Exam Week 13

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  1. When does the neuro exam begin?
    • as soon as client enters the room
    • observe gait, balance, appearance, symmetry
    • observe speech, behavior, and responses during nursing history
  2. Mental Status reveals the client's
    • general cerebral function
    • Intellectual (cognitive) functioning
    • Emotional (affective) functioning
  3. What are the 3 major considerations to determine extent of exam?
    • Client's Chief Compliant
    • Client's Physical Condition
    • Client's willingness to participate and cooperate
  4. Mental Status

    Level of Consciousness
    • Varies from Alert to Comatose
    • Alert Client- responds to questions spontaneously
    • Comatose client- may not respond
  5. Mental Status

    • does client have difficulty speaking?
    • Point to objects and have them ID
    • Match words to pictures
    • Ask to follow verbal and written commands
  6. Examination of the Neurological System includes assessment of .......
    • Mental Status (Language, Orientation, Memory, Attention span & Calculation)
    • Level of Consciousness (Alert or comatose)
    • Cranial Nerves
    • Reflexes
    • Motor Function (proprioceptors & cerebellar function)
    • Sensory Function
  7. what are the major areas of mental status assessment.
    • Language
    • Orientation
    • Memory
    • Attention Span and Calculation
  8. Aphasia
    any 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
  9. Sensory or Receptive Aphasia
    • loss of the ability to comprehend written or spoken words
    • two types: auditory and visual
  10. Motor or Expressive Aphasia
    loss of power to express oneself by writing, making signs, or speaking
  11. Orientation
    • "oriented x3"
    • oriented to person, place and time
  12. mental status

    • assess 3 types
    • Immediate Memory
    • Recent Memory (earlier that day)
    • Remote Memory (months or year ago)
  13. Mental Status

    Attention Span & Calculation
    • clients ability to focus on a mental task
    • recite alphabet
    • count backwards
    • count by 7s or 3s
  14. scale used to asses comatose clients
    Glasgow Coma Scale

    originally developed to predict recovery from headinjury
  15. Glasgow Coma Scale
    • Assess LOC
    • 3 major Areas
    • Eye Response
    • Motor Response
    • Verbal Response
    • 15 Normal
    • 7 or lower Comatose
  16. Reflexes
    • automatic response of the body to a stimulus
    • Not Voluntary/Conscious

    Quality of reflex varies among individuals and decreases with age
  17. DTR
    Deep Tendon Reflex

    activated when tendon is stimulated and it muscle contracts
  18. common reflexes tested during routine exam include
    • biceps
    • triceps
    • brachioradialis
    • patellar
    • achilles
    • plantar (Babinski)
  19. positive Babinski is abnormal after
    a child ambulates or is 2 years old
  20. Motor Function involves
    Proprioception and cerebellar function
  21. Proprioceptors are ...
    Sensory nerve terminals, mostly in muscles, joint, tendons and internal ear.

    Gives information about movement and position of the body
  22. Assess Motor Function by ....
    usually the Romberg and one other gross motor function test
  23. Romberg
    • client stands feet together, arms resting at sides, first with eyes open then with eyes closed
    • Negative: may sway slightly but maintains upright position
    • Positive: moves feet apart- cannot maintain balance
  24. what are some "gross" motor function assessments
    • standing one 1 foot with eyes closed
    • heel to toe walking
    • toe to heel walking
    • walking gait
    • Romberg test
  25. What are some Fine Motor Function Tests for upper extremities
    • Finger to Nose
    • Alternating Supination and Pronation of hands on knees
    • Finger to finger
    • Finger to Thumb
    • Finger to Nose and to Nurse's Finger
  26. Fine Motor Function Assessments to Lower Extremities
    • run heel down shin of opposite leg
    • Toe or Ball of Foot to Nurse's Finger
  27. What is Sensory Function?
    • Touch
    • Pain
    • Temp
    • Position (Kinesthetic-Sensation)
    • Tactile Discrimination
    • Top 3 are Routine all for detailed exam
  28. what are the 3 types of tactile discrimination that are generally tested
    one and two-point discrimination  and stereognosis
  29. tactile discrimination

    one and two point discrimination
    the ability to sense whether one or two areas of the skin are being stimulated by pressure
  30. Tactile discrimination

    the act of recognizing objects by touching and manipulating them
  31. tactile discrimination

    the failure to perceive touch on one side of the body when two symmetric areas of the body are touched simultaneously
  32. clients that complain of numbness, strange sensation or paralysis. what is the assessment?
    Nurse must check over the surface of the area every inch to determine boundaries
  33. What are the abnormal response for touch
    • loss of sensation (anesthesia)
    • more than normal sensation (hyperesthesia)
    • abnormal sensation such as burning, pain, electrical shock
  34. lifespan considerations for infants

    • Rooting
    • Suckling
    • palmar grasp
    • moro
    • stepping
    • tonic neck reflex

    will disappear between 4 and 6 months of age
  35. lifespan considerations: Children
    • Present as a game
    • note hyperactivity & decreased attention span
    • assess/recall memory
    • can they understand and follow direction
    • under 5 use Denver developmental for motoe function
  36. Children should be able to walk backwards by
    age 2
  37. children should be able to balance on one foot  for 5 sec by
    age 4
  38. children should be able to walk heel to toe
    by age 5
  39. children should walk heel to toe backwards by
    age 6
  40. what age can Romberg be used
    over 3
Card Set:
Exam Week 13
2013-11-18 03:02:05
Nur 103

Neurology Assessment
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