U of R SCHOOL OF NURSING > CLASS 3 - NEUROLOGICAL ASSESSMENT > Flashcards

CLASS 3 - NEUROLOGICAL ASSESSMENT Flashcards

(62 cards)

Study These Flashcards
1
Q

CNS COMPONENTS

A
  • Brain

- Spinal cord

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

PNS COMPONENTS

A
  • 12 cranial nerves

- 31 pairs of spinal nerves

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

BRAIN COMPONENTS

A
  • Frontal lobe
  • Temporal lobe
  • Parietal lobe
  • Occipital lobe
  • Cerebellum
  • Brain stem
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

FRONTAL LOBE ACTIONS

A
  • Personality
  • Behavior
  • Intelligence
  • Emotion
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

TEMPORAL LOBE ACTIONS

A
  • Smell
  • Taste
  • Hearing
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

PARIETAL LOBE ACTIONS

A
  • Sensation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

OCCIPITAL LOBE ACTIONS

A
  • Visual
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

CEREBELLUM ACTIONS

A
  • Motor

- Balance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

BRAIN STEM ACTIONS

A
  • Autonomic nervous system
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

SPINAL CORD COMPONENTS

A
  • Extends 1st cervical vertebrae to the 1st lumbar vertebrae
  • Protected by the spinal vertebrae
  • Facilitates communication between the brain and periphery
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

SPINAL NERVE COMPONENTS

A
  • 31 pairs of spinal nerves
  • 8 cervical
  • 12 thoracic
  • 5 lumbar
  • 5 sacral
  • 1 coccygeal
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

CRANIAL NERVE COMPONENTS

A
  • Nerves that emerge directly from the brain - Divided based on specific functions
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

TYPES OF NEUROLOGIC ASSESSMENT

A
  • Screening neurologic exam
  • Complete neurologic exam
  • Neurologic recheck exam
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

PAST MEDICAL HISTORY ASSESSMENT

A
  • Hypertension
  • Seizures
  • Headaches
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

PERSONAL/SOCIAL HISTORY ASSESSMENT

A
  • Environmental hazards

- Exposure to insecticides, lead, radiation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

LIFESTYLE/HEALTH PRACTICES HISTORY ASSESSMENT

A
  • Diet/exercise
  • Smoking/alcohol or substance abuse
  • Safety practices
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

FAMILY HISTORY ASSESSMENT

A
  • Hypertension
  • Stroke
  • Cancer
  • Cardiac/renal disease
  • Bleeding disorders
  • Seizure disorders
  • Brain tumors
  • Neurological disorders (Alzheimer’s, dementia, Parkinson’s, ALS)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

REVIEW OF SYSTEMS ASSESSMENT

A
  • Headaches, trauma, dizziness, fainting, loss of balance
  • Weakness, numbness, tingling
  • Visual disturbance, double vision photophobia
  • Difficulty with swallowing/speaking
  • Motor deficit, incontinence
  • Memory, thought process, speech, mood, or personality changes
  • Seizures, tremors
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

RISK FACTORS FOR NEUROLOGIC IMPAIRMENT

A
  • Hypertension*
  • Chronic atrial fibrillation and flutter
  • Obesity*
  • Sedentary life-style*
  • Smoking tobacco products*
  • Stress*
  • Increased levels of serum cholesterol, lipoproteins, and triglycerides*
  • Use of oral contraceptives in high-risk women*
  • Family history of diabetes mellitus, CVD, hypertension, increased serum cholesterol levels
  • Congenital cerebrovascular anomalies
  • Modifiable risk factors - Health Promotion Opportunities
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

PHYSICAL EXAMINATION ASSESSMENT

A
  • Mental status: LOC, speech, cognitive, orientation, memory function, emotional status
  • Glasgow coma scale
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

T/F: Level of consciousness is the most sensitive indicator of neurologic deterioration

A
  • True
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

ALERTNESS LOC EXAMINATION ASSESSMENT

A
  • Speak to patient in a normal tone of voice

- Alert patient opens eyes, looks at you, responds fully and appropriately to stimuli

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

LETHARGY LOC EXAMINATION ASSESSMENT

A
  • Speak to the patient in a loud voice
  • Call the patient’s name or ask “how are you?”
  • Patient appears drowsy but opens eyes and looks at you
  • Responds to questions then falls asleep
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

OBTUNDATION LOC EXAMINATION ASSESSMENT

A
  • Shake patient gently
  • Patient opens eyes and looks at you
  • Responds slowly and somewhat confused
  • Alertness and interest are decreased
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
STUPOR LOC EXAMINATION ASSESSMENT
- Apply a painful stimulus (pinch tendon) - Arouses from sleep only after painful stimuli - Responses slow or absent - Lapses into unresponsive state when stimulus ceases - Minimal awareness
26
COMA LOC EXAMINATION ASSESSMENT
- Apply repeated painful stimuli - Unarousable with eyes closed - No evident response to inner need or external stimuli
27
GLASGOW COMA SCALE
- Objective assessment that defines level of consciousness by giving it a numeric value - Divided into: eye opening, verbal response, motor response - Monitors for trends of neurologic deterioration - Minimum score = 3 - Maximum score = 15 - Coma = < 8
28
CRANIAL NERVE I ASSESSMENT ASSESSMENT
- OLFACTORY | - Occlude each nostril and test different smells
29
CRANIAL NERVE II ASSESSMENT
- OPTIC - Test visual acuity with Snellen chart/card - Inspect fundi - Screen visual fields by confrontation
30
CRANIAL NERVE III, IV, VI ASSESSMENT
- OCULOMOTOR, TROCHLEAR, ABDUCENS - Inspect pupils - Test extra ocular movements in 6 directions of (EOM's) - Test convergence (corneal light reflex)
31
CRANIAL NERVE V ASSESSMENT
- TRIGEMINAL - Palpate temporal and masseter muscles while patient is clenching - Light touch on forehead, cheek and jaw - Sharp and dull sensation on forehead, cheek and jaw
32
CRANIAL NERVE VII ASSESSMENT
- FACIAL - Assess for asymmetry, tics, abnormal movements - Raise eyebrows - Frown - Close eyes tightly - Smile - Grimace - Puff both cheeks
33
CRANIAL NERVE VIII ASSESSMENT
- ACOUSTIC | - Test hearing by: whisper test, weber, and rinne test
34
CRANIAL NERVE IX & X ASSESSMENT
``` - GLOSSOPHARYNGEAL, VAGUS Assess if voice hoarse - Say "AH" - Gag reflex - Assess swallow ```
35
CRANIAL NERVE XI ASSESSMENT
- SPINAL - Assess strength - Patient shrugs shoulders up against your hands - Contraction of opposite sternocleidomastoid muscle as patient forces head against your hand
36
CRANIAL NERVE XII ASSESSMENT
- HYPOGLOSSAL - Assess for symmetry, atrophy - Patient to protrude tongue and move side-to-side and up-and-down
37
SENSORY SHARP/DULL ASSESSMENT
- U/L & bi-lateral extremities able to distinguish sharp/light touch - Eyes closed - Start distally and prick area on both sides and ask if sensation is sharp or dull
38
SENSORY LIGHT TOUCH ASSESSMENT
- Light touch using cotton wisp and ask if patient feels touch
39
SENSORY VIBRATORY SENSE ASSESSMENT
- Tap 128 Hz tuning fork on the DIP joint of the patient's finger - "What do you feel?" - "Tell me when it stops"
40
DISCRIMINATIVE SENSATION ASSESSMENT FACTORS
- Stereognosis - Graphesthesia - 2-Point discrimination - Localization - Extinction
41
STEROGNOSIS ASSESSMENT
- Place familiar object in patient's hand and ask to identify object
42
GRAPHESTHESIA ASSESSMENT
- Outline a number in the patient's palm and ask to identify number
43
TWO-POINT DISCRIMINATION ASSESSMENT
- Using two ends of an opened paper-clip, touch finger pad in two places simultaneously - Ask the patient to identify 1 or 2 touches
44
LOCALIZATION ASSESSMENT
- Touch a point on the patient's skin and ask the patient to point to that spot
45
EXTINCTION ASSESSMENT
- Touch 1 or 2 points on the patient's skin and ask them to tell you where you pointed
46
MOTOR FUNCTION ASSESSMENT FACTORS
- Balance, gait, coordination - Romberg test - Pronator drift - Rapid alternating movements (RAM) - Finger-to-nose or finger-to-finger - Heel-to-shin
47
BALANCE, GAIT, COORDINATION ASSESSMENT
- Have patient walk across room - Walk heel-to-toe - Walk on toes then on heels - Hops in place
48
ROMBERG ASSESSMENT
- Have patient stand with feet together and arms at sides - Close eyes and stand for 20-30 seconds - Loss of balance = positive test - Always be guarding in case patient starts to sway!
49
PRONATOR DRIFT ASSESSMENT
- Have patient stand with feet together and arms straight forward, palms up - Close eyes for 20-30 seconds and examiner taps arms briskly downward - Pronation and downward drift of the arm = positive test
50
RAPID ALTERNATIVE MOVEMENTS ASSESSMENT
- Patient turns hand rapidly over and back on thigh - Taps tip of index finger rapidly on distal thumb - Taps ball of foot rapidly on your hand
51
FINGER-TO-NOSE ASSESSMENT
- Patient touches nose then your index finger as you move it different positions
52
HEEL-TO-SHIN ASSESSMENT
- Patient moves heel from opposite knee down the shin to the big toe and back up
53
DEEP TENDON REFLEX ASSESSMENT FACTORS
- Biceps - Triceps - Brachioradialis - Patellar - Achilles - Plantar Response (+/- Babinski) - Assess for Clonus - Graded 0 to 4+ scale
54
0 - 4+ DEEP TENDON GRADING SCALE
- 4+ : Very brisk, hyperactive, with clonus - 3+ : Brisker than average, but not necessarily indicative of disease - 2+ : Average; normal - 1+ : Somewhat diminished; low normal - 0 : No response
55
BICEPS TENDON ASSESSMENT
- Place thumb on palpated biceps tendon | - Strike thumb with a brisk, direct movement
56
TRICEPS TENDON ASSESSMENT
- Palpate triceps tendon and strike with a brisk, direct movement
57
BRACHIORADIALIS TENDON ASSESSMENT
- Hold thumb of hand you are planning to test (helps relax wrist) - Strike right below the bony protrusion on the wrist - Can feel the thumb vibrate
58
PATELLAR TENDON ASSESSMENT
- Strike the patellar tendon with a brisk, direct movement
59
ACHILLES TENDON ASSESSMENT
- Hold the foot in dorsiflexion and strike the achilles tendon directly
60
PLANTAR RESPONSE ASSESSMENT
- Drag of object in a j motion starting at the heel on the lateral side, ending at the big toe Curling in of toes (normal) - Fanning out of toes (abnormal)
61
CLONUS
- Tested when the reflexes are hyperactive | - Rapid, rhythmic contractions of the calf muscle and movement of the foot
62
FURTHER NEUROLOGIC ASSESSMENT
- Mental status changes or change from baseline - Known or suspected brain lesion (stroke, tumors, trauma) - Memory deficits or confusion - Vague behavioral complaints from friends or family - Aphasia - Irritability - Motor or sensory deficits
U of R SCHOOL OF NURSING
flashcards
Decks in class (12)
# Cards
Brainscape helps you reach your goals faster, through stronger study habits.
© 2026 Bold Learning Solutions. Terms and Conditions