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80 Cards in this Set
- Front
- Back
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Mental status determine ________ functioning.
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cerebral
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When is mental status assessed?
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during history
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True/False:
Mental status remains constant throughout life. |
False- age related changes occur during growth and development.
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What 5 things compose the mental status exam?
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- general appearance and behavior
- state of consciousness - mood and affect - thought content - intellectual capacity |
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True/False:
When assessing the patient, you should look for symmetry; therefore you always compare left to right. |
true
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When assessing orientation (state of consciousness), you should ask what type of questions to determine mental status?
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Person, place & time
* What is your name? What is your spouse's name? * Where are you? What is the state capitol? * What day is it? What year is it? |
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Eye opening is what component of consciousness?
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arousal
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(def)
aware of self and the environment with the ability to focus and interact |
awareness
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If a person if fully conscious, we document this how?
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awake, alert, and oriented x 4
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What level of consciousness?
disoriented to time, place, person, or situation; short attention span; poor memory; easily bewildered |
confused
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What level of consciousness?
oriented with slow, sluggish speech and mental processes; responds appropriately |
lethargic
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What level of consciousness?
arouses to stimulation; responds with 1-2 words; follows 1 step commands to stimulation |
obtunded
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What level of consciousness?
lies quietly with minimal movement; responds only to vigorous and repeated stimulation; opens eyes and responds to pain appropriately; responds to pain appropriately; makes incomprehensible sounds |
stuporous
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What level of consciousness?
sleep-like state with eyes closed; does not respond appropriately to bodily or environmental stimuli; no verbal sounds |
comatose
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True/False:
A person who cannot be woken should be documented as unconscious on the medical chart. |
False- this is a non-medical term; refer to proper medical terminology
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What are the 5 types of stimuli used to gauge a response (in order, from the first mechanism attempted to the last)?
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1. voice
2. touch 3. shaking 4. voice and shaking 5. noxious/painful stimuli |
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What are the 3 components of the glasgow coma scale?
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1. Eye opening
2. Motor Response 3. Verbal Response |
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A glasgow coma scale score of 13 indicates what?
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mild brain injury
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A glasgow coma scale score of 9-12 indicates what?
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moderate brain injury
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A glasgow coma scale score <8 indicates what?
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severe brain injury
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Language and speech are assessed together. What part of the brain controls this?
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The left (dominant) side
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Which side of the brain controls written and spoken language, reasoning, number skills, scientific knowledge and right hand control.
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The left side
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Which side of the brain controls insight, 3-d forms, art and music awareness, imagination, and left hand control?
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the right side
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(def)
a disorder in processing language |
aphasia
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(def)
a disorder in programming speech (saying the wrong word) |
apraxia of speech
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(def)
a disorder in the mechanics of speech |
dyarthria
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Which Cranial Nerve?
Smell |
CN I (Olfactory)
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Which Cranial Nerve?
vision |
CN II (Optic)
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Which Cranial Nerve?
moves eyes in all directions except outward and down∈ constricts pupil; opens eyelid |
CN III (Oculomotor)
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Which Cranial Nerve?
moves eyes down and in |
CN IV (Trochlear)
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Which Cranial Nerve?
moves eyes outward |
CN VI (abducens)
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What 3 cranial nerves do we check when assessing extraocular muscles?
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III, IV, and VI (3, 4, and 6 make the eyes do tricks)
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How do we assess the pupil's reaction to light?
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penlight is moved from the side to in front of the client's eye; pupil should constrict
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How do we assess the pupil's accommodation?
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The normal pupil constricts when focused on a near object and dilates when focused on a far object
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How do we assess convergence of the eyes?
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Move your finger towards the client's nose; eyes should converge (cross-eyed appearance)
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How are EOM's tested?
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BY assessing cardinal fields of vision for coordination and alignment
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Which Cranial Nerve?
Has 3 branches- sensation to the face; cornea and the scalp; opens jaw against resistance |
CN V (Trigeminal)
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Which Cranial Nerve?
moves the face; taste |
CN VII (Facial)
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Which Cranial Nerve?
Has 2 branches; hearing and balance |
CN VIII (Acoustic)
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Which Cranial Nerve?
moves the pharynx (swallow, speech & gag) |
CN IX (glossopharyngeal)
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Which Cranial Nerve?
Voice Quality |
CN X (Vagus)
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Which Cranial Nerve?
turns head and elevates shoulders |
CN XI (Spinal Accessory)
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Which Cranial Nerve?
moves tongues |
CN XII (hypoglossal)
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What is sixth nerve palsy? How do you assess for it?
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double vision- cover one eye, should correct if positive. Offer a patch over the "good" eye
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(def)
involuntary eye movement |
nystagmus
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Describe how to do a sensory assessment?
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use a wisp of cotton and lightly touch one specific spot, and then the same spot on the other side of the body. Patient says yes when cotton if felt.
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What is a pain assessment?
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using the blunt and sharp points of a reflex hammer, have the client say sharp or dull as you touch anatomical areas at random
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What assessment is done if the pain sensation test results show an area(s) non-reactive to pain?
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the temperature sensation test (test temperature sensation by using hot and cold vials against the skin)
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What are purposeful movements?
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direct, specific movements (scratching nose,etc)
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What are localizing movements?
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moving toward or removing a painful stimulus/moving away from a stimulus
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Moving towards a painful stimulus is an action triggered in what part of the brain?
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cortex
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Moving away from a painful stimulus is an action triggered in what part of the brain?
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hypothalamus
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What are non-purposeful movements?
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flexion, abnormal extension, fisted hands, flexed wrists, etc.
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The cerebellum controls what 3 things?
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1. balance
2. coordination 3. ability to perform skilled movements |
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What part of the brain is tested when assessing coordination, smooth movement, and position sense?
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cerebellum
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How do you perform a cerebellar test?
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- observe for leaning to one side
- test finger to nose, making sure patient fully extends arm **weakness occurs on the side with the deficit** |
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(def)
Loss of the ability to coordinate muscular movement. |
ataxia
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(def)
a lack of coordination of movement typified by the undershoot or overshoot of intended position with the hand, arm, leg, or eye |
dysmetria
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What is the Romberg test and how is it performed?
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- neurological test to detect poor balance and coordination
- have patient stand still with heels together and to close their eyes. If the patient loses their balance, the test is positive |
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What does a Heel-to-toe test assess for?
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Abnormalities in coordination, balance, and ability to perform skilled movements
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How do you assess the motor function of this nerve?:
Radial Nerve |
have client move wrist back and forth
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How do you assess the motor function of this nerve?:
Median nerve |
have client perform thumb opposition with remaining 4 fingers
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How do you assess the motor function of this nerve?:
Ulnar nerve |
abduction of fingers (spread fingers apart)
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How do you assess the motor function of this nerve?:
Femoral nerve |
have the client perform a straight leg raise
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How do you assess the motor function of this nerve?:
Tibial nerve |
have the client plantar flex foot (down)
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How do you assess the motor function of this nerve?:
peroneal nerve |
have the client dorsiflex foot (up)
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How do you assess the sensory function of this nerve?:
radial nerve |
touch the space between the thumb and 2nd finger
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How do you assess the sensory function of this nerve?:
median nerve |
touch or stroke the tip of the second finger
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How do you assess the sensory function of this nerve?:
Ulnar nerve |
touch or stroke tip of the 5th finger
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How do you assess the sensory function of this nerve?:
Femoral Nerve |
stroke the anterior thigh
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How do you assess the sensory function of this nerve?:
tibial nerve |
stroke the sole of the foot
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How do you assess the sensory function of this nerve?:
peroneal nerve |
stroke the web space between the 1st and 2nd toe
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What are 3 causes for injury to the radial nerve?
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1. direct trauma (broken arm)
2. prolonged pressure on the nerve (under arm pressure such as "crutch palsy") 3. compression of the nerve due to swelling or injury to nearby structures |
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How can the median nerve be injured? (3)
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1. trauma
2. entrapment (pressure where the nerve passes through a narrow structure) 3. inflammation |
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Carpal tunnel syndrome is linked to what nerve?
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median nerve
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How can the ulnar nerve be damaged?
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- direct pressure
- prolonged exposure to pressure - compression due to injury or swelling |
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What nerve is commonly injured at the elbow due to elbow fracture or dislocation?
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ulnar nerve
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Prolonged pressure to the base of the palm of the hand may injure what nerve?
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ulnar nerve
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The tibial and peroneal nerves are branches of what larger nerve?
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sciatic nerve
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Injury to the knee, leg, or fibula could damage what nerve?
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peroneal nerve
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