RLE: Neurological Assessment Flashcards
(156 cards)
1
Q
A thorough neurologic examination may take 1 to 3 hours; however,
??? are usually done first
A
routine screening tests
2
Q
Assessment of mental status reveals the client’s ???
A
general cerebral function
3
Q
Any defects in or loss of the power to express oneself by speech, writing, or signs, or to comprehend spoken or written language due to disease or injury of the cerebral cortex, is called ???
A
aphasia
4
Q
Aphasias can be categorized as:
A
sensory or receptive aphasia,
motor or expressive aphasia.
5
Q
is the loss of the ability to comprehend written or spoken words
A
Sensory or receptive aphasia
6
Q
Two types of sensory aphasia are
A
auditory (or acoustic) aphasia and visual aphasia
7
Q
Clients with ??? aphasia have lost the ability to understand the symbolic content associated with sounds. Clients with ??? aphasia have lost the ability to understand printed or written figures.
A
auditory;
visual
8
Q
involves loss of the power to express oneself by writing, making signs, or speaking.
A
Motor or expressive aphasia
9
Q
This aspect of the assessment determines the client’s ability to recognize other people (person), awareness of when and where they presently are (time and place), and who they, themselves, are (self).
A
orientation
10
Q
Nurses often chart that the client is “awake, alert, & oriented x3” (or
“times three”). This refers to accurate awareness of ???
A
persons, time, and place.
11
Q
The nurse assesses the client’s recall of information
A
memory
12
Q
information presented seconds
previously
A
immediate recall
13
Q
events or information from earlier in the day or examination
A
recent memory
14
Q
knowledge recalled from months or years ago
A
remote or long-term memory
15
Q
This component determines the client’s ability to focus on a mental task that is expected to be able to be performed by individuals of normal intelligence.
A
attention span and calculation
16
Q
Level of consciousness (LOC) can lie anywhere along a continuum
from a state of ??? to ???
A
alertness to coma
17
Q
Reflexes are tested using a percussion hammer. The response
is described on a scale of ?
A
0 to 4
18
Q
Generalist nurses do not commonly assess each of the deep tendon reflexes except for possibly the ???, indicative of possible spinal
cord injury.
A
plantar (Babinski) reflex
19
Q
Glasgow Coma Scale (3 faculties measured)
A
Eye opening (4)
Verbal response (5)
Motor response (6)
20
Q
Glasgow coma scale: 15 pts
A
normal
21
Q
Glasgow coma scale: 8-11 pts
A
emergency
22
Q
Glasgow coma scale: 4-8 pts
A
slightly braindead
23
Q
Glasgow coma scale: 3 pts
A
braindead
24
Q
eye opening responses
A
spontaneous
to verbal command
to pain
no response
25
motor responses
To verbal command
To localized pain
Flexes and withdraws
Flexes abnormally
Extends abnormally
No response
26
Verbal responses
Oriented, converses
Disoriented, converses
Uses inappropriate words
Makes incomprehensible
sounds
No response
27
Neurologic assessment of the motor system evaluates ??? and ???
proprioception and cerebellar function
28
are sensory nerve terminals that occur chiefly in the muscles, tendons, joints, and internal ear. They give information about movements and the position of the body
Proprioceptors
29
loss of sensation
anesthesia
30
more than normal sensation
hyperesthesia
31
less than normal sensation
hypoesthesia
32
abnormal sensation such as burning, pain, or an electric shock
paresthesia
33
A detailed neurologic examination includes (3)
position sense,
temperature sense,
tactile discrimination.
34
Three types of tactile discrimination are generally tested:
one- and two-point discrimination
stereognosis
extinction
35
the ability to sense whether one or two areas of the skin are being stimulated by pressure
one- and two-point discrimination
36
the act of recognizing objects by touching and manipulating them
stereognosis
37
negative stereognosis (can't identify/recognize objects)
astereognosis
38
the failure to perceive touch on one side of the body when two symmetric areas of the body are touched simultaneously
extinction
39
Determine the client’s orientation to time, place, and person by
??? questioning
tactful
40
Ask the client the time of day, date, day of the week, duration of illness
assessing orientation
41
??? questions may elicit a more accurate clinical picture of the client’s orientation status than questions directed to time, place, and person.
“Why”
42
three categories of memory
are tested:
immediate recall, recent memory, and remote memory
43
Test the ability to concentrate or maintain attention span by
asking the client to ??? or ???
recite the alphabet or to count backward from 100
44
A comatose client scores ??? on Glasgow Coma Scale
7 or less
45
Babinski: all five toes bend
downward
negative (normal)
46
Babinski: the toes spread
outward and the big toe moves upward.
positive (abnormal)
47
Ask the client to walk across the room and back, and assess the client’s gait.
WALKING GAIT
48
Ask the client to stand with feet together and arms resting at the sides, first with eyes open, then closed. Stand close during this test.
Romberg Test
49
If client cannot maintain balance with the eyes shut, client may have
sensory ataxia (lack of coordination of the voluntary muscles)
50
If balance cannot be maintained whether the eyes are open or shut, client may have ???
cerebellar ataxia
51
Ask the client to close the eyes and stand on one foot. Repeat on the other foot. Stand close to the client during this test.
STANDING ON ONE FOOT WITH EYES CLOSED
52
STANDING ON ONE FOOT WITH EYES CLOSED: Normal
Maintains stance for at least 5 seconds
53
Ask the client to walk a straight line, placing the heel of one foot directly in front of the toes of the other foot
HEEL-TOE WALKING
54
Ask the client to walk several steps on the toes and then on the heels.
TOE OR HEEL WALKING
55
Compare the light-touch sensation of symmetric areas of the body.
Rationale:
Sensitivity to touch varies among different skin areas.
56
Test areas on the forehead, cheek,
hand, lower arm, abdomen, foot, and lower leg. Check a distal area of the limb first (i.e., the hand before the arm and the foot before the leg).
Rationale: The sensory nerve may be assumed to be intact if sensation is felt at its most distal part.
57
Able to discriminate “sharp” and “dull” sensations
pain sensation
58
kinesthetic sensation
sense of position
59
Commonly, the ??? fingers and the ??? toes are tested for the kinesthetic sensation (sense of position).
middle;
large
60
newborn reflex: Stroke the side of the face near mouth; infant opens mouth and turns to the side that is stroked
rooting
61
newborn reflex: Place nipple or finger 3 to 4 cm (1.2 to 1.6 in.) into mouth; infant sucks vigorously.
Sucking
62
newborn reflex: Place infant supine, turn head to one side; arm on side to which head is turned extends; on opposite side, arm curls up (fencer’s pose).
Tonic neck
63
newborn reflex: Place finger in infant’s palm and press; infant curls fingers around
Palmar grasp
64
newborn reflex: Present loud noise or unexpected movement; infant spreads arms and legs, extends fingers, then flexes and brings hands together; may cry.
Moro
65
??? Babinski reflex is abnormal after the child ambulates or
at age 2
Positive
66
For children under age 5, the provides a comprehensive neurologic evaluation, particularly for motor function.
Denver Developmental Screening
Test II
67
Use of the Romberg test is appropriate for children ages ?
3 and
older
68
A decline in ??? is not a normal result of aging.
mental status
69
Older Adults: Acute, abrupt-onset mental status changes are usually caused by ???
delirium
70
older adult: Short-term memory is often ???. Long-term memory is ???
less efficient;
usually unaltered.
71
Many older adults show loss of ??? reflex, and the ??? reflex may be difficult to elicit.
Achilles;
plantar
72
sensory/motor?
CN I
sensory
73
sensory/motor?
CN II
Sensory
74
sensory/motor?
CN III
MOTOR
75
sensory/motor?
CN IV
MOTOR
76
CN V
SENSORY, MOTOR
77
sensory/motor?
CN VI
MOTOR
78
sensory/motor?
CN VII
MOTOR, SENSORY
79
sensory/motor?
CN VIII
SENSORY
80
sensory/motor?
CN IX
MOTOR, SENSORY
81
sensory/motor?
CN X
MOTOR, SENSORY
82
sensory/motor?
CN XI
MOTOR
83
sensory/motor?
CN XII
MOTOR
84
CN: smell
Olfactory
85
CN: Vision and visual fields
Optic
86
CN: Extraocular eye movement (EOM); movement of sphincter of pupil; movement of ciliary muscles of lens
OCULOMOTOR
87
CN: EOM; specifically, moves eyeball downward and laterally
TROCHLEAR
88
CN: Sensation of cornea, skin of face, and nasal mucosa, Sensation of skin of face and anterior oral cavity (tongue and teeth).
Muscles of mastication; sensation
of skin of face
TRIGEMINAL
89
CN: EOM; moves eyeball laterally
ABDUCENS
90
CN: Facial expression; taste
FACIAL
91
CN: Equilibrium, Hearing
VESTIBULOCOCHLEAR
92
CN: Swallowing ability, tongue movement, taste (posterior tongue)
GLOSSOPHARYNGEAL
93
CN: Sensation of pharynx and larynx; swallowing; vocal cord movement
VAGUS
94
CN: Head movement; shrugging of
shoulders
ACCESSORY
95
CN: Protrusion of tongue; moves tongue up and down and side to side
HYPOGLOSSAL
96
Nervous System's two structural components:
the central nervous system (CNS) and the peripheral nervous system.
97
The CNS encompasses the (2)
brain and spinal cord
98
brain and spinal cord are covered by ???, three layers of connective tissue that protect and nourish the CNS.
meninges
99
surrounds the brain and spinal cord.
The subarachnoid space
100
the subarachnoid space is filled with ???, which is formed in the ventricles of the brain and flows through the ventricles into the space.
cerebrospinal fluid (CSF)
101
Electrical activity of the CNS is governed by ??? located throughout the sensory and motor neural
pathways.
neurons
102
the brain has four major divisions:
the cerebrum, the diencephalon, the brain stem, and the cerebellum
103
The cerebrum is divided into the right and left cerebral hemispheres, which are joined by the ???—a bundle of nerve fibers responsible for communication between the hemispheres.
corpus callosum
104
The lobes are composed of a substance known as ???, which mediates higher level functions such as memory, perception, communication, and initiation of voluntary movements.
gray matter
105
lies beneath the cerebral hemispheres and consists of the thalamus and hypothalamus.
The diencephalon
106
Most sensory impulses travel through the gray matter of the ???, which is responsible for screening and directing the impulses to specific areas in the cerebral cortex.
thalamus
107
(part of the autonomic nervous system, which is a part of the peripheral nervous system) is responsible for regulating many body functions, including water balance, appetite, vital signs (temperature, blood pressure, pulse, and respiratory rate), sleep cycles, pain perception, and emotional status
The hypothalamus
108
Located between the cerebral cortex and the spinal cord, the ???consists of mostly nerve fibers
brain stem
109
3 parts of brain stem:
the midbrain, pons, and medulla oblongata
110
serves as a relay center for ear and eye reflexes, and relays impulses between the higher cerebral centers and the lower pons, medulla, cerebellum, and spinal cord.
The midbrain
111
links the cerebellum to the cerebrum and the midbrain to the medulla. It is responsible for various reflex actions.
The pons
112
contains the nuclei for cranial nerves, and has centers that control and regulate respiratory function, heart rate and force, and blood pressure
The medulla oblongata
113
its primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone.
cerebellum
114
The spinal cord is located in the ??? and extends from the ??? to ???
vertebral canal;
medulla oblongata to the first lumbar vertebra.
115
conducts sensory impulses up ascending tracts to the brain, conducts motor impulses down descending tracts to neurons that stimulate glands and muscles throughout the body, and is responsible for simple reflex activity. Reflex activity involves various neural structures.
The spinal cord
116
Sensory impulses travel to the brain by way of two ascending neural pathways
the spinothalamic tract and posterior columns
117
Sensations of pain, temperature, and crude and light touch travel by way of the ??? tract;
sensations of position, vibration, and fine touch travel by way of the ??? columns.
spinothalamic;
posterior
118
Motor impulses are conducted to the muscles by two descending neural pathways:
the pyramidal (corticospinal) tract and extrapyramidal tract
119
Carrying information to and from the CNS, the peripheral nervous system consists of ?? pairs of cranial nerves and ??? pairs of spinal nerves. These nerves are categorized as two types of fibers: ???
12;
31;
somatic, autonomic
120
??? fibers carry CNS impulses to voluntary skeletal muscles;
??? fibers carry CNS impulses to smooth, involuntary muscles (in the heart and glands).
somatic
autonomic
121
Comprising [specific numbers] nerves, the 31 pairs of spinal nerves are named after the vertebrae below each one’s exit point along the spinal cord
8 cervical,
12 thoracic,
5 lumbar,
5 sacral, and
1 coccygeal
122
Have you noticed a decrease in your ability to smell or to taste?
OLDER ADULT CONSIDERATIONS
Decreased taste and scent sensation occurs normally in older adults.
123
Ringing in the ears and decreased ability to hear may occur with dysfunction of cranial nerve VIII (acoustic).
OLDER ADULT CONSIDERATIONS
There is a normal decrease in the older person’s ability to hear.
124
Have you noticed any change in your vision?
OLDER ADULT CONSIDERATIONS
There is a normal decrease in the older person’s ability to see.
125
Older adults may experience ??? tremors
intentional
126
are brief, rapid, jerky, irregular, and unpredictable. They occur at rest or interrupt normal coordinated movements. Unlike tics, they seldom repeat themselves. The face, head, lower arms, and hands are often involved.
Choreiform movements
127
are brief, repetitive, stereotyped, coordinated movements occurring at irregular intervals. Examples include repetitive winking, grimacing, and shoulder shrugging.
Tics
128
are slower, more twisting and writhing than choreiform movements, and have a larger amplitude. They most commonly involve the face and the distal extremities.
Athetoid movements
129
Corneal reflex may be absent or reduced in ?
clients who wear contact lenses
130
Recognize the signs and symptoms of stroke. Act FAST!
Face drooping
Arms weakness
Speech
Time
131
Make sure that the client leaves the tongue protruded to identify the flavor. Otherwise, the substance may move to the posterior third of the tongue (???nerve innervation).
vagus
132
CN VIII: The ??? component, responsible for equilibrium, is not routinely tested.
vestibular
133
Noting any unusual involuntary movements
OLDER ADULT CONSIDERATIONS
Some older clients may normally have hand or head tremors or dyskinesia (repetitive movements
of the lips, jaw, or tongue).
134
It is best to assess gait when the client is [aware or not aware?] that you are directly observing the gait.
not aware
135
Gait and Balance:
OLDER ADULT CONSIDERATIONS
Some older clients may have a slow and uncertain gait. The base may become wider and shorter and the hips and knees may be flexed for a bent-forward appearance.
136
For some older clients, rapid alternating movements are
difficult because of ???
decreased reaction time and flexibility
137
In some older clients, light touch and pain sensations may be ???
decreased
138
When to test for temperature sensation?
only if abnormalities are found in
the client’s ability to perceive light touch and pain sensations.
139
increased sensitivity to touch
Hyperesthesia
140
absence of pain sensation
Analgesia
141
decreased sensitivity to pain
Hypalgesia
142
increased sensitivity to pain
Hyperalgesia
143
a decrease or loss of vibratory sense is one of the earliest signs of ???
sensory loss
144
In some older clients, the ??? reflex may be absent or difficult
to elicit
Achilles
145
Pain and increased resistance to extending the knee are ???. When the sign is bilateral, the examiner suspects meningeal irritation.
positive Kernig signs
146
Pain and flexion of the hips and knees are ???, suggesting meningeal inflammation.
positive Brudzinski signs
147
Wide-based, staggering, unsteady gait
Romberg test results are positive (client cannot stand with feet together).
Seen with cerebellar diseases or alcohol or drug intoxication
CEREBELLAR ATAXIA
148
Shuffling gait, turns accomplished in very stiff manner
Stooped-over posture with flexed hips and knees
Typically seen in Parkinson disease and drug-induced parkinsonian because of effects
on the basal ganglia
PARKINSONIAN GAIT
149
Stiff, short gait; thighs overlap each other with each step.
Seen with partial paralysis of the legs
SCISSORS GAIT
150
Flexed arm held close to body while client drags toe of leg or circles it stiffly outward
and forward.
Seen with lesions of the upper motor neurons in the cortical spinal tract, such as occurs
in stroke
SPASTIC HEMIPARESIS
151
Client lifts foot and knee high with each step, then slaps the foot down hard on the
ground.
Client cannot walk on heels.
Characteristic of diseases of the lower motor neurons
FOOTDROP
152
inability to smell
neurogenic anosmia
153
swelling of the optic nerve
papilledema
154
oculomotor nerve paralysis
dilated pupils
155
peripheral injury of CN VIII
Bell's Palsy
156
range of contraction
1+ to 3+
