NURS 5220-Advanced Health Assessment-Test 2

cranial nerve I

Olfactory (smell)

cranial nerve II

Optic - vision

cranial nerve III

Oculomotor

cranial nerve IV

Trochlear

how do you test cranial nerve IV?

cardinal field test

cranial nerve V

Trigeminal

how do you test trigeminal nerve?

Assess facial sensation (hot/cold, dull/sharp), clench teeth, corneal reflex

cranial nerve VI

Abducens

how do you test abducens nerve?

6 fields of gaze for lateral movement

what 3 cranial nerves are tested together?

III, IV, VI

corneal reflex

blinking in response to corneal stimulation by a cotton wisp

Cranial Nerve VII

Facial - controls most facial expressions & secretion of tears & saliva & taste

cranial nerve VIII

Vestibulocochlear (hearing and balance)

cranial nerve IX

Glossopharyngeal

cranial nerve IX and X

ability to identify sour and bitter tastes on each side of the tongue. Test gag reflex and ability to swallow.

Inspect palate and uvula for symmetry with speech sounds and gag reflex. Observe for swallowing difficulty. Evaluate quality of guttural speech sounds (presence of nasal or hoarse quality to voice).

cranial nerve XI

spinal accessory

how to test cranial nerve XI?

shrug shoulders and rotate head against resistance

cranial nerve XII

Hypoglossal

how to test cranial nerve XII?

inspect tongue in mouth and while protruded for symmetry, tremors, atrophy. Inspect tongue movement toward nose and chin. Test tongue strength with index finger when tongue is pressed against cheek. Evaluate quality of lingual speech sounds (l, t, d, n).

achilles reflex tests....

plantar flexion of foot

DTR 0

no response

DTR 1+

sluggish or diminished

DTR 2+

active or expected response

DTR 3+

more brisk than expected, slightly hyperactive

DTR 4+

brisk, hyperactive with intermittent or transient clonus

clonus

rapidly alternating involuntary contraction and relaxation of a muscle in response to sudden stretch

extension of the elbow tests for....

triceps reflex

triceps reflex

C7-C8

Kernig's sign

a diagnostic sign for meningitis marked by the person's inability to extend the leg completely when the thigh is flexed upon the abdomen and the person is sitting or lying down

Brudzinski's sign

Sign of meningitis; positive when a patient's legs lift involuntarily when lifting a patient's head

palmar grasp

An infant reflex that occurs when something is placed in the infant's palm; the infant grasps the object.

Plantar grasp

Touch sole of foot, toes curl downwards

Moro reflex

Infant reflex where a baby will startle in response to a loud sound or sudden movement.

placing reflex

Hold the infant upright under the arms, close to a table.

Let the dorsal "top" of foot touch the underside of the table.

Note flexing of hip and knee, followed by extension at the hip, to place foot on table

Reflex appears at 4 days after birth

stepping reflex

a neonatal reflex in which an infant lifts first one leg and then the other in a coordinated pattern like walking

fencing reflex

When baby is lying on her back, depending on the direction of the head- that arm will straighten while the other hand raises up at the head

cremasteric reflex

upward pull of testicles and scrotum due to touch

abdominal reflex

Normal response is the ipsilateral contraction of the abdominal muscles with an observed deviation of the umbilicus towards the stroke.

Babinski reflex

Reflex in which a newborn fans out the toes when the sole of the foot is touched

Positive Babinski sign

dorsiflexion of the big toe and fanning of all toes

point location

touch skin and withdraw stimulus promptly; ask person to put finger where you touched

Graphesthesia

ability to "read" a number by having it traced on the skin

extinction phenomenon

Simultaneously touch two areas on each side of the body.

Similar sensations should be felt bilaterally.

two point discrimination

ability to distinguish the separation of two simultaneous pinpricks on the skin

Stereognosis

ability to recognize objects by feeling their form, size, and weight while the eyes are closed

What is the cerrebellum responsible for?

balance and coordination

Cerrebellum

part of the brain that controls balance, movement, and coordination

descending tracts in the spinal cord are primarily responsible for....

voluntary motor activity

stereognosis tests the ability of the patient to ....

identify an object by touch

portions of the body that are innervated by specific spinal nerves are identified as ....

dermatomes

Tanner stage 1 breast

prepubertal

tanner stage 2 girls

Breast bud stage: A small mound of breast and nipple develops; the areola widens.

Tanner stage 3 girls

Breast enlargement without separate nipple contour

Pubic hair fills out but is straight

Tanner stage 4 female

Secondary mound occurs in the breast at the areola; Pubic hair is adult like

Which breast Tanner stage corresponds to secondary areola mound development above the breast?

4

You have asked a patient to close his eyes and identify an object in his hand. You are evaluating

stereognosis

Inspection of the breasts usually begins with the patient in which position?

sitting

You are seeing a 16-year-old female gymnast patient. She is athletic and thin. Radiography of an ankle injury reveals a stress fracture. You should question this patient about her:

menstrual cycles

The strength of the trapezius muscle is evaluated by having the patient:

push his or her head against the examiners head

Which medical condition would exclude one from sport's participation?

fever

You have a pregnant patient in clinic. She eats a well-balanced diet and is usually has a daily soft bowel movement. You should explain that constipation is common during pregnancy due to changes in the colorectal areas such as:

decreased movement through the colon and increased water absorption from stool

Environmental hazards and cognitive function are data needed for the personal and social history section of a neurologic assessment for:

every patient

A patient presents to the emergency department after a motor vehicle accident. The patient sustained blunt trauma to the abdomen and complains of pain in the upper left quadrant that radiates to the left shoulder. What organ is most likely injured?

spleen

Which of the following is a concern, rather than an expected finding in older adults?

bilateral pill rolling of the fingers

a primitive reflex that is not normally present in a newborn is....

graphestesia

mental or neurological status assessment begins with....

observation

cerebrum

Largest part of the brain; responsible for voluntary muscular activity, vision, speech, taste, hearing, thought, and memory.

what part of the brain is primarily responsible for a person's mental status?

cerebrum

mediates certain patterns of behavior that determines survival

limbic system

located in the brainstem, it regulates the level of wakefulness or arousal

reticular activating system

Reticular Activating System (RAS)

a dense network of neurons found in the core of the brain stem; it arouses the cortex and screens incoming information

what lobe of the brain is not fully developed in children?

frontal lobe

Are all of the brain's neurons present at birth?

yes

speed of information processing and psychomotor speed decline after what age?

30

verbal skills and general knowledge increase into the ______ and remain stable until the _____

60s, 80s

Edinburgh Postnatal Depression Scale

Screening tool; Self-report assessment; 10 statements

static

(adj) fixed, not moving or changing, lacking vitality

automatism

unconscious bodily movements

agnosia

the inability to recognize familiar objects.

visual agnosia

occipital lobe damage

auditory agnosia

temporal lobe damage

tactile agnosia

parietal lobe damage

agnosia of body parts and relationships correspond to

posterior-inferior regions of parietal lobe

Apraxia

inability to perform particular purposive actions, as a result of brain damage.

receptive aphasia

temporal lobe-wernickes area

expressive aphasia

inferior-posterior frontal -brocas area

visual receptive aphasia

Parietal-occipital area

Expressive writing aphasia

posterior frontal area

coordinated sucking and swallowing is a function of the..

cerebellum

cremasteric reflex corresponds to what spinal area

T12 & L1

biceps reflex corresponds to what spinal area

C5 & 6

brachioradial reflex corresponds to what spinal area

C5&6

triceps reflex corresponds to what spinal area

C 6,7,8

patellar reflex corresponds to what spinal area

L 2,3,4

achilles reflex corresponds to what spinal area

S 1 &2

Clonus is associated with

upper motor neuron disease

plantar reflex corresponds to what spinal area

S 1 & 2

tinnel sign

-tests for nerve sensitivity of the median nerve (tap on volar carpal lig)

-tingling into thumb, index, and ½ of ring fingers.

myasthenia gravis

a chronic autoimmune disease that affects the neuromuscular junction and produces serious weakness of voluntary muscles

Gullain-Barre syndrome

an inflammation of the myelin sheath of peripheral nerves, characterized by rapidly worsening muscle weakness that may lead to temporary paralysis; also known as infectious polyneuritis