Neurological Assessment & Interventions
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72 Terms
What are the three main somatic senses?
Touch
Kinesthetic (proprioceptive) sensation
Visceral sensation
What are the primary functions controlled by the frontal lobe of the cerebrum?
Personality, behavior, emotion, intellectual functions, and motor function (precentral gyrus).
How are Deep Tendon Reflexes (DTR) graded on the clinical scale?
• 0: No response • 1+: Diminished reflex (may be normal) • 2+: Normal • 3+: Brisker than normal (may be normal) • 4+: Hyperactive (upper motor neuron disorder suspected
How is the Romberg test performed and what does it assess?
• Performance: Patient stands upright with feet together and eyes closed for 20 seconds while nurse checks balance.
• Purpose: Assesses cerebellar function and balance.
What are the main functions of the cerebellum?
Motor coordination, equilibrium, and balance.
What are the functions of Cranial Nerve VII (Facial) and how are they assessed?
• Functions: Facial expressions and taste on anterior 2/3 of tongue.
• Assessment: Ask patient to smile, frown, raise eyebrows; identify sweet/salty/sour tastes.
What core parameters are evaluated during a routine Neurologic Recheck ("Neuro Check")?
Level of consciousness
Motor function
Pupillary response
Vital signs
Glasgow Coma Scale (GCS)
How do pupils normally respond during accommodation testing for close versus distant vision?
• Close object: Eyes converge and pupils constrict.
• Distant object: Eyes straighten and pupils dilate.
What is the function of Cranial Nerve IV (Trochlear)?
Lateral and downward movement of the eyeball.
What sensory signals are carried by the lateral spinothalamic tract?
Pain and temperature sensations.
What is a delusion?
Definition: A fixed, false belief held despite clear evidence to the contrary.
What is expressive (Broca's) aphasia?
Definition: Damage to the motor speech area resulting in difficulty producing language, while comprehension remains relatively intact.
Example: A person knows they want a drink but can only utter single broken words like "Water... cup."
What is dementia?
Definition: A chronic, progressive, and irreversible decline in cognitive function.
Example: Gradual memory loss and cognitive decline seen in Alzheimer's disease.
What level of paralysis results from an L1 spinal cord injury?
Paraplegia (paralysis below the waist).
What is the function of Cranial Nerve XII (Hypoglossal) and how is it assessed?
• Function: Tongue position and movement.
• Assessment: Ask patient to stick tongue out midline and move it side to side.
What is global aphasia?
Definition: Severe impairment affecting both the expression and comprehension of language.
How many pairs of spinal nerves originate from each region of the spinal cord?
• Cervical: 8 pairs • Thoracic: 12 pairs • Lumbar: 5 pairs • Sacral: 5 pairs • Coccygeal: 1 pair
What does each letter in the pupil assessment acronym PERRLA stand for?
• P: Pupils • E: Equal (3–7 mm) • R: Round • R: React to light • L: Light direct or consensual • A: Accommodation
What is a hallucination?
A false sensory perception in the absence of an external physical stimulus.
What sensory signals are carried by the posterior (dorsal) columns?
Fine touch, position, and vibration sensations.
Which four spheres are assessed when checking a patient's orientation?
Person (Who are you?)
Place (Where are you?)
Time (What is today's date?)
Situation (What is happening right now?)
What is learning?
The capability of the nervous system to acquire and store new memories and skills. Example: Learning how to tie shoes or ride a bicycle.
What levels of consciousness progress along the assessment continuum from fully awake to non-responsive?
Hypervigilant → Alert → Lethargic → Obtunded → Semi-Coma → Coma
What is sensation?
The ability to receive environmental stimulation through sensory organs (eyes, ears, nose, mouth, skin).
What are the functions of Cranial Nerve X (Vagus) and how are CN IX and X assessed together?
• Function: Swallowing, vocal cord movement, pharyngeal sensation.
• Assessment: Observe palate and pharynx movement while patient says "ah" and test gag response with a tongue blade.
Where is Wernicke's area located, and what is its main function?
Located in the temporal lobe; responsible for speech comprehension.
What is dysarthria?
Difficulty articulating words clearly due to motor weakness or lack of muscle control involved in speech.
Example: Slurred or mumbled speech caused by facial muscle weakness after a stroke.
What is perception?
The brain's process of organizing and interpreting raw sensory input into meaningful information.
Example: Recognizing that a ringing sound is your mobile phone's alarm.
What physical posture characterizes decerebrate rigidity?
Abnormal extension of both upper and lower extremities, with arms stiffly extended at the sides and wrists pronated.
What is the function of Cranial Nerve XI (Spinal Accessory) and how is it assessed?
• Function: Head and shoulder movement.
• Assessment: Ask patient to turn head side to side and shrug shoulders against hand resistance.
What is cognition?
The systematic way a person thinks, reasons, and uses language.
Example: Solving a math problem or planning daily tasks.
What is the function of Cranial Nerve I (Olfactory) and how is it assessed?
• Function: Sense of smell.
• Assessment: Ask patient to identify mild aromas (e.g., vanilla, coffee).
What are the functions of Cranial Nerve IX (Glossopharyngeal)?
Taste on posterior 1/3 of tongue, swallowing, tongue movement, and gag reflex.
What is the function of Cranial Nerve VI (Abducens)?
Lateral movement of the eyeball.
What is memory?
Definition: The ability to recall a thought or information at least once and usually again.
Example: Remembering your home phone number or what you ate for breakfast.
What is judgment (insight)?
The logical process of reasoning to make safe, appropriate decisions.
Example: Choosing to wear a heavy winter coat when going outside into freezing temperatures.
What is the primary function of the parietal lobe?
Processing sensory information (postcentral gyrus / primary sensory area).
What is the function of Cranial Nerve VIII (Auditory / Acoustic) and how is it assessed?
• Function: Hearing.
• Assessment: Whisper voice test, Weber test, or Rinne test.
What action is strictly prohibited during an active seizure?
Do NOT place anything in the patient's mouth and do NOT restrain the patient.
What is a "stocking-glove" pattern in peripheral neuropathy?
Sensory loss or numbness affecting the distal ends of the hands and feet symmetrically.
What is the function of Cranial Nerve III (Oculomotor) and how is it assessed?
• Function: Pupillary reflex and extraocular eye movement.
• Assessment: Test pupil reaction to light and direction of gaze.
What causes an ischemic stroke versus a hemorrhagic stroke?
• Ischemic Stroke: Blockage of blood vessels leading to lack of blood flow to affected brain tissue.
• Hemorrhagic Stroke: Rupture of a blood vessel resulting in bleeding into brain tissue
What postictal assessments should be documented following a seizure?
• Mental status, oxygen saturation, and vital signs
• Precipitating behaviors or presence of an aura • Sequence, type of movements, duration, and injuries
What is the difference between a direct light reflex and a consensual light reflex?
• Direct light reflex: Pupil constricts in the same eye exposed to light.
• Consensual light reflex: Pupil constricts in the opposite eye simultaneously.
Where is Broca's area located, and what is its main function?
Located in the frontal lobe; controls motor speech production
What is sensory overload?
An inability to process or manage an excessive quantity or intensity of incoming sensory stimuli.
What are the primary functions of the temporal lobe?
Hearing, taste, smell, and speech comprehension (Wernicke's area).
What is aphasia?
A complete or partial loss of language abilities, affecting speech, understanding, reading, or writing.
What level of paralysis results from a C4 spinal cord injury?
Quadriplegia / Tetraplegia (complete paralysis below the neck).
What physical posture characterizes decorticate rigidity?
Abnormal flexion of the upper extremities (arms pulled in tightly to the core) with extension of the lower extremities.
What level of paralysis results from a T6 spinal cord injury?
Paraplegia (paralysis below the chest).
What cerebellar clinical tests assess motor coordination and balance?
• Gait (tandem heel-to-toe walk) • Romberg test • Finger-to-nose test • Rapid alternating movements
On the Mini-Mental State Examination (MMSE), what score threshold indicates significant cognitive impairment?
A score of 20 or below.
What is the primary function of the occipital lobe?
Visual reception and processing.
What does each letter in the stroke warning sign acronym FAST represent?
• F: Facial drooping • A: Arm weakness • S: Speech difficulties • T: Time to call emergency services immediately
How do Glasgow Coma Scale (GCS) total scores correlate with brain injury severity?
• 13–15: Mild brain injury • 9–12: Moderate brain injury • 3–8: Severe brain injury
What is orientation (reality perception)?
Awareness of oneself in the dimensions of person, place, time, and situation
What key safety measures should a nurse take during a patient's active seizure?
• Lower patient to floor or bed and protect head • Clear away nearby furniture • Position patient on side with head flexed forward • Loosen tight clothing and stay with patient
What is the purpose of the Jendrassik maneuver (reinforcement technique) during reflex testing?
It distracts the patient and enhances deep tendon reflex responses when reflexes are difficult to elicit.
What is sensory deprivation?
A significant reduction or lack of meaningful sensory input.
How are error scores interpreted on the Pfeiffer Short Portable Mental Status Questionnaire?
• 0–2 errors: Normal mental functioning • 3–4 errors: Mild cognitive impairment • 5–7 errors: Moderate cognitive impairment • 8 or more errors: Severe cognitive impairment
What is comprehension?
Grasping the underlying meaning of incoming stimuli or information.
Example: Reading a set of instructions and understanding how to assemble furniture.
What is receptive (Wernicke's) aphasia?
Damage to the speech comprehension area causing inability to understand spoken or written language, while speech production remains fluent but meaningless.
Example: Speaking in fluent sentences made of made-up words that do not make logical sense.
What three response categories are assessed in the Glasgow Coma Scale (GCS)?
Eye-Opening Response (1–4)
Verbal Response (1–5)
Motor Response (1–6)
What is delirium?
An acute, fluctuating, and usually reversible state of confusion.
Example: A hospitalized patient suddenly becoming disoriented and agitated due to a urinary tract infection.
What is the function of Cranial Nerve V (Trigeminal) and how is it assessed?
• Function: Sensation to cornea, facial skin, and nasal mucosa.
• Assessment: Touch cotton wisp to sclera for blink reflex; measure facial touch/pain sensation.
What is the function of Cranial Nerve II (Optic) and how is it assessed?
• Function: Vision.
• Assessment: Ask patient to read a Snellen chart or test visual acuity.
What is communication?
The exchange of information between two or more people using language to process and transmit thoughts.
Example: Speaking with a doctor about your current symptoms.
What is disorganized thinking?
A condition where thinking, reasoning, and remembering occur in an altered or disorderly fashion.
What level of paralysis results from a C6 spinal cord injury?
Partial paralysis of hands and arms as well as lower body.
What is attention in cognitive function?
The ability to concentrate on and take in specific sensory stimuli.
What sensory signals are carried by the anterior spinothalamic tract?
Crude touch sensation.