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69 Cards in this Set

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List the 12 Cranial Nerves
Olfactory, Optic, Oculomotor, Trochlear, Trigeminal,Abducens, Facial, Acoustic, Glossopharyngeal, Vagus, Spinal Accessory, Hypoglossal
List the 12 cranial nerves function, sensory, motor, or both
1 sensory 2 sensory 3 motor 4 motor 5 both 6 motor 7 both 8 sensory 9 both 10 both 11 motor 12 motor
How many spinal nerves are there and what are they called?
31 pair, dermatomes
List some risk factors for CVA. (10/12)
Older,African American,Obesity,Males,Familyhx,Pain meds,HTN,Previous CVA,TIA,DM,CAD,smoking
Give the minimal distance to the area for 2-point discrimination.

· Palm of hand
· Upper arms
· Fingertips
· Forearms
·Palm of hand- 8-12 mm or inch
· Upper arms – 3 inches
· Fingertips – 2-8mm
· Forearms – 1 1/2 inches
What lobe of the brain is responsible for sensation?
Parietal
What would be a positive/abnormal finding for the Babinski’s test?
Dorsiflexion of the great toe
What DTR’s do we perform in our check off assessment?
1. biceps
2. Triceps
3. Brachioradialis
4. Patellar
5. Achilles
6. Babinski’s
What would be an abnormal finding of stereognosis test and what is it an indicator of?
Unable to identify object in hand. Parietal lobe dysfunction or sensory nerve tract
Where does brain activity cease when a pt is in a coma?
There is no activity above the brain stem
Write the DTR scoring with the correct description…

______ brisk, clonus
______ Sluggish / diminished
______ No response
______ Active / expected
______ slightly hyperactive
__4+____ brisk, clonus
__1+____ Sluggish / diminished
__0 ____ No response
__2+____ Active / expected
__3+____ slightly hyperactive
What score is considered abnormal when assessing a client with the Glascow Coma Scale?
Less than 14 is considered abnormal
List some risk factors for hearing loss… (4/6)
Environmental noise, Autoimmune disease,Medications,hx of congenital hearing loss,Family hx, Age
What does tenderness of the mastoid area indicate?
Mastoiditis
What is the description of cerumen of dark and white skinned individuals?
Moist, sticky, and dark
What is the description of cerumen for Asians, Native Americans, and Alaskans?
Sparse, flaky, dry, and light
What tests would you perform to evaluate CN VIII and explain abnormals…
1.Whispered Test – under 50% of words repeated
2.Finger Rub test – if unable to hear, high frequency hearing loss
3.Weber’s Test – if not heard equally in both ears
4.Rinne test – if bone conduction is less than ½ of air conduction
What FHP is used in the assessment of CN’s?
Cognitive / Perceptual
What tests do you perform for coordination?
Rapid movements
Finger to nose
Finger to thumb
Heel to shin
What arteries supply 80% of the blood to the brain?
Carotid
What arteries supply 20% of the blood to the brain?
vertebral
What 2 components make up the Autonomic Nervous System, describe.
Sympathetic Nervous System – fight or flight response
Parasympathetic Nervous system – breed and feed
What components make up the CNS?
Brain and Spinal Cord
What components make up the PNS?
Cranial Nerves
Spinal Nerves
List and give a description of the ABCd’s of pain
A – affect – crying, anger

B – behavioral – what are they doing?

C – cognitive – what does this pain mean?

D – description – sharp, throbbing, rating
What is the proper degree of ear position and alignment? How else would you measure proper ear alignment?
10o and on a plane with occipit line
What does the Romberg test look for?
Tests for balance or equilibrium problems
In older adults, how does hearing loss generally proceed?
High frequency hearing loss to lower frequency hearing loss
List and describe some common problems with the ears and auditory system
obstructed ear canal – excessive cerumen,Foreign body,otitis externa (swimmers ear), Acute otitis media (infection of middle ear),Conductive hearing loss (air conduction),Sensorineural hearing loss (nerve of inner ear)
What are some abnormal conditions of the eye?
· Cataracts
· Glaucoma
· Macular degeneration
Describe how the following cultures possibly react to pain. Asians - hispanics –
Native Americans - Japanese –
Kenyans - Italians -
Asians - stoic hispanics – vocal Native Americans - stoic Japanese – stoic
Kenyans - stoic Italians - vocal
Name the 4 lobes of the brain and their functions
1.Frontal – motor, Broca’s area, awareness of self, emotion
2.Parietal – sensory, senses, touch, shapes and texture
3.Temporal – auditory, language comprehension
4.Occipital – visual
For what Snellen or Rosenbaum reading do you refer your pt to the optometrist?
Greater than 20/30
What is presbyopia?
Loss of elasticity of the lens of the eye
Give the terms and abbreviations for the following….

Right eye

Left eye

Each eye
Right eye – oculus dexter - OD

Left eye – oculus sinister - OS

Each eye – oculus uterque - OU
What 3 FHP’s can be used for Mental Status / Pain?
·Cognitive / Perceptual
·Coping – Stress Tolerance
·Self Perception – Self Management
What rating is considered legally blind?
20/200
What tests do we perform for meningeal inflammation? Please describe how each is performed
Kernig’s – lying flat, flex hip and extend knee
Brudinski’s – lying flat, flexion of neck
What would be an abnormal finding of the above tests?
Pain or reaction of the fetal position
What are Deep Tendon Reflex’s?
Spinal cord segmental responses
What is esotropia?
Inward (medially) deviation of the eye
What is exotropia?
Outward (laterally) deviation of the eye
What does and abnormal light reflection indicate?
Weak extraocular muscles
What test do you perform if the light reflection is asymmetrical?
Cover / uncover test
What is perception and how does it affect mental status?
The perception of a recent life even determines a person’s emotional or psychological reaction to it.
What is known as the emotional brain?
Limbic system
What are the 3 neurotransmitters that regulate mood and maintain arousal?
· Norepinephrine
· Serotonin
· Dopamine
Holmes Readjustment Scale – what does it measure for
· Mental health / stress
In the Holmes Readjustment Scale, what levels are considered “good” and describe its findings.
· Under 150 with a 1 in 3 chance of developing a serious illness in 2 years
What other scales can you use for a mental health assessment?
· Beck Depression
· Yesavage Geriatric Depression Scale
What would you include in your exam of a depressed client?
· Posture
· Movement
· Dress
· Hygiene
· Speech
· B/P
· H/R
· RR
· Weight
· UBW%
· Orientation tests
· Short memory
· Calculation
· Language
· Judgment
· Abstract
How do we rate pain?
On a scale of 1-10 with 0 being no pain and 10 being worst pain ever felt
How do we, as nursing students and future nurses, view a patient’s pain?
Pain is whatever a client says it is whenever a client says it occurs
What chemicals are released at the time of pain?
Prostaglandins
List the risk factors for depression (4/5)
1. Female (2:1)
2. Age (adolescents, adults btwx 24-44)
3. Genetics
4. Psychosocial environment (abuse, alcoholism, losses)
5. Personal characteristics (low self esteem, pessimistic
List the risk factors for anxiety (3/3)
1. Genetics
2. Physical health (sleep deprivation)
3. Psychosocial environment (finances, health, school work)
a. (****hahahahah ANY NURSING STUDENT AT USF
List the type of pain for the following descriptions:
· Phantom pain - true pain, produced by stimulation of a nerve
· Chronic pain - > 6 months
· Referred pain - pain in same spinal cord segment
· Acute pain - < 6 months, usually due to tissue damage
What is the condition called in which the eyes are not directed at the same object or point?
Strabismus
What condition can cause yellowing of the sclera?
Jaundice
What condition is caused by opacity of the crystalline lens?
Cataracts
What is glaucoma?
Increase in intraocular pressure
What superficial reflexes do we perform in our check off assessment (one currently and one previously)?
Babinski’s and Abdominal
What governing body do we use for our Pain standards?
JCAHO
What is the Gate theory of pain?
That is the gate can be blocked by other stimulus, the pain will not be felt or as severe.
What are the 4 steps of pain explain each.
1. Transduction – stimulus causes tissue damage releasing action potential and sensitizing substances
2. Transmission – action potential from site of damage to spinal cord
3. Perception – conscious experience of pain
4. Modulation – brain tries to inhibit impulses
What 3 scales do we use to assess pain?
1. McGill Pain Questionnaire
2. Analog Scales
3. FACES
What are some indicators of Pain in older adults?
· Fatigue
· Lethargy
· Anorexia
Under what conditions in older adults can pain go under detected?
· Dementia
· Denial
· Distraction
Pain is an expected part of aging
False?