NR 304 Exam 2 questions and answer with detailed rationales

central nervous system (CNS)

brain, spinal cord

peripheral nervous system (PNS)

everything but brain and spinal cord, 12 cranial nerves

cerebral cortex

2 hemispheres, 4 lobes per hemisphere

can get approximation or where a stroke happened

frontal lobe

personality, behavior, emotions, intellectual function

parietal lobe

primary center for sensation

occipital lobe

primary visual receptor center (back of head)

temporal lobe

auditory reception center, taste, smell

Wernicke's area

language comprehension

temporal lobe

receptive aphasia (hear sound, but it has no meaning)

Broca's area

mediates motor speech

frontal lobe

expressive aphasia (comprehends, but only garbled sounds comes out when try to speak)

hypothalamus

appetite, sex drive, temperature, heart rate, BP, sleep, anterior/posterior pituitary gland regulation, coordination of autonomic nervous system (ANS), stress response, emotional status

cerebellum

under occipital lobe

coordination of voluntary movements, equilibrium, muscle tone (does not initiate movements)

brainstem

automatic survival functions

cranial nerve (CN) III-XII originate here

pons (ascending sensory and descending motor tracts)

medulla (continuation of spinal cord in brain; contains all fiber tracts connecting brain and spinal cord)

spinal cord

mediates reflexes

butterfly shape with posterior/anterior horns

(ugh, the slide in the photo is beautiful<3)

upper motor neurons

located completely within CNS

diseases (cerebrovascular accident, cerebral palsy, multiple sclerosis, etc.)

lower motor neurons

final contact with muscles

in anterior gray column of spinal cord

movement must be translated into action by these:

-cranial nerves and spinal nerves of PNS

diseases (spinal cord lesions, poliomyelitis, amytrophic lateral sclerosis)

reflexes

basic defense mechanisms of NS

involuntary

What are the 4 types of reflexes?

1. deep tendon "myotatic" (ex: knee jerk)

2. visceral (ex: pupillary response to light)

3. superficial (ex: corneal, abdominal)

4. pathologic (ex: Babinski's, extensor plantar)

cranial nerves

enter/exit the brain

CN1 & CN2 extend from cerebrum,CN3-CN11 extend from lower diencephalon and brainstem

12 pairs CN's supply head/neck except vagus (travels to heart, respiratory muscles, stomach, gallbladder)

spinal nerves

31 pairs named for where exit:

8 cervical (C1-C8)

12 thoracic (T1-T12)

5 lumbar (L1-5)

5 sacral (S1-S5)

1 coccygeal (C0)

autonomic nervous system (ANS)

mediates unconscious activity

carry fibers divided into two parts:

-somatic fibers innervate skeletal (voluntary) muscles

-autonomic fibers innervate smooth (involuntary) muscles, cardiac muscle, and glands

infants and neurologic system

neurologic system not completely developed at birth

sensory and motor development proceed with gradual acquisition of myelin needed to conduct most impulses

aging adult and neurologic system

decreased muscle strength, impaired fine coordination/agility, loss of vibratory sense at ankle, decreased/absent Achilles reflex, pupillary miosis, irregular pupil shape, decreased pupillary reflexes, decreased velocity of nerve conduction (slow reaction time), increased delay at synapse (decreased sensation touch, pain, taste, smell), motor system delay (slowing down of movement, muscle strength, agility decreases), progressive decrease in cerebral blood flow and O2 consumption may cause dizziness and loss of balance

there is a lot here, but it's more a review than anything

race/ethnicity and strokes

4% of african americans have had stroke

6% of american indians/alaska natives have had stroke

2.5% of hispanics have had stroke

nationwide burden of stroke higher for african american and hispanic populations

stroke belt (KNOW)

11 states (southeast corner of the country except Florida)

What does FAST stand for?

acronym about strokes

1. Face (look for symmetry)

2. Arms (look for symmetry)

3. Speech (have repeat 3 easy words back)

4. Time (3 hours)

At what temperature are children at risk for seizures?

104F

tremors

three types:

-start at rest and go away once start moving (sign of Parkinson's, KNOW)

-start w/ intention (movement)

-anxiety induced

sequence for complete neurologic exam

1. mental status

2. CN's

3. motor system

4. sensory system

5. reflexes

CN I

olfactory - sense of smell

test pt. w/ loss of smell, head trauma, abnormal mental status, or when presence of intracranial lesion suspected

abnormality - anosmia (loss of sense of smell)

CN II

optic - sense of vision

confrontation, examine ocular fundus

abnormalities - defect or absent central vision, defect in peripheral vision/hemianopsia, absent light reflex, papilledema, optic atrophy, retinal lesions

CN III

oculomotor - eye movement

abnormalities - dilated pupil/ptosis (drooping of upper eyelid)/eye turns out and slightly down, failure to move eye up/in/down, absent light reflex

CN IV

trochlear - downward/inward eye movement

abnormalities - failure to turn eye down/out

CN V

trigeminal - sensation of skin on face and motor movement of jaw

motor (palpate temporal and masseter muscles while grinds teeth)

sensory (test light touch w/ cotton on forehead, cheeks, chin)

abnormalities - absent touch and pain sensation/paresthesias (abnormal sensation, normally tingling or pricking), no blink, weakness of masseter or temporalis muscle

CN VI

abducens - abduction of eyes

abnormalities - failure to move laterally/diplopia (double-vision) on lateral gaze

CN VII

facial - sensory and motor facial expressions

abnormalities - absent or asymmetric facial movement, loss of taste

CN VIII

auditory (vestibulocochlear) - sense of hearing

abnormalities - reduced/loss of hearing

CN IX

glossopharyngeal - sensation of taste and movement of swallowing

abnormalities - no gag reflex

CN X

vagus - sensation of pharynx and movement of vocal chords

abnormalities - uvula deviates to side, no gag reflex, voice quality (hoarse or brassy, nasal twang or husky), dysphagia/fluids regurgitate through nose

CN XI

accessory - movement of head and shoulders

abnormalities - absent movement of sternomastoid or trapezius muscles

CN XII

hypoglossal - position of tongue (motor)

abnormalities - tongue deviates to side, slowed rate of tongue movement

inspecting and palpating the motor system

size (difference of 1 cm or less = not significant)

strength (extremities, neck, trunk)

tone (normal tension in relaxed muscles)

involuntary movements (note if can control at will)

balance tests

gait, heel-to-toe, have walk on toes then heels, Romberg (close eyes see if sway), shallow knee bend or hop in place on one leg then other leg

rapid alternating movement (RAM) tests

that knee patting hand flipping test Monica really liked, touch thumb to each finger, finger-to-finger, finger-to-nose, heel-to-shin (while supine)

spinothalamic tests

pain (test with tip of pen, etc.), temperature, light touch (wisp of cotton)

post column tract tests

vibration (tuning fork)

position (kinesthesia)

tactile discrimination (fine touch, also sensory cortex)(stereognosis-define by feeling object w/ eyes closed, extinction-test if able to sense both sides of body being touched at same time, point location-touch and withdraw quickly ask where touched, graphesthesia-read # drawn on skin)

Know the abnormalities of the CN's!

There will be two questions like: "Pt. is exhibiting no gag reflex. Which cranial nerve is this related to?"

deep tendon reflexes (DTRs)

involuntary muscle contraction in response to striking muscle tendon with reflex hammer

DTRs 4 point scale

this is subjective!

4=very brisk, hyperactive w/clonus, indicative of disease

3=brisker than average, may indicate disease

2=average, normal

1=diminished, low normal, or occurs w/reinforcement

0=no response

abnormalities in muscle movement (KNOW)

paralysis, tics, seizure disorder, tremor, rest tremor, intention tremor

abnormal gaits (KNOW)

spastic hemiparesis (see photo), parkinson's, foot drop

common patterns of motor system dysfunction

cerebral palsy, muscular dystrophy, hemiplegia, parkinsonism, cerebellar, paraplegia, multiple sclerosis

biceps reflex

support pt.'s forearm on yours, place your thumb on biceps tendon and strike blow on your thumb

normally bicep contracts, forearm flexes

triceps reflex

tell pt. to let arm "go dead" as you strike triceps tendon just above elbow

normally forearm extends

brachioradialis reflex

hold pt.'s thumbs to suspend forearm in relaxation and strike forearm directly approximately 2-3 cm above radial styloid process

normally flexion, forearm supinates

quadriceps reflex (knee jerk)

let lower legs dangle to flex knee/stretch tendons, strike tendon directly just below patella

normally lower leg extends

achilles reflex (ankle jerk)

position pt. w/ knee flexed, hold foot in dorsiflexion and strike achilles tendon directly

normally foot plantar flexes against your hand

infantile automatisms

reflexes that have predictable timetable of appearance and departure

infant reflexes

rooting (run finger across cheek, baby turns face towards finger looking to suck)

grasp

tonic neck ("fencing" position)

Moro (see photo, surprised kitty??)

children reflexes

use finger, not reflex hammer

knee jerk present at birth, ankle jerk and brachial reflex appear, triceps reflex at 6 months

dyskinesias

repetitive stereotyped movements in jaw, lips, or tongue

may accompany senile tremors

abnormalities in muscle tone

flaccidity

spasticity

rigidity

cogwheel rigidity

spinal cord hemisection (Brown-Sequard Syndrome)

loss of pain and temperature, contralateral side, loss of vibration and position discrimination on ipsilateral side

flaccid quadriplegia

complete loss of muscle tone and paralysis of all four extremities

indicates nonfunctional brainstem

opisthotonos

prolonged arching of back with head and heels bent backward (looks like half-wheel pose if you ask me??)

indicates meningeal irritation

nonsynovial joints

bones united by fibrous tissue or cartilage

immoveable (sutures in skull) or slightly moveable (vertebrae)

synovial joints

move freely because bones separated and enclosed in joint cavity, cartilage cushions bone

bursa

enclosed sac filled w/ synovial fluid (normal)

What are the three types of muscle?

1. skeletal

2. smooth

3. cardiac

skeletal muscle movements

flexion (bend limb at joint)

extension (straightening limb at joint)

abduction (move body part away from midline)

adduction (move body part towards midline)

pronation (turn forearm so palm is down)

supination (turn forearms to palm is up)

circumduction (move arm in circle around shoulder)

inversion (move sole of foot inward at ankle)

eversion (move sole of foot outward at ankle)

rotation (move head around central axis)

protaction (move body part forward, parallel 2 ground)

retraction (move body part backward, parallel 2 ground)

elevation (raising body part)

depression (lowering body part)

temporomandibular joint (TMJ)

allows eating/talking with hinge action to open/close jaws, gliding action for protrusion and retraction, gliding for side-to-side movement of lower jaw

How many vertebrae are there in the spine and how many are there of each type?

33 total vertebrae:

7 cervical

12 thoracic

5 lumbar

5 sacral

3 or 4 coccygeal

spine

cervical/lumbar curve = concave

thoracic/sacro. curves = convex

absorbs shock

flexion, extension, abduction, rotation

What is the best position to have the pt. in to check ROM?

supine

Over half of the 206 bones in the human body are in the ________ and _______.

hands, feet

wrists and carpals

condyloid permits movement in two planes at right angles (flexion and extension, side-to-side deviation)

midcarpal joint (articulation allows flexion, extension, some rotation)

metacarpophalangeal and interphalangeal joints permit finger flexion and extension

knee

largest joint in the body/hinge joint/permits flexion and extension

kids and musculoskeletal development

by 3 months fetus forms skeleton of cartilage

longitudinal growth continues until closure of epiphyses and last closure at approx. 20 years

if kid has joint injury, check growth plate (damage can cause bone to stop growing)

pregnant women and musculoskeletal stuff

increased levels of circulating hormones cause increased mobility in joints

increased mobility in sacroiliac, sacrococcygeal, and symphysis pubis joints in pelvis (posture changes)

KNOW: progressive lordosis causes lower back pain, especially in 3rd trimester

aging adults and musculoskeletal stuff

in bone remodeling after 40 resorption occurs more rapidly than depression

kyphosis, backward head tilt, slight flexion of hips/knees

decrease in height, especially in 8th and 9th decades

they look up a lot and don't see what's on the floor (safety!)

bone remodeling

recycling of bone tissue

Calcium --> bones --> bloodstream

Ortolani's sign

infants, check for congenital hip problems (if clicking, then problem)

perform every visit until 1 year old

Allis test

infants, hip dislocation

shoulder

shrug against resistance

shoulder shrug tests CN XI

elbow

palpate flexed arm at about 70 degrees

Phalen's test

ask pt. to hold both hands back-to-back while flexing wrists 90 degrees

acute flexion of wrist for 60s produces numbness and burning in a positive test

Tinel's sign

direct percussion of location of median nerve at wrist produces burning and tingling along its distribution in a positive test

bulge sign/ballottement

tests for increased fluid in joint

McMurray test

tests for meniscal tears

perform if hx of trauma followed by locking, giving way, or local pain in knee

pt. supine, stand on affected side, rotate leg in and out

positive test if hear/feel "click"

straight leg raise test

"Lasègue test"

tests for herniated disc

raise affected leg just short of where produces pain, then dorsiflex foot

produces sciatic pain in a positive test

Which adolescents need extra attention regarding the spine?

tall, female adolescents

they have a tendency to slouch

abnormalities affecting multiple joints

inflammatory (rheumatoid arthritis, ankylosing spondylitis)

degenerative (osteoarthritis, osteoporosis)

abnormalities of the shoulder

atrophy, dislocation, joint effusion, tear of rotator cuff, frozen shoulder, adhesive capsulitis, subacromial bursitis

abnormalities of the elbow

olecranon bursitis, gouty arthritis, subcutaneous nodules, epicondylitis (tennis elbow)

abnormalities of the wrist/hand

ganglion cyst, colles' fracture, carpal tunnel syndrome, ankylosis, dupuytren's contracture

conditions caused by chronic rheumatoid arthritis:

swan neck and boutonniere deformities, ulnar deviation or drift, degenerative joint disease (osteoarthritis), acute rheumatoid arthritis, syndactyly, polydactyly

abnormalities of the knee

mild synovitis, prepatellar bursitis, swelling of menisci, post polio, osgood-schlatter disease, chondromalacia patellae

abnormalities of ankle/foot

achilles tenosynosynovitis, chronic/acute gout, hallux vagus with bunion and hammer toes, callus, plantar wart, ingrown toenail

abnormalities of spine

scoliosis, herniated nucleus pulposus (aka "herniated disc," test with straight leg raising)

pediatric abnormalities

congenital dislocated hip, talipes equinovarus (club-foot), spina bifida

anosmia

loss of sense of smelll

What time of day is rheumatoid arthritis the worst? Osteoarthritis?

RA = morning when arising

osteoarthritis = later in the day