Head, Neck, Neurological, Musculoskeletal

Front 1

When inspecting the external nose you are observing

Back 1

-shape
-size
-skin
-color
-presence of deformity or inflammation

*If swelling or deformities exist, palpate nose
-Note any tenderness, masses or underlying deviation

Front 2

Patency

Back 2

-should be present for each nostril w/o excessive faring

*Assess by occluding 1 nare @ at time while client is breathing with mouth Closed

Front 3

Normal mucosa of nares

Back 3

-pink and moist w/o lesions

Front 4

Illuminate the Anterior Nares and assess for?

Back 4

-color
-lesions
-discharge
-swelling
-evidence of bleeding

Front 5

Pale mucosa with clear discharge indicates?

Back 5

Allergy

Front 6

Mucoid discharge indicates?

Back 6

Rhinitis

Front 7

Yellowish or greenish discharge from nose is a result of?

Back 7

Sinus Infection

Front 8

Habitual use of intranasal cocaine and opioids causes?

Back 8

-puffiness
-increased vascularity of nasal mucosa
-perforation of septum

Front 9

Assess client with NG tube for?

Back 9

-skin breakdown
-redness
-skin sloughing

Front 10

EXCORIATION?

Back 10

-skin breakdown

Front 11

CN I?

Back 11

Olfactory (smell)

Front 12

POLYPS

Back 12

-tumor-like growths

*Note any polyps or purulent drainage

Front 13

Assess the Integrity of the NOSE by using?

Back 13

-Inspection
-Palpation-sinuses
-Percussion-sinuses

Front 14

Most effective way to assess for tenderness of sinuses?

Back 14

-Palpate frontal & Maxillary facial areas (do not apply pressure to the eyes)

Front 15

Technique for assessing the frontal sinuses?

Back 15

-Palpate by Pressing upward with thumbs from just belowthe eyebrows on either side bridge of nose

Front 16

Technique for assessing Maxillary Sinuses?

Back 16

-Palpate by pressing upward at the skin crevices that run from the sides of nose to corner of mouth

Front 17

*Client Teaching strategies for Nose & Sinus Assessment?

Back 17

-caution againt otc nasal sprays (leads to "rebound" effect, causing excessive nasal congestion)
-Instruct parents in care of a child with nosebleeds
-Older adults to install smoke detectors/check dated labels on food for spoilage

Front 18

Cherry colored lips indicates?

Back 18

-carbon monoxide poisoning

Front 19

Lips normally appear?

Back 19

-darker pigmented skin than face
-symmetrical
-smooth
-soft with no Lesion
-non tender

Front 20

Pallor of the Lips is caused by?

Back 20

Anemia

Front 21

Any lesions on Lips are related to?

Back 21

-infection
-irritation
-skin cancer

Front 22

Inspect Lips for

Back 22

-color
-hydration
-contour
-lesions

Front 23

Assessment of the mouth and pharynx detects signs of ...?

Back 23

-overall health
-oral hygiene needs

Front 24

When viewing the molar, the nurse should note?

Back 24

-color of teeth
-caries
-tarter
-extraction sites

Front 25

What is the early indication for dental caries?

Back 25

-brown or black discolorations

Front 26

When Inspecting the Oral Mucosa you are looking for?

Back 26

-color
-hydration
-texture
-lesions (ulcers, abrasions,cysts)

Front 27

Normally the Oral Mucosa appears?

Back 27

-pink
-soft
-moist
-smooth

Front 28

Cherry colored lips indicates?

Back 28

-carbon monoxide poisoning

Front 29

Lips normally appear?

Back 29

-darker pigmented skin than face
-symmetrical
-smooth
-soft with no Lesion
-non tender

Front 30

Pallor of the Lips is caused by?

Back 30

Anemia

Front 31

Any lesions on Lips are related to?

Back 31

-infection
-irritation
-skin cancer

Front 32

Inspect Lips for

Back 32

-color
-hydration
-contour
-lesions

Front 33

LEUKOPLAKIA

Back 33

-thick white patches
-precancerous lesion seen in heavy smokers & alcoholics

Front 34

Gums should appear?

Back 34

-coral pink
-tight against the teeth w/ no bleeding on gloves when palpated

Front 35

Gingivae

Back 35

-gums

Front 36

Inspection of Gums include?

Back 36

-color
-edema
-retraction-
-bleeding
-lesions

Front 37

Spongy gums that bleed indicates?

Back 37

-periodontal disease
-Vit C deficiency

Front 38

Inspections of the Tongue include?

Back 38

-color
-size
-position
-texture
-coatings or lesions

Front 39

How do you test the function of the hypoglossal nerve (CN-XII)?

Back 39

-relax mouth
-stick the tongue out halfway

Front 40

Normal appearance of tongue?

Back 40

-medium or dull red
-moist slightly rough on top surface
-smooth along the lateral margins

Front 41

Area of tongue that is highly vascular?

Back 41

-under surface of the tongue
-floor of mouth

Front 42

VARICOSITES

Back 42

-swollen, tortuous veins
-common in older adult/rarely cause problems

Front 43

EXOSTOSIS

Back 43

-bony growth

*commonly seen b/w soft and hard palates

Front 44

dysphagia

Back 44

-difficult swallowing

Front 45

Children, adults and older adults should have regular dental exam every?

Back 45

-6 months

Front 46

Common complaints and findings with Oral Cancer include?

Back 46

-nonhealing lip or mouth sore
-swelling or mass
-leukoplakia
-erthroplakia=slightly raised red patch or lesion,bleeds easily
-unusual bleeding
-unusual sensation
-chronic sore throat
-foreign body sensation in throat (tingling)
-voice change
-dysphagia

Front 47

Abnormality of Lymph Nodes reveal the presense of?

Back 47

-infection
-malignancy

Front 48

Muscles of the neck that divide each side of the neck into 2 trianagles?

Back 48

-SCM
-Trapezius

Front 49

Assessment of the MUSCULOSKELETAL SYSTEM includes:

Back 49

-alignment
-symmetry & muscle mass
-Muscle tone
-ROM
-any involuntarymvmt
-signs of inflammation (redness,swelling, warmth, tenderness, loss of function

Front 50

Age-Related changes in Musculoskeletal system:

Back 50

-height loss is due to thinner intervertebral discs, osteoporosis or kyphosis
-skeletal muscles decreases in size
-ROM decreases
-Posture changes are a result of a wider stance
-flexion of hips, knees & elbow is typical

Front 51

2 techniques used to assess musculoskeletal system?

Back 51

-inspection
-palpation

Front 52

Flexion

Back 52

decrease angle

Front 53

extension

Back 53

extend angle

Front 54

Hyperextension

Back 54

extreme extension (neck, back)

Front 55

supination

Back 55

ventral surface facing up

Front 56

Pronation

Back 56

ventral surface facing down

Front 57

Abduction

Back 57

move extremity away from midline

Front 58

Adduction

Back 58

move extremity toward midline

Front 59

Dorsiflexion

Back 59

mvmt toward dorsum (top of the wrist or foot)

Front 60

Plantar Flexion

Back 60

mvmt toward the plantar surface (bottom of foot)

Front 61

Eversion

Back 61

turn body part Away from midline

Front 62

Inversion

Back 62

turn body part Toward midline

Front 63

Which CN do you assess during the head & neck exam?

Back 63

-CN V (trigeminal)= assess face for strength & sensation

-CN VII (facial)= assess face for mvmt

-CN XI (spinal accessory) assess shoulders for strength

Front 64

3 Techniques used to examine a client's neck and head

Back 64

-inspection
-palpation
-auscultation

Front 65

What questions should the nurse ask the client during Head and Neck exam?

Back 65

-Headaches? (how often & location)
-pain in neck
-able to move head & shoulders w/ ease?
-Any unusual facial mvmt
-Lymph nodes swollen?

Front 66

What are you assessing for when u Inspect & Palpate the skull?

Back 66

-size
-depression
-deformities
-masses
-tenderness
-overall contour & symmetry

Front 67

Normocephalic

Back 67

normal skull size

Front 68

Inspection & Palpation of the FACE includes:

Back 68

-symmetry of facial features
-symmetry of expressions
-involuntary mvmts (abnormal)
-proportinate features (no thickening as in acromegaly)

Front 69

Acromegaly

Back 69

-excessive amoutn of growth hormone and the body tissues gradually enlarge.

Front 70

CN V ?

*Motor=
*Sensory=

Back 70

-Trigeminal

*test the STRENGHT of the muscle contraction by asking client to clench teeth while palpating the masseter and temporal muscles, then the temporomandibular joint

*Test LIGHT TOUCH by having client close her eyes, gently touching her face w/ a cotton swab & asking her to tell you when the touch is felt

Front 71

CN VII?

*Motor?

Back 71

-Facial

*Test FACIAL MVMT by having client smile, frown puff out cheeks, raise eyebrows, close eyes tightly & show teeth

Front 72

Normal appearance of muscles in the NECK?

Back 72

-should be equal in ht & w/ normal muscle mass

Front 73

(ROM) The client should be able to move head smoothly and w/o distess in what 3 directions?

Back 73

-chin to chin (flexion)
-ear to shoulder bilaterally (lateral flexion)
-Chin up (Hypertension)

Front 74

How do you assess for CN XI in the neck?

Back 74

-Hands on clients shoulders & ask the client to shrug the shoulders against resistance

Front 75

LYMPH NODES (glands)

Back 75

-small clusters of cells, surrounded by a capsule. Ducts go in and out of them. The cells in lymph nodes are lymphocytes, which produce antibodies (protein particles that bind foreign substances including infectious particles) and macrophages which digest the debris. They act as the "cleaner" cells of the body.
- part of the lymphatic system, a component of the body's immune system
-vital role in your body's ability to fight off viruses, bacteria and other causes of illnesses.
-Most often, lymph nodes swell and become inflamed as a result of an infection

Front 76

Lupus erythematosus

Back 76

auto immune disease

Front 77

**Lymph Nodes Location**

1. Occuipital
2. Preauricular
3. Postauricular
4. Submandibular
5. Tonsillar (retropharyngeal)
6. Submental
7. Anterior Cervical
8. posterior Cervical

Back 77

1. base of the skull
2. in front of the ear
3. over the mastoid
4. along the base of the mandible
5. angle of the mandible
6. midline under the chin
7. SCM muscle
8. posterior to SCM muscle

Front 78

*Client Teaching for Neck Assessment includes:*

Back 78

-stress importance of compliance w/ meds in clients w/ Thyroid disease
-instruct about lymph nodes & how infection commonly causes node tenderness
-call MD if client notices an enlarged lump of mass in the neck
-risk factors for HIV infection and other STD's

Front 79

When assessing lymph nodes they are normally?

Back 79

-Nonpalpable and nontender

Front 80

Abnormal assessment would indicate?

Back 80

-local infection
-systemic disease
-neoplasm

Front 81

Tenderness of the lymph nodes is an indication for?

Back 81

-inflammation

Front 82

Problem involvinga lymph node of the head & neck mean an abnormality in the?

Back 82

-mouth
-throat
-abdomen
-breast
thorax
arms

Front 83

Examine the Thyroid GLand by

Back 83

1. inspecting lower half of neck (looking for any enlargement)
2. have client sip H20 & watch the thyroid tissue move up
3 hyperextend neck

Front 84

While palpating the thyroid gland the nurse is looking for?

Back 84

-masses
-size
-smoothness

Front 85

Location of thyroid gland

Back 85

Front 86

Goiter

Back 86

visibly enlarged thyroid gland

Front 87

2 body systems that interacts with the musculoskeletal system?

Back 87

1. neurological-coordinates the functionof the musculoskeletal systems
2. depends on the muscles of the chest to protect the lungs and help with breathing (diaphram)

Front 88

Question to ask the client during assessment include:

Back 88

-pain in joints or muscles
-stiffness, weakness or twitching
-experienced any recent falls
-able to care for youself
-activity limited by any physical factors
-describe physical activity
-exercise?
-bone/muscle surgery?
-hx of arthritis, osteoporosis, fractures
-any changes in ADL's
-artifical limbs?
-assistive device?

Front 89

Major symptoms to watch for during musculoskeletal system assessment include:

Back 89

-pain (head/neck=place hand on side of face, ask client to push against your hand)

-weakness (check grip by having client squeeze your fingers)

-stiffness

-balance/coordination problems

Front 90

Muscular d/o are the result of

Back 90

neurological disease

Front 91

ataxia

Back 91

Ataxia is not a specific disease or a diagnosis, it is just a word used to describe certain, similar, types of symptom. Ataxia will mainly involve clumsiness and loss of coordination. Ataxia may affect the fingers and hands, the arms or legs, the body, speech or eye movements - it is a description of physical problems. Ataxia symptoms may included staggered gait (unsteady walking), problems with balance, poor limb control (co-ordination), slurred speech, choking problems, irregular eye movements and loss of reflexes.
(cerebellum d/o)

Front 92

Rheumatoid Arthritis

Back 92

associated with morning stiffness

Front 93

How do you inspect a client's gait and posture

Back 93

1.gait=observe when client is walking in room
-walk a straight line
*normal gait=walk w/ arms swinging freely at the sides and head leading the body
2. posture=observe client from the side in a standing position
*normal standing posture=upright w/ parallel alignment of hips and shoulders/holding the head erect

Front 94

Lordosis

Back 94

exaggerated curvature of the lumbar sping (common during toddler years and pregnancy)

Front 95

Kyphosis

Back 95

exaggerated curvature of the Thoracic spine (hunchback)

Front 96

SCOLIOSIS

Back 96

-lateral spinal curvature

Front 97

SCOLIOSIS

Back 97

-lateral spinal curvature

Front 98

Goniometer

Back 98

measures the degree of motion in a joint (use for clients who have a suspected reduction in joint mvmt

Front 99

Passive ROM

Back 99

assess by moving the client's joints through full ROM.
-Do Not move a joint past a point of pain or resistance

Front 100

Active ROM

Back 100

client repeats the mvmts demonstrate by the nurse

Front 101

Muscle Tone & Strength

1.HYPERTROPHY

Back 101

-enlargement of the muscle due to strengthening

-

Front 102

Hypotonicity

Back 102

-little tone
-feels flabby
-stroke patient

Front 103

HYPERTONICITY

Back 103

-increased muscle tone
-

Front 104

ATROPHY

Back 104

decrease in muscle size due to miss use

Front 105

Recommended Ca+ dose for
1. adult
2. post-menapause

Back 105

1. 1000mg/day
2. 1500mg/day

Front 106

Normal curvatures of the spine

Back 106

1. concave cervical
2. convex thoraic spine
3. concave lumbar spine

Front 107

When do you assess for muscle Tone?

Back 107

-during ROM

*Tone is determined by the presence of slight resistance of the muscles during relaxation

Front 108

Expected finding when assessing Muscle Strength?

Back 108

-strength equal or slightly stronger on the dominant side

Front 109

NEUROLOGICAL Assessement
*Integrate into other parts of the head to toe assessment

*Extent- based on the client LOC & general health status

Back 109

*

Front 110

Questions nurse should ask during Neuro Assessment/

Back 110

-any dizziness?
-Headaches?
-seizures
-hx of head trauma or LOC
-any change in speech, ability to think clearly, loss or change in memory
-weakness?
-numbness
-tremor or tingling (where?)

Front 111

Neuro Exam includes:

Back 111

-mental status to test cerebral function
-Cranial nerves
-motor function to test cerebral function
-sensory function
-reflexes
-

Front 112

Levels of Consciousness (5)
1. ALERT

Back 112

1. responsive & able to fully respond by opening eyes & attending to a normal tone of voice & speech

Front 113

2. LETHARGY

Back 113

2. open eyes and respond, BUT is DROWSY and falls ASLEEP readlily

Front 114

3. OBTUNDATION

Back 114

3. client needs to be lightly shaken to respond, BUT may be CONFUSED and SLOW to RESPOND

Front 115

4. STUPOR

Back 115

4. requires painful stimuli (pinching a tendon or rubbing the sternum) to achieve a brief response
-may not be able to respond verbally

Front 116

5. COMA

Back 116

-NO response to repeated painful stimuli

Front 117

What are the 2 Abnormal posturing in the comatose client?

Back 117

1. DeCORTicate RIGIDITY= flexion and internal rotation of upper extremity joints and legs

2. DeCEREbrate rigidity= neck and elbow extension, wrists and fingers flexed

Front 118

Equip for NEURO assessment

Back 118

-snellen & rosenbaum eye charts
-aromatic substances (CN I =olfactory)
-tongue blades
-penlight- PERRLA
-salt and sugar
-tuning fork
-reflex hammer
-cotton balls
-2 test tubes with 1 hot and 1 cold water
-

Front 119

*Assessment Category*

1.Determine client use of analgesics, alcohol, sedatives, hypnotics, antipsychotics, antidepressants or recreational drugs.

What is the Rationale?

Back 119

-these meds alter LOC or cause behavioral changes.
-Abuse can cause tremors, ataxia, and changes in peripheral neve function

Front 120

2. Determine if client has recent history of seizure/convulsions

What is the Rationale?

Back 120

-Seizure activity often originates for CNS alteration

Front 121

3. Screen client for sx of HA, tremors, dizziness, vertigo, numbness or tingling of body part, visual changes, weakness,pain or changes in speech.

What is the Rationale?

Back 121

-These sx frequently originate from alterations in CNS or PNS function.
-id of specific patterns aids in dx of pathological condition

Front 122

4. Discuss w/ client's family any recent changes in client's behavior (mood swings, memory losss, changes in energy level)

What is the Rationale?

Back 122

-Behaviral changes sometimes result from intracranial pathological states

Front 123

5. Assess client for hx of change in vision, hearing, smell, taste or touch.

What is the rationale?

Back 123

-sensory nerves originate from brain stem. These symptoms help to localize nature of the problem

Front 124

6. If an older client displays suddne acute confusion (delirium), review hx for drug toxicity (anticholinergics, diuretics, digoxin, cimetidine, sedatives, antihypertensives, antiarrhythmics) serious infections, metabolic disturbances, heart failure and severe anemia

What is the rationale

Back 124

-one of the most common mental d/o in older persons.
-condition is always potentially reversible

Front 125

7. Review past hx for head or spinal cord injury, meningitis, congenital anomalies, neuro disease

What is the rationale?

Back 125

7. factors cause neuro sx or behavioral changes to develop

Front 126

What are the functions of the Neuro system?

Back 126

-initiation
-coordination of mvmt
-reception and perception of sensory stimuli
-organization of thought process
-control of speech
-storage of memory

Front 127

The client will need a complete neuro assessment with c/o Headache or recent loss of function in an extremity.

T/F

Back 127

True

Front 128

Test used to measure orientation and cognitive function?

Back 128

The Mini-Mental state Examination (MMSE)
-score of 21 or less reveal cognitive impairment.

*Question
-orientation to time
-registration =say 3 words/have client repeat back to you
-naming= "what is this" (point to a pencil)
-Reading= "please read this and do what it says" CLOSE YOUR EYES

Front 129

What are the functions of the cerebral cortex?

Back 129

-controls and integrates intellectual functioning

-controls and integrates emotional functioning

Front 130

A disturbance in cerebral function reflects an alteration in?

Back 130

-emotional or emotional status

Front 131

What are some example of factors that change Cerebral Function?

Back 131

-primary brain d/o
-medication
-metabolic changes

Front 132

An acute mental d/o characterized by confusion, disorientation and restlessness

Back 132

Delirium (common mental d/o in older adults
-often misdiagnosed for dementia
-it is NOT due to a preexisting or evoling dementia.
-develops over a short period of time, usually hors to days and tends to flucutate during the course of the day.
-a direct physiological consequence of a general medical condition
-can occur in younger clients

Front 133

Why is Delirium so often overlooked in older adults?

Back 133

-failure to adequately assess mental status

Front 134

What are the signs/symptoms for Delirium?

Back 134

-reduced clarity of awareness of the environment
-ability fo focus, sustain or shift attention is impaired
-irrelevant stimuli easily distract the person
-change in cognition (memory impairment, disorientation, language disturbacne
-effects recent memory
-language disturbance (inability to name objects)
-perceptual disturbances=hallucination,unsteady gait, tremors, asterixis or myoclonus

Front 135

An objective measurement of consciousness on a numerical scale

Back 135

GLasgow Coma Scale

-allows evaluation of a clients neurological status over time
-the higher the score the better the clients neuro function
-use caution when using the scale if a client has sensory losses (vision/hearing)

Front 136

A response that indicates the absence of muscle tone in the extremities and severe injury to the brain tissue

Back 136

Flaccid

Front 137

What is the normal response to a painful stimuli?

Back 137

withdrawal of the body part

-elicit the pain response by applying firm pressure with the thumb over the root of the clients' fingernail

Front 138

GLASGOW COMA SCALE

*ACTION
1. Eyes Open
What is the response and score?

2. Best Verbal Response:
What is the response and score?

3. Best Motor Response

Back 138

-spontaneoulsy 4
-to speech 3
-to pain 2
-None 1

Oriented 5
confused 4
inappropriate words 3
incomprehensible sounds 2
None 1

Obeys commands 6
localized pain 5
flexion withdrawal 4
abnormal flexion 3
abnormal extension 2
flaccid 1

Front 139

What is Intellectual Function?

Back 139

includes memory (recent, immediate & past)
-knowledge
-abstract thinking
-association
-judgement

Front 140

MEMORY (immediate, past, recent)

How do clients demonstrate IMMEDIATE MEMORY?

Back 140

by repeating a series of numbers (6 9 12), in the order they are presented or in reverse

Front 141

What are some questions to ask the client that will test their PAST MEMORY?

Back 141

-Mother's madien name
-DOB
-special date in history
-ask open-ended questions

*stoke patient's DON'T loss past memory*

Front 142

What question do you ask client that will test their RECENT MEMORY?

Back 142

-Who came to see you today?
-Ask questions that recall events occurring the same day (Vaildate infor w/ family member)

*Stoke patient LOSE their recent memory*

Front 143

What are some questions to ask to assess client's KNOWLEDGE?

Back 143

-ask how much does the client know about their illness or reason for seeking health care

*Helps to determine a clients ablity to learn or understand

Front 144

How do you assess ABSTRACT THINKING?

Back 144

-ask the client the interpretation of a cliche such as "A bird in the hand is worth two in the bush"

*determines a higher level of thought

Front 145

Assessment of APPEARANCE includes:

Back 145

-hygiene
-grooming
-clothing choice

*expected findings: well-kept, clean, and dressed appropriately for the environment or situation

Front 146

GLASGOW COMA SCALE

*ACTION
1. Eyes Open
What is the response and score?

2. Best Verbal Response:
What is the response and score?

3. Best Motor Response

Back 146

-spontaneoulsy 4
-to speech 3
-to pain 2
-None 1

Oriented 5
confused 4
inappropriate words 3
incomprehensible sounds 2
None 1

Obeys commands 6
localized pain 5
flexion withdrawal 4
abnormal flexion 3
abnormal extension 2
flaccid 1

Front 147

Intellectual/Cognitive Function includes?

Back 147

-memory (recent, immediate & past)
-knowledge
-abstract thinking
-association
-judgement

Front 148

MEMORY (immediate, past, recent)

How do clients demonstrate IMMEDIATE MEMORY?

Back 148

by repeating a series of numbers (6 9 12), in the order they are presented or in reverse

Front 149

What are some questions to ask the client that will test their PAST MEMORY?

Back 149

-Mother's madien name
-DOB
-special date in history
-ask open-ended questions

*stoke patient's DON'T loss past memory*

Front 150

What question do you ask client that will test their RECENT MEMORY?

Back 150

-Who came to see you today?
-Ask questions that recall events occurring the same day (Vaildate infor w/ family member)

*Stoke patient LOSE their recent memory*

Front 151

What questions would you ask a client to assess their KNOWLEDGE?

Back 151

-"What do you Know about your about current hospitalization or illness?"

*these questions help to understand client's ability to learn or understand*

Front 152

Asking a client to interpret Cliche such as "a stitch in time saves nine" or "don't count your chickens before they hatch" , is assessing which intellectual function?

Back 152

-ABSTRACT THINKING (this would demonstrate a higher level of thought process)

-client w/ altered mental status will probably interpret the phrase literally or merely rephrase the words

Front 153

When asking client to explain how various concepts are related, such as a creek and a river you are assessing which intellectual functioning?

Back 153

ASSOCIATION-involves finding similarities or associations b/w concepts

*a dog is to a beagle as a cat is to a Siamese

Front 154

Requires a comparison and evaluation of facts and ideas to understand their relationships and to form appropriate conclusions. Which intellectual functioning is being assessing?

Back 154

JUDGEMENT-ask client about the solution to a specific dilemma

"what would you do if you locked your keys in your car?"
(the response should be logical)

Front 155

What are the 6 SENSORY FUNCTION TEST that are performed on all four extremities with the client's eyes closed?

Back 155

1. Pain
2. Temperature
3. Light touch
4. Vibration
5. Position
6.2-Point Discrimination

*perform all test w/ the clients eyes CLOSED!

Front 156

How do you assess for PAIN sensation?

Back 156

-alternating sharp and dull objects on the skin & asking client to report what he feels.

*note areas of numbness or increased sensitivity*

Equip: broken tongue blade
Precautions: areas where skin is thick, such as heel or sole of foot are less sensitive to pain

Front 157

How do you assess for TEMPERATURE?

Back 157

-touch skin w/ test tube, asking client to identify hot & cold sensation

-Equip: 1 test tube w/ hot H2O
1 test tube w/ cold H2O
-Precautions: omit test if pain sensation is normal.

Front 158

LIGHT TOUCH sensory function test includes:

Back 158

-applying different wisp of cotton to different points along skins surface.
-Ask client to voice when the feel a sensation

-Precaution: apply to areas where skin is thin or more sensitive (neck, face, inner aspect of arms, top of feet and hands)

Front 159

Assess VIBRATION sensory function by asking client?

Back 159

-to report when & where they feel the handle of the vibrating tuning fork on the skin

-apply stem of vibrating fork to distal interphalangeal joint of fingers and interphalangeal joint of great toe, elbow and wrist.

-Precautions: be sure client feels vibration and not pressure

Front 160

How do you assess the POSITION sensory function?

Back 160

-by repositioning the client's appendages and asking him to report whether it is positioned up or down. Ask client to state when finger is up or down, alternating w/ the toes (up/down)

-Precautions: avoid rubbing adjacent appendages as you move finger or toe.
-don't move joint laterally;return to neutral positon before moving again.

Front 161

Explain TWO_POINT DISCRIMINATION sensory function test:

Back 161

-use open paper clips or broken tongue blades to determine the distance at which the two points are felt as one
-compare bilaterally
-minimal distance will vary depending on the body part being evaluated (2 to 8 cm)

-apply to the same anatomical site (palm of hand, upper arms, fingertips)

Front 162

What are 2 other DISCRIMINATION test?

Back 162

-stereognosis
-graphesthesia

Front 163

test that uses a familiar object (key, cotton ball) by placing it in the client's hand and asking client to identify object is?

Back 163

Stereognosis

Front 164

Graphesthesia

Back 164

ask client to identify a number drawn on his palm with the blunt end of a pencil

Front 165

What part of the brain controls coordination, balance and reflexes?

Back 165

-cerebellum (motor function)

*Cerebellum coordinates muscular activity, maintains balance and equilibrium and controls posture*

Front 166

How do you assess for COORDINATION?

Back 166

-by asking the client to extend arms and rapidly touch his finger to his nose, alternating hands and then doing the technique w/ eyes closed

-expected findings include:smooth, coordinated mvmt

Front 167

Assess balance by using what to 2 test?

Back 167

1. romberg
2. Heel to toe walk

Front 168

ROMBERG test?

Back 168

-ask client to stand w/ feet at a comfortable distance apart, arms at sides and eyes closed. (30 sec. w/ eyes open, 30 sec. w/ eyes closed)

*Expected findings: client should be able to stand w/ minimal swaying for at least 5 sec.

*loss of balance=Positive Romberg

*assess gross motor function

Front 169

HEEL to TOE WALK?

Back 169

-ask the client to place the heel of one foot in front of the toes of the other foot as he walks in a straight line.

*Expected findings: the client is able to walk in a straight line w/o losing his balance

Front 170

What test is used to assess COORDINATION?

Back 170

-RRAM (assesses fine motor function)

R-apid
R-hymatical
A-lternating
M-ovement

Front 171

2 ways to assess coordination by using RRAM??

Back 171

1. ask client to extend arms and rapidly touch finger to nose, alternating hands, then doing same technique w/ eyes closed.
-Expected findings: smooth, coordinated mvmts

2. upper extremity coordination: touching each finger w/ the thumb of the same hand in a rapid sequence

Front 172

Provides data about the integrity of sensory & motor pathways of th reflex arc & specific spinal cord segments?

Back 172

-Elicting REFLEX (does not determine higher neural center functioning)

Front 173

Each muscle contains a small sensory unit called_________.

Back 173

Muscle spindle which controls muscle tone and detects changes in the length of muscle fibers.

*Reflex hammer=tapping a tendon w/ reflex hammer stretches the muscle & tendons, lengthening the spindle

Front 174

What are the 2 categories of REFLEXES?

Back 174

1. Deep tendon reflexes (DTRs)=elicited by milding strengthing a muscle & tapping a tendon

2. Superficial/Cutaneous Reflex= elicted by stimulating the skin superfically (Babinski reflex)

Front 175

Babinski Reflex?

Back 175

-superficial reflex
-assess w/ head injury
-tests plantar reflex

*Abnormal Finding=
-Positive BABINSKI**= dorsiflexion of great toe w/ or w/o fanning of other toes

Front 176

Why is it normal for an infant to have a "Present Babinski"?

Back 176

-Most newborn babies are not neurologically mature and therefore show a Babinski response. Upon stimulation of the sole, they extend the great toe . Many young infants do this, too, and it is perfectly normal. However, in time during infancy the Babinski response vanishes and, under normal circumstances, should never return.

A Babinski response in an older child or adult is abnormal. It is a sign of a problem in the central nervous system (CNS), most likely in a part called the pyramidal tract.

Asymmetry of the Babinski response -- when it is present on one side but not the other -- is abnormal. It is a sign not merely of trouble but helps to lateralize that trouble (tell which side of the CNS is involved).

Front 177

If superficial reflexes were tested on a 12 month old, what would be the result of the Babinski test?

Back 177

Babinski's reflex is one of the infantile reflexes. It is normal in children up to 2 years old, but it disappears as the child ages and the nervous system becomes more developed. It may disappear as early as 12 months.

The presence of a Babinski's reflex after age 2 is a sign of damage to the nerve paths connecting the spinal cord and the brain (the corticospinal tract). This tract runs down both sides of the spinal cord, therefore a Babinski's reflex can occur on one side or on both sides.

An abnormal Babinski's reflex can be temporary or permanent.

Front 178

Grading of deep tendon reflex(dtf) is done on a scale of ______.

Back 178

- 0 to 4
0= No response

1+ sluggish or diminished

2+ active or expected repsonse

3+ more brisk than expected,
slightly hyperactive

4+ brisk and hyperactive w/ intermittent or transient clonus

Front 179

What reflex grade would a client w/ alcohol, cocaine or opioid intoxication have?

Back 179

4+ hyperactive

Front 180

-acute elevations in Mg levels
-hypoactive Deep tendon reflexes
-decreased depth & rate of respiration, hypotension & flushing

Back 180

_Hypermagnesemia=electrolyte imbalance

*Related Causes:
renal failure
excess oral or parenteral intake of Mg

Front 181

-What is the abnormal flexion position? (medical term)
-assessment of Motor Response using Glasgow Coma Scale (GCS), Flexion Upon Pain (Decorticate) = 3 pts

Back 181

DECORTICATE

Front 182

-Lacking firmness, resilience, or muscle tone

Back 182

FLACCID

Front 183

Using the Glasgow Coma Scale (GCA), how often do you assess a client neruological status changes?

Back 183

-every 15 minutes the 1st hour, then every 30 mins for 1 hour