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109 Cards in this Set
- Front
- Back
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What are 16 ways to assess the mental status?
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appropriate answers?...
behavior and facial expressions appropriate?... speech pattern of normal tone, rate, rhythm, volume?... answers complete?... appearance neat or untidy?... appearance appropriate for age?... appearance appropriate for current weather?... cooperative?... euphoric?... hostile?... anxious?... withdrawn?... guarded?... hallucinations?... delusions?... posture and hygiene appropriate?... |
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Glasgow Coma Scale
Eye Opening? |
spontaneous 4
to sound 3 to pain 2 never 1 |
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Glasgow Coma Scale
Motor Response? |
obeys commands 6
localizes pain 5 normal flexion (withdrawal) 4 abnormal flexion 3 extension 2 none 1 |
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Glasgow Coma Scale
Verbal Response? |
oriented 5
confused conversation 4 inappropriate words 3 incomprehensible sounds 2 none 1 |
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Highest possible score of Glasgow Coma Scale is?
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15
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Go over stick scale figure 44-11
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okay
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Special considerations are taken for clients who will receive a contrast agent as part of their diagnostic test.
Following institutional guidelines regarding ____ ____? |
informed consent
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Special considerations are taken for clients who will receive a contrast agent as part of their diagnostic test.
Determine whether the client has any _____ or ____ restriction before the test. |
food or fluid
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Special considerations are taken for clients who will receive a contrast agent as part of their diagnostic test.
Ask client about allergies to ___ ____, ____, or ____. |
contrast agents
shellfish iodine |
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Determine the factors for contrast-induced nephropathy (renal damage) which include?
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pre-existing renal disease
diabetic nephropathy heart failure dehydration medications that interfere with renal perfusion, such as metformin (diabetic clients on the metformin require preprocedure and postprocedure changes in their medication regimen) |
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Notify ____ if client has reported a risk factor.
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hcp
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Checking the client's ____ level (Clients with a level greater than _____ are more at risk for contrast-induced nephropathy.)
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creatinine
1.5 mg/dL |
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CSF pressure of less than 20 cm H20 is considered?
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normal range
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If color or appearance of CSF is clear and colorless, it's considered?
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normal
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If color or appearance of CSF is pink-red to orange, it indicates that?
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red blood cells present
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If color or appearance of CSF is yellow, it indicates that?
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bilirubin present owing to hemolysis of rbcs; possible causes include:
subarachnoid hemorrhage jaundice increased CSF protein hypercarotenemia hemoglobinemia |
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If color or appearance of CSF is brown, it indicates?
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methemoglobin present, indicating meningeal hemorrhage
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If color or appearance is unclear or hazy, it indicates?
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cell count is elevated
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If the CSF contains cells that are 0-5 small lymphocytes/mm3, it indicates?
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normal
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If the CSF contains cells that are more than 5 lymphocytes/mm3, it indicates?
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reaction to infection, tumor, chemical substance, or blood
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If proteins in CSF total 15-45 mg/dL, it indicates?
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normal
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If proteins in CSF total 45-100 mg/dL, it indicates?
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paraventricular tumor
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If proteins in CSF total 50-200 mg/dL, it indicates?
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viral infection
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If proteins in CSF total more than 500 mg/dL, it indicates?
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bacterial infection, Guillain-Barre syndrome
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If proteins in CSF total less than 15 mg/dL, it indicates?
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meningismus
pseudotumor cerebri hyperthyroidism normal finding after lumbar puncture |
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In CSF, if immune gamma globulin (IgG, the most important protein) is 3% to 12% of total protein, then it's considered?
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normal
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In CSF, if immune gamma globulin (IgG, the most important protein) is more than 3% to 12% of total protein, it's considered?
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multiple sclerosis
neurosyphilis viral infection |
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In CSF, if albumin/globulin ratio is 8:1, it's considered?
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normal
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In CSF, if glucose is 50 to 75 mg/dL or 60% to 70% of blood glucose level, it's considered?
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normal
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In CSF, if glucose is less than 50 mg/dL (usually accompanied by the presence of pathologic organisms), it indicates?
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bacterial, fungal, or viral
meningitis CNS leukemia cancer |
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In CSF, normal lactic acid is?
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10-25 mg/dL
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In CSF, if lactic acid is more than 10-25 mg/dL, then it might indicate (2)?
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systemic acidosis
increased CSF glucose metabolism |
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In CSF, if glutamine is less than 20 mg/dL, then it's considered?
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normal
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In CSF, if glutamine is more than 20 mg/dL, it's considered?
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hepatic coma or cirrhosis of liver
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In CSF, if lactate dehydrogenase is 10% of serum level or 2.0-7.2 units/mL, then it's considered?
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normal
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In CSF, if lactate dehydrogenase is more than 10% of serum level, then it may indicate?
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bacterial meningitis
inflammatory diseases of CNS |
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If a client is having an electroencephalogram, thoroughly explain the procedure to the patient.
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okay
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If a client is having an electroencephalogram, if the order is for theh client to be "sleep deprived", tell the client to awaken about ___ to ___ a.m. and to stay awake for the rest of the night.
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2 to 3 a.m.
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If a client is having an electroencephalogram, instruct the client to avoid ___ ____ or _____; without _____ only if instructed by the physician
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CNS depressants
stimulants anticonvulsants |
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If a client is having an electroencephalogram, tell the client not to drink _____-____ fluids, such as coffee or tea, on the day of the test
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caffeine-containing
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If a client is having an electroencephalogram, reassure the client that the test is not ____ or _____.
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dangerous
uncomfortable |
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If a client is having an electroencephalogram, ask the client to wash ____ on the morning of the test and to remove all ____, ____, or ____.
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hair
hairpins, sprays, oils |
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If a client is having an electroencephalogram, inform the client that the hair will need to be washed again after the test to remove the ____ ____.
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electrode glue
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Name the sites of acetylcholine?
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brain
brainstem basal ganglia ANS |
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Name the function of acetylcholine?
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nerve and muscle transmission...
parasympathetic and preganglionic sympathetic system... |
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Name the action of acetylcholine?
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excitatory, but some inhibitory
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Name the action of serotonin?
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medial brainstem
hypothalamus dorsal horn of spinal cord |
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Name the function of serotonin?
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possible onset of sleep, mood control;
pain pathway inhibitor in spinal cord |
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Name the action of serotonin?
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inhibitory
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What are 2 catecholamines?
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dopamine
norepinephrine (epinephrine parallels) |
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What is the site for dopamine?
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substantia nigra to basal ganglia
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What is the function for dompamine?
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complex movements emotional response regulation, attention
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What is the action of dopamine?
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usually inhibitory
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What is the site for NE?
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hypothalamus
brainstem reticular formation cerebellum sympathetic nervous system |
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What is the function of NE?
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maintenance of arousal, reward system, dreaming sleep, mood regulation
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What is the action of NE?
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mainly excitatory
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Name 4 amino acids that are transmitters?
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aspartate
gamma-aminobutyric acid (GABA) glutamate glycine |
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What is the site for transmitter aspartate?
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brain
spinal cord interneurons |
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What is the function for transmitter aspartate?
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sensation
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What is the action for transmitter aspartate?
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excitatory
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Where is the site for transmitter gamma-aminobutyric acid (GABA)?
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brain
brainstem basal ganglia ANS |
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What is the function of transmitter gamma-aminobutyric acid (GABA)?
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nerve and muscle transmission
possibly one third of brain neurons |
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What is the action of gamma-aminobutyric acid (GABA)?
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inhibitory
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What is the site for transmitter glutamate?
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sensory pathways
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What is the function for transmitter glutamate?
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sensation
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What is the action for transmitter glutamate?
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excitatory
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What is the site for glycine?
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spinal cord interneurons
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What is the function of glycine?
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muscle control
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What is the action of glycine?
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inhibitory
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What are 2 transmitter peptides?
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substance P
endorphine, enkephalins |
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What is the site for transmitter peptide substance P?
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brain
neurons in spinal cord |
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What is the function for transmitter peptide substance P?
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pain transmission
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What is the action for transmitter peptide substance P?
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excitatory
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What is the site for transmitter peptide endorphins, enkephalins?
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thalamus
hypothalamus spinal cord pituitary |
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What is the function for transmitter peptide endorphins, enkephalins?
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pleasure sensation
reward system analgesia (inhibits release of substance P), released with ACTH (corticotropin) during stress |
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What is the action for peptide transmitter endorphins, enkephalins?
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probably excitatory
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What are two transmitter gases and where are their sites?
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nitric acid
carbon monoxide neurons |
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What is the function for transmitter gas nitric acid?
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not stored in specific site; made by enzymes as needed; released by diffusion
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What is the action for transmitter gas nitric acid?
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excitatory
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The function and action of the transmitter carbon monoxide is?
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not well understood and questionable
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The transmitters that are excitatory are?
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acetylcholine
NE aspartate glutamate substance P nitric acid endorphins, enkephalins (probably) |
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The transmitters that are inhibitory are?
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serotonin
dopamine (usually) gamma-aminobutyric acid (GABA) glycine |
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The 5 cranial lobes are?
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frontal
limbic occipital parietal temporal |
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What are the functions of the frontal lobe?
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primary motor area ("strip")
Broca's speech center on dominant side voluntary eye movement sensory data (access to current) past information or experience (access to) affective response to a situation regulates behavior based on judgment and foresight judgment long-term goals (ability to develop) reasoning, concentration, abstraction |
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What are the functions of the parietal lobe?
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understand sensation,
texture, size, shape, and spatial relationships 3-dimensional (spatial) perception important for singing, playing musical instrument, and processing nonverbal visual experiences perception of body parts and body position awareness taste impulses for inter- pretation |
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What are the functions of the temporal lobe?
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auditory center for sound
interpretation complicated memory patterns Wernicke's area for speech |
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What are the functions of the occipital lobe?
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primary visual center
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What are the parts of the diencephalon?
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thalamus
hypothalamus epithalamus subthalamus |
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The function of the thalamus is?
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all sensation except smell
sensation perceived at the thalamic level is crude and cannot be localized or qualified |
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The function of the hypothalamus is?
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regulates water metabolism,
appetite, sleep-wake cycle, temperature control, and thirst hormonal activity posterior pituitary hormones, such as vasopressin and oxytocin anterior pituitary hormone excretion growth, thyrotropin, and follicle-stimulating hormones, prolactin, and corticotropin regulates emotions and controls basic drive for self-preservation |
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The function of the epithalamus is?
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often calcified by young
adulthood and is radiopaque used as a point of reference on an x-ray film or a computed tomography scan |
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The function of the subthalamus is?
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contains sensory tracts
connectors to basal ganglia |
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What are the 3 brainstem structures?
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medulla
pons midbrain |
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What are the functions of the medulla?
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cardiac-slowing center
respiratory center cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic) |
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What are the functions of the pons?
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cardiac acceleration and
vasoconstriction centers pneumotaxic center helps control respiratory pattern and rate four cranial nerves originate from the pons: V (trigeminal), VI (abducens), VII (facial), VIII (acoustic) |
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What are the functions of the midbrain?
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contains the cerebral
aqueduct or aqueduct of Sylvius location of periaqueductal gray, which may abolish pain when stimulated cranial nerve nuclei III (oculomotor) and IV (trochlear) located here |
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What are some inherited diseases?
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Huntington
neuromuscular disorders movement disorders migraine headaches epilepsy (mutated ion channels for the last 4) Alzheimers multiple sclerosis |
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Which 2 diseases have been tied to neurofilament mutations?
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Parkinson disease
amyotropic lateral sclerosis |
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Changes in ADLs might be a result of subtle changes in ____ function.
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neurologic
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It's important to find out if the patient is left-handed or right-handed because?
The client may be somewhat stronger on the 1____ side. The effects of cerebral injury or disease are more pronounced if the 2____ hemisphere is involved |
1 dominant
2 dominant |
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Assess the following 3 when assessing sensory function?
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pain
temperature touch |
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Assess the following when assessing mental status?
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LOC
memory attention language and coping cognition |
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When assessing cerebellar function, be sure to assess these 3?
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coordination
gait equilibrium |
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When assessing motor function, be sure to assess these 2?
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muscle strength
cerebral/brainstem integrity |
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When taking a pain assessment, start with the ____ noxious irritation or pressure and move upward if patient doesn't respond...gently shake...if no response, move to these areas in this order?
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least
supraorbital pressure trapezius squeeze mandibular pressure sternal rub |
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How to apply supraorbital pressure (first method)?
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place thumb under orbital rim in middle of eyebrow and push upward...don't use if client has orbital or facial fractures
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The second technique to assess painful stimuli is to 1_____ or 2____ the trapezius muscle located at the angle of the shoulder and neck muscle. If client remains unresponsive, apply pressure to the 3_____ using index and middle fingers. If the client doesn't respond, make a fist and rub the 4_____ of the hand against the sternum in a twisting motion. The tissue in this area is tender, and 5_____ is not unusual. Therefore exercise judgment regarding the value of the information gained from frequent or prolonged sternal rubs.
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1 pinch
2 squeeze 3 mandible 4 knuckles 5 bruising |
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The initial response to pain may be abnormal 1____ or 2____. Continued application of pain for no more than 3____ to ____ seconds may demonstrate that patient can localize or withdraw. If the client doesn't respond after 4____ to ____ seconds, it isn't necessary to continue applying the painful stimulus.
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1 flexion
2 extension 3 20 to 30 4 20 to 30 |
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If the client responds by moving, but not all extremities move, assess the ____ response to pain. Place a pen or pencil on top of the client's ___ ___ at the base of the cuticle and apply pressure. This maneuver is performed only on the extremity that did ___ move.
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peripheral
nail bed not |
