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