SG Quiz 3 FUNDS

Janice Mark Spring 2026

What are the key elements of cognition and how would you assess each one? Give an example. (multiple flashcards)

Orientation: Awareness of person, place, time, and situation

Registration: Ability to repeat named prompts

Attention & Calculation: Ability to remember objects named earlier

Recall: Ability to remember objects named earlier

Language: Ability to follow series of spoken or written instructions

What are the key elements of cognition and how would you assess each one? (ORIENTATION) Give an example. (multiple flashcards)

Orientation Assessment

Person: Please tell me your name?

Place: Please tell me where are you?

Time: What day is it today? What’s the date today

Purpose: Can you tell me why you are here?

Documentation:

▪ If patient oriented to person, time, place, situation→ “Oriented x 4”

▪ If patient not fully oriented → “Oriented x ____” ▪ More accurate -→ “oriented to _______ and ______ only”

What are the key elements of cognition and how would you assess each one? (REGISTRATION) Give an example. (multiple flashcards)

Registration: Ability to repeat named prompts

EX MMSE Question:

“I’m going to say 3 words and try to remember them. Ball, Cat, Boat. Can you repeat them back to me?”

Give 1 point for each correct answer, repeat until he/she learns all 3. Count and record number of trials it takes to learn all 3.

“Ball, Cat, Boat” (1 trial)

“Okay try to keep those in mind we’re going to come back to them.”

What are the key elements of cognition and how would you assess each one? (ATTENTION & CALCULATION) Give an example. (multiple flashcards)

Attention & Calculation: Ability to remember objects named earlier

EX MMSE Question:

Serial 7’s. 1 point for each correct answer. Stop after 5 answers.

Alternatively spell “world” backwards

“How is your math normally?” “Good” “Okay we’re going to do serial 7’s so start counting off from 100 in 7s backwards start when you’re ready.”

“93, 86, 79, 72, 65..” “Okay that’s good thank you”

What are the key elements of cognition and how would you assess each one? (RECALL) Give an example. (multiple flashcards)

Recall: Ability to remember objects named earlier

“I asked you to remember 3 words a moment ago, what were they?”

Ask for the 3 objects repeated from Registration. Give 1 point for each correct answer

“Cat, Basketball, and I don’t know the last one”

“That’s fine thank you (1/3 points)”

What are the key elements of cognition and how would you assess each one? (LANGUAGE) Give an example. (multiple flashcards)

Language: Ability to follow series of spoken or written instructions

Language

• Name a pencil and watch.

• Repeat the following "No ifs, ands or buts."

• Follow a 3-stage command:

"Take a paper in your hand, fold it in half and put it on the floor."

• Read and obey the following CLOSE YOUR EYES.

• Write a sentence.

• Copy the design shown.

What is consciousness and how do you differentiate each level (LOC)?

Being aware of one’s own existence, feelings, thoughts and of the environment

What is consciousness and how do you differentiate each level (LOC)?

Alert, Lethargic, Obtunded, Stupor, Coma

What is consciousness and how do you differentiate each level (LOC)? (ALERT)

• Awake and oriented

• Patient open eyes at your approach or spontaneously

• Oriented to person, place, time, and situation

• Can follow verbal commands appropriately

What is consciousness and how do you differentiate each level (LOC)? (LETHARGIC)

• Not fully awake and oriented

• Not fully alert throughout interaction

• Drowsy, responds to questions slow, inattentive, loses train of thought

• Drift to sleep when not stimulated. MORE than just sleepy

What is consciousness and how do you differentiate each level (LOC)? (OBTUNDED)

• Mostly sleeps and difficult to wake

• Responds to light shaking but slow to respond and may confused

• Falls asleep multiple times throughout interaction

• Speech mumbled, converses in monosyllables, acts confused when awake

What is consciousness and how do you differentiate each level (LOC)? (STUPOR)

• Unconscious

• Vigorous stimulus or pain for a response

• Pain stimulation to wake up (trap pinch, sternum pressure, supraorbital pressure)

• Has motor response

• Pulls away from painful stimulation, groans mumbles, or moves restlessly

What is consciousness and how do you differentiate each level (LOC)? (COMA)

Unresponsive, completely unconscious

No response to pain or any stimulus

Light coma: Some motor response

Deep Coma: No motor response

Is there a particular order to arousing a patient?

1. Call name in normal tone

2. Call name in loud voice

3. Light touch on arm w/ loud voice

4. Vigorous shoulder shake w/ loud voice

5. Apply pain

• (trap pinch, sternum pressure, supraorbital pressure, nail bed pressure)

Define Orientation

Ability to comprehend and adjust to person, place, time and situation

How would you assess for orientation?

Ask questions about person, place, time, and situation

Person: Please tell me your name?

Place: Please tell me where are you?

Time: What day is it today? What’s the date today

Purpose: Can you tell me why you are here?

Documentation:

▪ If patient oriented to person, time, place, situation→ “Oriented x 4”

▪ If patient not fully oriented → “Oriented x ____” ▪ More accurate -→ “oriented to _______ and ______ only”

What are the common tests used to assess cognition? What are the normal responses and scores? When would you use each one?

Mini-Mental State Examination (MMSE)

Mini-Cog

What are the common tests used to assess cognition? What are the normal responses and scores? When would you use each one? (MMSE)

MMSE used as an initial assessment and as a serial measure (repeated over time to track changes in cognitive impairment)

30 Questions: Assesses Orientation, Registration, Attention & Calculation, Recall, Language

Maximum score 30

• 23-30 → Normal

• 19-23 → Borderline

• <19 → Impaired

What are the common tests used to assess cognition? What are the normal responses and scores? When would you use each one? (Mini-Cog)

Used when you need to screen for cognitive impairment in otherwise healthy older adults

Consists of 3-item recall test

Clock Drawing test

Total Score 0-5

Score 3, 4, or 5 → Lower likelihood of Dementia

Score < 3 → Validated for dementia screening and further assessment

What does the Pupillary Light Reflex assess?

CN II (optic) and CN III (oculomotor) and brainstem activity

What are the steps to perform Pupillary Light Reflex assessment and what are the assessment elements? What are normal & abnormal responses? How would you document your findings? What is accommodation and how do we assess for it?

1. Prepare environment (dim/darken room)

2. Inspect pupils before testing (size, shape and symmetry)

3. Test direct light reflex (shine penlight from side and watch for constriction)

4. Test consensual light reflex (observe opposite pupil, both should constrict same time without shining light on it)

Assessment Elements:

PERRL(A)

Pupils, Equal, Round, React to Light, Accommodation

What are the steps to perform Pupillary Light Reflex assessment and what are the assessment elements? What are normal & abnormal responses? How would you document your findings? What is accommodation and how do we assess for it?

Normal Responses

• Pupil constricts (direct light reflex)

• Normal findings document PERRLA: P 3-5 mm, E symmetry, equal, R round shape, RL response to light, brisk bilateral

• Opposite pupil constricts same time without shining light on it (consensual light reflex)

Abnormal Response

• Pupils don’t react to light / remain dilated (Optic nerve injury (CN II) )

• Opposite pupil doesn’t constrict (Oculomotor injury (CN III) )

What are the steps to perform Pupillary Light Reflex assessment and what are the assessment elements? What are normal & abnormal responses? How would you document your findings? What is accommodation and how do we assess for it?

• Accommodation is adaptation of the eye for near vision

• With focus on distant object → pupils dilate

• With focus on a near object → pupils constrict

Normal findings

• Pupil constriction and convergence

• Interpretation: Patient has good CN2, CN3 and brain stem function, neurologically intact

What is the purpose of a motor assessment? What does ______ movement require?

• To check voluntary movement by giving the person specific commands

• Voluntary movement requires transmission of a message from cerebral cortex to the appropriate muscle on opposite side of body

Normal finding of pupillary light reflex and how do we document?

• Document: PERRLA - Pupils Equal Round React to Light Accommodation

• 3-5mm (Pupil)

• Symmetry, equal (Equal)

• Round shape (Round)

• Response to light, brisk bilateral (React to Light)

• Accommodation (A)

What is Anisocoria?

When the pupils are different sizes (not symmetrical)

How do you assess motor function in a neurological exam as discussed in class? What are the assessment elements? What are the normal and abnormal responses?

Check for strength & symmetry of CN VII (Facial), upper extremity, lower extremity

• CN VII: lift eyebrows, frown, bare teeth

• Upper extremity: hand grasps

• Lower extremity: push one foot at a time against you psalms one at a time

How do you assess motor function in a neurological exam as discussed in class? What are the assessment elements? What are the normal and abnormal responses?

• Symmetrical, equal

• strong

• coordinated

CN VII: Patient raise eyebrows symmetrically. Frown smile symmetrical on both sides of the face

Upper Extremity: Symmetrical motor function. Strong and equal strength on both sides of hands

Lower Extremity: Patient has strong and equal strength on both sides. Symmetrical motor function.

Interpretation: Patient neurologically intact. No Neurological deficits

What is the purpose of a musculoskeletal assessment? What are the key elements?

Assess function, mobility, detect abnormalities

• Inspection and Palpation for abnormalities or deformities

• Range of motion of joints (ROM)

• Muscle strength and tone

• Soft Tissue Integrity

• Mobility: Gait and Balance

What assessment techniques are used? What characteristics are used to assess musculoskeletal system? What are the normal and abnormal responses?

• Inspection

• Palpation

• Range of motion

• Strength Testing

• Tone assessment

• Functional mobility test

What assessment techniques are used? What characteristics are used to assess musculoskeletal system? What are the normal and abnormal responses?

• Symmetry

• Size and shape

• Tenderness, swelling, warmth, erythema, deformities

• Crepitus

• Postural abnormalities

• Pain

What assessment techniques are used? What characteristics are used to assess musculoskeletal system? What are the normal and abnormal responses?

• Normal: Equal bilaterally and able to fully resist opposing force

• Abnormal: No muscle contraction, no movement, can’t resist against force

Abduction

Movement away from the body

Adduction

Movement toward the body

Internal rotation

Turning limb toward midline

External rotation

Turning limb away from midline

Muscle strength

Ability to contract and create force against resistance

Muscle tone

Tension in a muscle at rest

How is muscular tone assessed? What is normal and abnormal muscle tone?

Felt through movement of muscle in a relaxed state

Normal: Mild, even resistance through entire range

Abnormal: Hypertonic (rigid), Hypotonic (flaccid)

What is ROM? Define some of the terms to describe ROM as discussed in class? What are the assessment elements for assessing ROM?

Range of Motion

Terms: Abduction, Adduction, Internal rotation, External rotation

What is ROM? Define some of the terms to describe ROM as discussed in class? What are the assessment elements for assessing ROM?

Assessment elements through exercises that moves a joint through the extent of its limitations

• Active ROM (Pt moves their own joint)

• Passive ROM (external force moves their joint via PT or equipment)

Compare for Symmetry

• Ease of movement

• Pain or Tenderness

• Full ROM or Limited ROM

• Crepitus

What joints did we assess ROM? What questions do we ask?

Shoulder, Elbow, Wrist, Hip, Knee, Ankle

Questions:

• Full ROM or limited?

• Symmetrical? (on both sides)

• Any pain, tenderness, or crepitation?

How do you assess muscular strength? What are the normal and abnormal responses?

Grades 0-5 Table of muscle strength

Normal Findings:

• Equal bilaterally and ability to fully resist opposing force

• 5/5

Abnormal

• Unequal bilaterally (unequal strength on both sides)

• Less than 5 grade

What are the elements of a mobility assessment?

• Range of motion (ROM)

• Balance (Romberg, Tandem Walking, Gait)

• Activity tolerance

• Functional ability (Activities of Daily Living (ADLs) )

What are the elements for assessing patient safety for mobility and when are you able to move through the different levels of mobility?

Elements of assessing patient safety begin in position of most support and move to higher levels according to his or her tolerance

• Lying down

• Sitting up

• Standing

• Transfer to chair

• Walking

What are the tests/tools used to assess balance? How do you perform each test and what are the normal responses?

• Romberg

• Tandem Walking

• Gait

What are the tests/tools used to assess balance? How do you perform each test and what are the normal responses? (Romberg Test)

Ask person to close eyes and hold position of standing with feet together and arms at side. Stand close in case he/she falls

• Normal response (negative): patient can hold posture and balance, maybe some swaying

• Interpretation normal: Patient had good balance; patient has good cerebellar brain function

• Abnormal response (positive): increase sway/inability to keep balance

What are the tests/tools used to assess balance? How do you perform each test and what are the normal responses? (Tandem Walking)

Walk in a straight line heel to toe

• Normal: walk straight and stay balances

• Interpretation normal: Patient has good balance

• Abnormal: inability to walk straight/can't keep balanced

What are the tests/tools used to assess balance? How do you perform each test and what are the normal responses? (Gait)

Person walk 10-20 feet away from you, turn, and return to starting point

• Normal: ability to move with a sense of freedom, smooth, rhythmic, effortless, opposing arm swing coordinate, steady

• Interpretation normal: has no gait deficits and is able to keep balance

• Abnormal: deviation from normal pattern of walking, change in posture, stride, foot placement, rhythm

What are the elements for assessing activity tolerance?

Able to perform activity without undue exertion/possible injury

• Assess for dyspnea, fatigue, chest pain when activity begins

• Assess for change in vital signs if such s/s develop

What are the different complications as a result of immobility? What are preventative measures for each one?

• Contractures

• Muscle weakness

• Loss of muscle mass and strength

• Orthostatic hypotension

• Thrombus formation (blood clots)

• Respiratory Complications

• Pressure injuries (Integumentary complications)

What are the different complications as a result of immobility? What are preventative measures for each one? (Muscle Weakness)

Prevention of Muscle Weakness

• Encouraging daily out of bed activity or mobilization

• Walking

• Sitting in chair/wheelchair

• Physical Therapy

What are the different complications as a result of immobility? What are preventative measures for each one? (Thrombus formation)

Definition: Blood clot formed withing the vascular system caused by stagnant blood

Preventative:

• Leg, foot, and ankle exercises

• Provide fluids if permitted

• Frequent position changes

• Educate patient about risk

• SCD device (compression device)

• Compression socks

• Medication prophylaxis (e.g. heparin, lovenox)

What are the different complications as a result of immobility? What are preventative measures for each one? (Respiratory Complication)

• Mobilization/High Fowlers

• Cough and Deep Breathing

• Fluid increase

• incentive spirometer

What are the different complications as a result of immobility? What are preventative measures for each one? (Skin Complications)

Pressure Injuries

Prevention

• Reposition body every 1-2 hours in bed and every hour when sitting up in a chair

• Teach patient who are able, to shift weight every 15 minutes

• Skin care

• Apply pressure relieving devices including specially designed beds

• Nurses IRL uses a lot of pillows

What is orthostatic hypotension and when do you assess for it? When is a patient positive for orthostatic hypotension?

Orthostatic (relates to posture & position)

Hypotension (low blood pressure)

Definition: Low blood pressure that occurs due to a position change from lying down or sitting to standing up

Assess for it for patients at risk:

• Elderly (greatest risk)

• Prolonged bedrest

• Hypovolemic

• Some medications

What is orthostatic hypotension and when do you assess for it? When is a patient positive for orthostatic hypotension?

Positive for patients with drop of blood pressure or following symptoms

• Greater or equal than 20 mmHg systolic pressure (↓ >20 mmHg)

• Lying BP 140/70 → Standing BP 115/68 BP

OR

• Greater or equal than 10 mmHg diastolic pressure (↓ >10 mmHg)

• Lying BP 140/70 → Standing BP 138/58

Symptoms

• Dizziness

• Lightheadness

• Nausea

• Tachycardia

• Pallor or fainting when patient changes from supine → standing

Orthostatic hypotension prevention

Mobilize patient as soon as physical condition allows to minimize risk

Expected findings in Healthy Adult (normal) orthostatic blood pressure

Systolic pressure of 10 mmHg or less with position change (↓ >10 mmHg)

EX: Lying BP 140/70 → Standing BP 131/68

How to assess orthostatic hypotension

Have patient rest supine for 2-3 minutes

▪ Take baseline BP and P (supine)

▪ Take BP and pulse with patient sitting on side of bed

▪ Take BP and pulse with patient standing

Take within 1-2 minutes of each position change

What if the patient is too weak of dizzy to stand?

• Assess Supine and then sitting on side of bed with legs dangling

• Don’t sit this patient up at the side of the bed without help

• You must help them

What are principles of body mechanics?

• Plan ahead

• Broad base of support

• Lower the center of gravity

• Face direction of movement, don’t twist

• Keep close to the patient

What is the purpose of a lung assessment?

Assess ventilation, respiratory function and detect possible respiratory problems

What are the common elements of a subjective lung assessment? How do we further assess each one? What are the normal and abnormal findings?

Asking questions

"Do you any problems with breathing?”

• “Do you have it at rest or with activity?”

“Do you have a cough?”

• “Do you cough up any phlegm or sputum?”

• - “How much?”

• - “What color is it?”

• - “What is the consistency?”

• - “Are you coughing up any blood?”

What are the common elements of a subjective lung assessment? How do we further assess each one? What are the normal and abnormal findings?

Further assessed through

• Inspection

• Palpation

• Percussion

• Auscultation

Normal findings: Clear and symmetrical on both sides for anterior and posterior lung sounds

What is the purpose of auscultation? What sounds to note for?

To listen to lung sounds using a stethoscope. Assess ventilation and note if the lung sounds are either clear, diminished, and adventitious.

What are the posterior landmarks for lung assessment?

• Scapula

• C7 Vertebra prominens

• T3 spinous process

What are the posterior reference lines for lung assessment?

• Vertebral line

• Scapular line

What are the posterior reference lines for lung assessment?

• Posterior axillary line

• Mid-axillary line

What are the anterior landmarks for lung assesssment?

• Suprasternal notch

• Sternal angle (angle of Louis)

• Costal margin

• 2nd Intercostal space

What are the anterior vertical lines for lung assessment?

A.

• Anterior axillary line

• Midclavicular line

• Midsternal line

B

• Posterior axillary line

• Anterior axillary line

Where are the lungs located anteriorly?

Apices (top/apex plural) in the supraclavicular areas down to the 6th rib

Where are the lungs located posteriorly?

Apices (top/apex plural) are at C-7 and extend to the Bases (around T-10)

What is the proper process/technique for auscultating lungs?

Evaluate presence and quality of normal breath sounds both anteriorly and posteriorly

• Using flat diaphragm of stethoscope, listen to at least one full respiration (one inspiration/expiration cycle) in each location

• Perform bilateral comparison (side to side comparison)

• Note quality and location of breath sounds (Quality: clear, diminished, adventitious)

What are the proper placements and sequence for auscultating lungs anteriorly?

1. Above clavicle

2. 2nd ICS

3. 3rd ICS

4. 4th ICS

5. 5th ICS

6. 6th ICS (midaxillary)

What are the proper placements and sequence for auscultating lungs posteriorly?

• Above shoulder blade

• C7 to T3 (assesses upper lobes)

• T3

• T4

• T3 to T10 (assess lower lobes)

• Almost midaxillary

Anterior Lobes (Right Lung/Left Lung)

Right

• RUL

• RML

• RLL

Left

• LUL

• LLL

Posterior Lobes (Right Lung/Left Lung)

Left

• LUL

• LLL

Right

• RUL

• RLL

What are the 3 different normal breath sounds and where can you locate each one?

• Bronchial (B) (trachea, larynx)

• Bronchovesicular (BV) (major bronchi)

• Vesicular (V) (peripheral lung fields)

Anterior Breath Sounds

B, BV, V

Posterior Breath Sounds

BV, V

Vesicular Heart Sounds

What it sounds like

Bro