NURSING EXAM 3 FULL STUDY GUIDE

Ataxia

Lack of coordination.

Dysarthria

Slurred speech.

Aphasia

Inability to speak or understand language.

Syncope

Temporary loss of consciousness.

Vertigo

Spinning sensation.

Decorticate posture

Flexed arms; indicates brain damage.

Decerebrate posture

Extended arms; indicates severe brain injury.

Seizure (tonic)

Stiffening.

Seizure (clonic)

Jerking.

Postictal

State after a seizure.

Ascites

Fluid in the abdomen.

Melena

Black tarry stool indicating upper GI bleed.

Hematochezia

Bright red blood in stool.

Rebound tenderness

Pain when pressure is released.

Tympany

Drum-like sound indicating gas.

Dullness

Dense sound indicating mass or fluid.

Peritonitis

Inflammation of the peritoneum.

Aneurysm

Vessel dilation with AAA risk.

Kyphosis

Exaggerated thoracic curve.

Lordosis

Inward lumbar curve.

Scoliosis

Lateral spine curvature.

Crepitus

Crackling in joints.

Contracture

Permanent muscle shortening.

Foot drop

Inability to dorsiflex foot.

Range of Motion (ROM)

Joint movement.

Muscle strength grading

Scale from 0–5; 5 equals normal.

DTRs

Deep tendon reflexes scale from 0–4+, with 2+ being normal.

CN I

Cranial nerve responsible for smell.

CN II

Cranial nerve responsible for vision.

CN III, IV, VI

Cranial nerves responsible for eye movement.

CN V

Cranial nerve responsible for facial sensation.

CN VII

Cranial nerve responsible for facial expression.

CN VIII

Cranial nerve responsible for hearing and balance.

CN IX, X

Cranial nerves responsible for swallowing.

CN XI

Cranial nerve responsible for shoulder shrug.

CN XII

Cranial nerve responsible for tongue movement.

What does melena indicate?

It indicates an upper GI bleed.

Which posture indicates severe brain injury?

Decerebrate posture.

What is normal DTR?

Normal DTR is 2+.

What is ataxia?

Ataxia is a lack of coordination.

What assessment finding suggests AAA?

Aneurysm indicates AAA risk.

CN I (Olfactory)

Smell

CN II (Optic)

Vision

CN III (Oculomotor)

Pupil constriction, eye movement

CN IV (Trochlear)

Downward eye movement

CN V (Trigeminal)

Facial sensation, chewing

CN VI (Abducens)

Lateral eye movement

CN VII (Facial)

Facial expressions, taste (anterior)

CN VIII (Acoustic)

Hearing & balance

CN IX (Glossopharyngeal)

Taste (posterior), gag reflex

CN X (Vagus)

Swallowing, parasympathetic

CN XI (Spinal Accessory)

Shoulder shrug, head turn

CN XII (Hypoglossal)

Tongue movement

Inspection, Auscultation, Percussion, Palpation

The correct order of abdominal assessment.

Contour, symmetry, lesions

Things to inspect during abdominal assessment.

Bowel sounds

What to auscultate before touching the abdomen.

Tympany

Normal sound during percussion.

Dullness

Indicates mass or fluid during percussion.

Light palpation

Technique used to assess tenderness and masses.

Rebound tenderness

Sign of possible peritonitis.

Ascites test

Fluid wave or shifting dullness to test for fluid in the abdomen.

Melena

Black tarry stool, indicates GI bleed.

AAA signs

Signs include pulsating mass and severe pain.

Facial expression

Controlled by CN VII (Facial).

Rebound tenderness indication

Possible peritonitis.

Normal DTR grade

Typically a grade of 2.

Concerning symptom for stroke

Unilateral facial droop.

Difference between delirium and dementia

Delirium is acute and reversible; dementia is chronic and progressive.

CN VIII function

Assesses hearing and balance.

Melena indication

Suggests a GI bleed.

GCS highest score

The highest score on the Glasgow Coma Scale is 15.

Decerebrate posture

An abnormal body posture indicating severe brain injury.

Priority for black tarry stool

Immediate assessment for GI bleeding.

Affected CN in shoulder shrug

CN XI (Spinal Accessory) is affected.

Emergency indication in abdomen

Presence of rebound tenderness or rigidity.

Likely diagnosis for rapid confusion in elderly

Delirium.

Condition with unilateral facial droop but able to raise eyebrows

Indicates likely a transient ischemic attack (TIA) or Bell's palsy.