurological status helps identify specific deficits and functional impairments, guiding the development of individualized care plans aimed at maximizing recovery, preventing complications, and supporting adaptation to any lasting impairments.
46
What strategies can healthcare providers use to improve communication about pain with patients who have language barriers or cognitive impairments?
Strategies include using interpreters, employing visual aids or pain scales adapted for cognitive impairments, observing non-verbal cues, involving family members, and using technology-assisted communication tools to enhance understanding and accurately assess pain.
47
Discuss the role of interdisciplinary teams in managing neurological conditions and pain.
Interdisciplinary teams, including physicians, nurses, therapists, pharmacists, and social workers, play a crucial role in managing neurological conditions and pain by offering comprehensive care that addresses the physical, psychological, and social aspects of patient care, ensuring a coordinated approach to treatment and rehabilitation.
48
How does understanding the pathophysiology of neurological conditions enhance the effectiveness of the nursing assessment?
Understanding the underlying pathophysiology of neurological conditions allows nurses to recognize clinical manifestations, anticipate potential complications, and implement targeted interventions, improving patient outcomes through early detection and appropriate management.
49
What considerations should be taken into account when assessing pain in elderly patients?
Considerations include the presence of multiple comorbidities, altered pain perception, cognitive impairments, communication barriers, and the potential for polypharmacy, requiring careful assessment and tailored pain management strategies to meet the unique needs of elderly patients.
50
How do ethical considerations influence the approach to neurological assessment and pain management?
Ethical considerations, such as respect for patient autonomy, informed consent, confidentiality, and the principle of non-maleficence, guide healthcare providers in conducting thorough neurological assessments and pain management in a manner that respects patients' rights, preferences, and values, ensuring that care is both effective and ethically sound.
51
What tools are used to assess pain in children?
Tools like the FLACC scale (assessing Face, Legs, Activity, Cry, and Consolability) for non-verbal children and the Wong-Baker FACES Pain Rating Scale for older children can help in assessing pain levels.
52
What distinguishes acute pain from chronic pain in terms of physiological response?
Acute pain typically results from tissue damage, has a sudden onset, and elicits physiological stress responses. Chronic pain persists beyond the normal healing period, often without a clear physiological cause, and may not present with typical stress responses.
53
Can you explain nociceptive pain and how it is typically managed?
Nociceptive pain arises from actual or threatened damage to non-neural tissue and is processed by nociceptors. It is usually managed with medications like NSAIDs, opioids, and adjunctive therapies such as physical therapy.
54
What is neuropathic pain, and why is it challenging to treat?
Neuropathic pain is caused by a lesion or disease affecting the somatosensory nervous system. It is challenging to treat due to its complex mechanisms, often requiring combinations of medications like antidepressants, anticonvulsants, and topical agents.
55
Describe the characteristics of visceral pain and how it is commonly assessed.
Visceral pain arises from internal organs and is often described as deep, pressure-like, dull, or diffuse. It can be challenging to localize and is assessed based on patient description, associated symptoms (e.g., nausea, changes in vital signs), and sometimes diagnostic imaging.
56
What role do psychological factors play in the perception and management of pain?
Psychological factors, including stress, anxiety, and depression, can significantly influence the perception of pain and its management. Addressing these factors through cognitive-behavioral therapy, mindfulness, and other supportive therapies can be crucial components of effective pain management.
57
The Glasgow Coma Scale evaluates three aspects: eye opening, _______ response, and motor response.
verbal
58
________ pain is described as a sharp, localized sensation, often felt in the skin or soft tissues
Cutaneous
59
In assessing pediatric pain, the FLACC scale stands for Face, Legs, Activity, Cry, and __________
Consolability
60
"Which of the following is NOT a component of the FAST assessment for stroke?" A) Facial drooping B) Arm weakness C) Speech difficulties D) Temperature sensitivity
D) Temperature sensitivity
61
"What type of pain results from damage to the nervous system?" A) Nociceptive B) Neuropathic C) Visceral D) Somatic
B) Neuropathic
62
True or False The reticular formation, thalamus, and cortex are areas of the brain involved in the sensation of pain
False (They are involved in consciousness and alertness.)
63
True or False Children do not feel pain with the same intensity as adults
False (Children do feel pain, but their expression and assessment of pain may differ from adults.)
64
Match the following terms to their definitions: Transduction a. The process by which pain signals are modified by the nervous system before they reach the brain. b. The conversion of a painful stimulus into electrical signals that are transmitted to the spinal cord. c. The movement of pain signals from the spinal cord to the brain. d. The brain's interpretation of pain signals.
Transduction b. The conversion of a painful stimulus into electrical signals that are transmitted to the spinal cord.
65
Match the following terms to their definitions: Transmission a. The process by which pain signals are modified by the nervous system before they reach the brain. b. The conversion of a painful stimulus into electrical signals that are transmitted to the spinal cord. c. The movement of pain signals from the spinal cord to the brain. d. The brain's interpretation of pain signals.
Transmission c. The movement of pain signals from the spinal cord to the brain.
66
Match the following terms to their definitions: Modulation a. The process by which pain signals are modified by the nervous system before they reach the brain. b. The conversion of a painful stimulus into electrical signals that are transmitted to the spinal cord. c. The movement of pain signals from the spinal cord to the brain. d. The brain's interpretation of pain signals.
Modulation a. The process by which pain signals are modified by the nervous system before they reach the brain.
67
Match the following terms to their definitions: Perception a. The process by which pain signals are modified by the nervous system before they reach the brain. b. The conversion of a painful stimulus into electrical signals that are transmitted to the spinal cord. c. The movement of pain signals from the spinal cord to the brain. d. The brain's interpretation of pain signals.
Perception d. The brain's interpretation of pain signals.
68
A 6-year-old child is brought to the ER after falling off a bike. The child is crying, refuses to move the left arm, and grimaces when touched. Which pain assessment tool is most appropriate for this situation A) Visual Analog Scale B) Numeric Rating Scale C) FLACC Scale D) Verbal Rating Scale
C) FLACC Scale
69
"A nurse is conducting a neurological assessment on a patient who experienced a head injury. The patient is able to open their eyes in response to verbal commands, is confused about their location, and withdraws their arm in response to pain. What is the patient's Glasgow Coma Scale score?"
A) Eye opening to verbal command = 3 B) Confused verbal response = 4 C) Withdrawal response to pain = 4 Total GCS Score: 11
70
"An acute, temporary decrease in blood flow to the brain, often called a 'mini-stroke,' is known as a ___________."
Transient Ischemic Attack (TIA)
71
"Pain that arises from internal organs and is often described as dull, deep, or aching is referred to as __________ pain."
visceral
72
"Which cranial nerve is assessed by testing the patient's sense of smell?" A) Olfactory Nerve (I) B) Trigeminal Nerve (V) C) Facial Nerve (VII) D) Vestibulocochlear Nerve (VIII)
A) Olfactory Nerve (I)
73
"Which of the following is not a recognized physiological indicator of pain?" A) Elevated blood pressure B) Decreased pulse rate C) Dilated pupils D) Pallor
B) Decreased pulse rate
74
True or False "Chronic pain is defined as pain that lasts for more than 3 months."
True
75
True or False "The Glasgow Coma Scale (GCS) is primarily used to assess a patient's renal function."
False (It's used to assess a patient's level of consciousness.)
76
Match the types of pain to their sources: Neuropathic Pain a. Pain from skin, bones, and muscles b. Pain from internal organs c. Pain caused by nerve damage d. Pain from tissue injury
Neuropathic Pain c. Pain caused by nerve damage
77
Match the types of pain to their sources: Nociceptive Pain a. Pain from skin, bones, and muscles b. Pain from internal organs c. Pain caused by nerve damage d. Pain from tissue injury
Nociceptive Pain d. Pain from tissue injury
78
Match the types of pain to their sources: Somatic Pain a. Pain from skin, bones, and muscles b. Pain from internal organs c. Pain caused by nerve damage d. Pain from tissue injury
Somatic Pain a. Pain from skin, bones, and muscles
79
Match the types of pain to their sources: Visceral Pain a. Pain from skin, bones, and muscles b. Pain from internal organs c. Pain caused by nerve damage d. Pain from tissue injury
Visceral Pain b. Pain from internal organs

NUR1114 Nursing (16 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions