Health Assessment NEURO

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Rhenea
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147302
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Health Assessment NEURO
Updated:
2012-04-12 20:29:08
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Health Assessment central nervous system
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central nervous system..... UGH!!!
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  1. Smell is what CN?
    I Olfactory
  2. Vision - Sight is what CN?
    II Optic Nerve
  3. The trochlear nerve or CN III performs what function?
    Eye movement
  4. What function dose the trigeminal nerve (CN V) serve?
    Facial sensory and motor function.
  5. Movement of the eyes toward the nose is a function of what nerve?
    CN IV - Trochlear Nerve
  6. Lateral eye movement is a function of which CN?
    VI - Abducense
  7. CN VIII Vestibulocochlear is responsible for what?
    Hearing and Balance tested by the WEBBER TEST and other hearing test :-)
  8. The Nerve responsible for facial expression and sensory is
    what?
    VII Facial (Duh!) :-)
  9. The CN that controls the tongue & throat motor sensory
    tested by sticking out the tongue and saying Ahhh is what?
    IX - Glossopharyngeal
  10. Say AHHH is testing for which CN nerve?
    • X - Vagus - Parasympathetic
    • Ahh all 10 of us wanna go to vagus (LoL) ;-)
  11. CN XI Accessory control the function of what?
    Swallowing & head, neck, and shoulder movement.
  12. Speech, chewing & swallowing are controlled by which CN?
    CN XI Hypoglossal
  13. Find a neumonic that works for you.
    OOO to taste and finsih velvety glass vodka AaaHhh (or Veno if you like wine)
    OOO to touch and feel very good vein AaaHhh.
    • O olfactory
    • O optic
    • O oculomotor
    • T trochlear
    • T trigeminal
    • A abducens
    • F facial
    • V vestibulocochlear
    • G gloccopharyngeal
    • V vagus
    • A accessory
    • H hypoglossal
  14. Pathways of the CNS consist of which of the following?
    Crossed representation
    Sensory pathways
    Spinothalamic tract
    Posterior (dorsal) column
    • ALL OF THEM
    • Crossed representation
    • Sensory pathways
    • Spinothalamic tract
    • Posterior (dorsal) column
  15. Motor pathways consist of what three components?
    • Corticospinal or pyramidal tract
    • Extrapyramidal tracts
    • Cerebellar system
  16. Which of the following is part of the Peripheral Nervous
    System?
    Cranial nerves
    Spinal nerves
    Autonomic nervous system
    Reflex arc
    Crossed representation
    Sensory pathways
    • Cranial nerves
    • Spinal nerves
    • Autonomic nervous system
    • Reflex arc
  17. Equipment needed to perform a neurologic screening
    examination, complete neurologic examination check all that apply.
    _____Penlight
    _____Tongue blade
    _____Cotton swab
    _____Cotton ball
    _____Tuning fork (128 Hz or 256 Hz)
    _____Percussion hammer
    _____Occasionally need: familiar aromatic substance
    • _____Penlight
    • _____Tongue blade
    • _____Cotton swab
    • _____Cotton ball
    • _____Tuning fork (128 Hz or 256 Hz)
    • _____Percussion hammer
    • _____Occasionally need: familiar aromatic substance
  18. Pain, Temperature, Light touch come from ___________ tract.
    Spinothalamic tract
  19. Posterior column tract
    Vibration
    Position (kinesthesia)
    Tactile discrimination (fine touch)
    •Stereognosis
    •Graphesthesia
    •Two-point discrimination
    •Extinction
    •Point location
  20. Put the defense mechanisms of the nervous system Reflex Arc
    in order.
  21. How many nerves are there Cervical vertebrae?
    • Nerves are C1-C8 (C6, C7 & C8 control the Thumb (1st), Middle Finger (3rd), & Pinky finger (5th finger)
    • Vertebrae there are C1-C7
  22. How do you assess for Delirium?
    • Confusion Assessment Method Originally designed for ICU use
    • Adapted for non-ICU patients
    • Use Flow Sheet - some examples include
    • Assess for level of Conciousness
    • able to follow commands
    • able to recognize items and recall items
    • assess for range of motion
    • assess for PERRLA ECT...
  23. Abnormal Findings and Abnormalities in Muscle Movement
    include all of the following except
    Paralysis
    Fasciculations
    Tic
    Myoclonus
    Tremor
    Rest tremor
    Intention tremor
    Chorea
    Athetosis
    • Paralysis
    • Fasciculations
    • Tic
    • Myoclonus
    • Tremor
    • Rest tremor
    • Intention tremor
    • Chorea
    • Athetosis
  24. The terms describing the level of conscious are ambiguous;
    ________ _______ scale was developed as an accurate and reliable quantitative tool to assess objective data to define the level of consciousness.
    • Glasgow Coma Scale
    • Examples
    • BEST Eye Opening
    • 4 = spontaneously
    • 3 = to speech
    • 2 = to pain
    • 1 = no response
    • BEST Verbal Response
    • 5 = Oriented x 3
    • 4 = Confused conversation
    • 3 = Inappropriate words
    • 2 = Incomprehensible sounds
    • 1 = No speech/sounds
    • Best Motor Response
    • 6 = Obeys verbal commands
    • 5 = Localizes to pain
    • 4 = Withdraws to pain
    • 3 = Abnormal flexion
    • 2 = Abnormal extension
    • 1 = none
    • http://www.youtube.com/watch?v=pN2V21KBNsw
  25. Slow, twisting, writhing, continuous movement, resembling a
    snake or worm, involves distal part of limb more than proximal part.
    Athetosis
  26. Decreased muscle tone or hypertonia; Muscle feels limp, soft
    and flabby; muscle is walk and easily fatigued; limb feels like a rag doll is known as what condition??
    Flaccidity - Lower motor neuron injury anywhere from the anterior horn cell in the spinal cord to the peripheral nerve
  27. Increased tone or hypertonia; Increased resistance to passive
    lengthening; then may suddenly give way (clasp-knife phenomenon like a pocket knife sprung open is what condition?
    Spasticity Upper motor neuron injury to corticospinal motor tract spasticity days or weeks after incident
  28. Constant state of resistance (lead-pipe rigidity); resists passive movement in any directions; dystonia is what condition.
    Rigidity - Injury to extrapyramidal motor tracts basal ganglia with parkinsonim)
  29. Type of rigidity in which the increased tone is released by
    degrees during passive range of motion so it feels like small regular jerks is what condition?
    Cogwheel rigidity - Parkinsonism
  30. Neuro Nursing assessment diagnosis examples
    • Impaired verbal communication R/T effects of CVA.
    • Impaired physical mobility R/T neuromuscular impairment.
    • Disturbed body image R/T effects of loss of body function.
    • Self-Care deficits: Feeding bathing toileting,
    • dressing/grooming R/T muscular weakness.
    • Disturbed sensory perception (absent right visual fields) R/T neurologic impairment.
    • Risk for injury R/T visual field deficit.
  31. Normal objective Cranial nerves assessment responses for CN
    II would be?
    Acuity normal, fields by confrontation
    EMO's intact no ptosis or nystagmus PERLA
    Shoulder shrug, head movement weaker or right
    Tongue protrudes midline no tremors
    Acuity normal, fields by confrontation
  32. CN III, IV, VI, Normal objective data would be which of the
    following.
    Acuity normal, fields by confrontation
    EMO's intact no ptosis or nystagmus PERLA
    Shoulder shrug, head movement weaker or right
    Tongue protrudes midline not tremors
    Hearing intact
    Shoulder shrug, head movement weaker even
    bi-lateral
    EMO's in tact no ptosis or nystagmus PERLA
  33. Sensations intact to pinprick and light touch jaw strength
    symmetrical bi-laterally is objective data for which CN?
    CN V Trigmeinal Face motor and sensory
  34. Able to wrinkle forehead bilaterally, smile/frown symmetrical,
    perform silent scream and tiny face symmetrical bilaterally assesses for which CN?
    CN VII Facial expression and sensory
  35. Hearing in tact is which CN?
    VII Vestibulocochlear (Hearing & Balance)
  36. Which of the following would state CN IX & X objective
    date best?
    Sensation intact, to pinprick and light touch jaw
    strength equal bilaterally
    Shoulder shrug, head movement equal bilaterally
    Swallowing intact, gag reflex present, uvula rises
    midline on phonation
    Tongue protrudes midline, no tremors.
    Swallowing intact, gag reflex present, uvula risesmidline on phonation.
  37. Shoulder shrug, head movement equal bilaterally is normal objective assessment finding for which CN?
    • XI - Accessory Shoulders
    • JUST FOR FUN TRY
    • raise your arms in the air what do you see "11" put your hands together over your head using accessory muscles to mak an A - for Accessory
  38. Sticking your tongue out moving it all about bilaterally equal and midline with no tremors is objective data for which CN?
    XII - Hypoglossal - Talking, chewing, swallowing

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