health assessment: exam 2
Neurologic Assessment
-Cognitive changes -Motor changes -Sensory changes -Cranial nerve assessment -CV assessment
arterial insufficiency symptoms
-Cool temperature, -Pulses, diminished or absent -Loss of hair on toes, feet, nails thickened and ridged
venous insufficiency symptoms
-Progressive, pitting edema of leg -warmth -Discomfort with standing -Ankle skin is swollen, shiny, and brownish
Stroke is the ____ leading cause of death in the US
3rd
left mid-clavicular line is the
5th intercostal space
The spinous process termed the vertebra prominens is in which cervical vertebra
7th
tardive dyskinesia
A neurological disorder marked by chronic tremors and involuntary spastic movements.
Gatekeeper
AV node 40-60 bpm conduct a delay to allow blood to empty into the ventricles
What cranial nerve is VI
Abducens nerve
While performing an examination of the head and neck, a nurse notices left sided facial drooping. The nurse recognizes this as what condition?
Bell's Palsy
indicative of completely nonfunctional brain stem
C3, C4 is a highly level injury
Testing CN V
Check for symmetry of jaw clenching and movement; touch pt's face with sharp and dull points in area of the 3 branches, assess for pain only where sharp point has touched;
While assessing the eyes of an adult client, the nurse uses a wisp of cotton to stimulate the client's
Corneal reflexes
The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment?
Cranial nerve VII
pectus excavatum (funnel chest)
Depression of the sternum
The nurse is assessing cranial nerves III, IV, and VI. Which instructions should the nurse provide to the client in order to perform this assessment?
Follow my finger with only your eyes.
spastic hemiparesis gait
From a stroke
What cranial nerve is IX
Glossopharyngeal
What is the most common type of hyperthyroidism?
Grave's disease
what cranial nerve is XII
Hypoglossal
A client has an edematous face, hands, and legs. Which health problem should the nurse suspect this client is experiencing?
Hypothyroidism
A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching?
I must take thyroid hormone replacement medication for the rest of my life.
Babinski reflex
Infant reflex where if its foot is stroked, the baby's toes fan out
A nurse performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test?
Legs should be elevated for 15 seconds
In reviewing a client's health history, the nurse notes that the client has had a history of TMJ pain. The nurse recognizes that which of the following bones is involved in this dysfunction?
Mandible
Cranial nerve III
Oculomotor
Cranial nerve I
Olfactory
pill-rolling tremor
Parkinson's
A client complains of pain in the calves, thighs, and buttocks whenever he climbs more than a flight of stairs. This pain, however, is quickly relieved as soon as he sits down and rests. The nurse should suspect which of the following conditions in this client?
Peripheral arterial disease
Neurovascular assessment
Peripheral vascular: -Color and temperature -Capillary refill -Pulses -Edema
Which precaution should a nurse take to ensure the safety of a client when performing the Romberg test?
Place arms around the client without touching.
Testing CN III, IV, VI
Pupillary reaction, extraocular movements
A client admitted to the health care facility is diagnosed with vertigo. Which test is appropriate for the nurse to perform to assess for equilibrium in the client?
Romberg test
stroke warning signs
SUDDEN numbness or weakness of face, arm or leg - especially on one side of the body. SUDDEN confusion, trouble speaking or understanding. SUDDEN trouble seeing in one or both eyes. SUDDEN trouble walking, dizziness, loss of balance or coordination. SUDDEN severe headache with no known cause.
Spinal accessory nerve
Trapezius muscle sternomastoid shrug shoulders
what cranial nerve is V
Trigeminal nerve
While assessing the head and neck of an adult client, the client tells the nurse that she has been experiencing sharp shooting facial pains that last from 10 to 20 seconds but are occurring more frequently. The nurse should refer the client for possible
Trigeminal neuralgia
When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the
Vestibule, nasal passages, and nasopharynx
What cranial nerve is VIII
Vestibulocochlear (Acoustic)
peripheral vascular disease (PVD)
a condition in which the legs, feet, arms, or hands do not have enough blood circulation
stupor
a state of near-unconsciousness or insensibility
scoliosis
abnormal lateral curvature of the spine
varicose veins
abnormally swollen veins, usually occurring in the superficial veins of the legs
decorticate rigidity
arms adducted and flexed, wrists and fingers flexed; legs extended, internally rotated, plantar-flexed
decerebrate rigidity
arms stiffly extended, abducted from body, internally rotated; legs stiffly extended, plantar-flexed
Facial nerve
assess mobility & symmetry of the pt facial features e.g. frown, smile, show teeth, puff out cheeks
peripheral artery disease (PAD)
atherosclerosis occurring in the lower extremities, such as in the feet, calves, or legs, or in the arms
p-wave
atrial depolarization sinoatrial node
popliteal pulse
behind the knee
Hypothalamus
brain region controlling the pituitary gland regulates body temperature
apical impulse (PMI-Point of Maximal Impulse)
brief systolic beat usually found in the 5th left ICS, 7-9 cm from the midsternal line
The nurse is palpating a client's cervical vertebrae. Which vertebra can be easily palpated when the neck is flexed and should help the nurse locate the other vertebrae?
c7
arteries
carry blood away from the heart
veins
carry blood back to the heart
C1-C7
cervical (of the neck) vertebrae
dub
closing of aortic and pulmonic valves
lub
closing of mitral and tricuspid valves
Lub-dub heart sound
closure of the valves S1 & S2
venous stasis
condition of slow blood flow in the veins
Vagus nerve
coughing make the pt say "ahh"
Trochlear Nerve
down and inward movement of the eye motor
a change in alter mental status is
early sign
Oculomotor Nerve
eye movement, Opening of eyelid (parasymathetic)
Glasgow Coma Scale
eyes, verbal, motor max-15pts concern if 12 acute phase 10 <8 intubate zero "dead"
What cranial nerve is VII
facial nerve
Trigeminal nerve
feel of temporal mandibular joint clenches teeth innervates at the temporal and masseter muscles
generalize weakness
feeling all over the body
Purkinje fibers
fibers in the ventricles that transmit impulses to the right and left ventricles, causing them to contract 20-40 bpm
2 types of abnormal muscle movement
fine coarse
Glossopharyngeal nerve
gag reflex swallowing
temporal lobe
hearing taste smell
Vestibulocochlear
hearing and balance Rinne & weber (air & bone conduction)
tandem walking
heel to toe
kyphosis
hunchback
autonomic nervous system
involuntary actions e.g. smooth muscles, cardiac muscle & glands
changes in pupil response in neurologic change means
late sign
abducens nerve
lateral eye movement, motor
centralized weakness
local to one area
AV bundle (bundle of His)
located in the septum (between the right & left ventricles) of the ventricles
flaccid quadriplegia
loss of muscle tone, paralysis of all four extremities, nonfunctional brainstem
inspect for varicosities and thrombophlebitis by asking the client to stand
manual compression test trendelenburg test
sternum
manubrium, body, xiphoid process
Branistem
midbrain pons cerebellum medulla spinal cord
cerebellum
motor coordination equilibrium balance
Broca's area
motor speech
coarse abnormal muscle movement
occurs w/cold exposure of fatigue & is not significant
fine abnormal muscle movement
occurs w/lower motor neuron disease, associate w/ atrophy & weakness
Cranial nerve II
optic nerve
sinoatrial node
pacemaker of the heart
Homan's sign
pain in *calf upon dorsiflexion* of foot and may indicated thrombophlebitis
frontal lobe
personality behavior emotions intellectual functions
olfactory nerve
pertaining to smell sensory
PMI
point of maximum impulse
lethargic
pt appears drowsy but eyes opens, responds to questions, & falls asleep
Obtunded LOC
pt eyes open, responds slowly & somewhat confused
Fasciculation
rapid continuous twitching of resting muscle without movement of limb
myoclonus
rapid sudden jerk of a muscle (hiccup)
AV node (atrioventricular node)
region of the heart between the right atrium and right ventricle from which electrical impulses spread to the ventricles during a heartbeat
SA node(sinoatrial node)
responsible for depolarization (contraction) 60-100 bpm
C3-C5 injury
risk for ariway r/t phrenic nerve controlling the diaphragm
what does the SA node do?
sends out impulses within the right and left atriums
parietal lobe
sensation
murmurs
sounds created by abnormal, turbulent flow of blood in the heart
Wernicke's area
speech comprehension
what cranial nerve is XI
spinal accessory
Cerbellar ataxia
staggering, wide-based gait
Romberg's test
standing up with feet together, arms out and eyes closed, see if they can maintain balance
coma
state of profound unconsciousness
paralysis
temporary or permanent loss of motor control
allen test
test that determines the patency of the radial and ulnar arteries by compressing one artery site and observing return of skin color as evidence of patency of the other artery
atrophy
to waste away decrease muscle size
Hypoglossal nerve
tongue movement stick out your tongue
dorsalis pedis pulse
top of foot
TIA
transient ischemic attack....mini stroke, no dead tissue.
While assessing the head and neck of an adult client, the client tells the nurse that she has been experiencing sharp shooting facial pains that last from 10-20 seconds but are occurring more frequently. The nurse should refer the client for possible
trigeminal neuralgia
What is cranial nerve IV
trochlear nerve
one of the risks associated with venous disease is the use of oral contraceptives
true
central suicus
trunk hand fingers face lips tongue
What cranial nerve is X
vagus nerve
A client has a brownish discoloration of the skin of both lower legs. What should the nurse suspect is occurring with this client?
venous insufficiency
Optic Nerve
vision (sensory) snellen chart & confrontation
occipital lobe
visual reception
somatic nervous system
voluntary control of skeletal muscles