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Nurs 228 Chapter 27
Health Assessment in Nursing: Chapter 27
| Question | Answer |
|---|---|
| What could cause numbness/tingling? | Damage to brain, spinal core, or peripheral nerves (basically nerve damage) |
| What could cause seizures? | Epilepsy, metabolic disorders, head injuries, and/or high fevers |
| What might cause morning headaches that subside after arising? | Increased intracranial pressure (e.g. brain tumor) |
| Dysfunction of what cranial nerve would diminish one's sense of smell? | Cranial nerve I (olfactory)...could also be caused by a brain tumor--a common diagnosis the television drama House. |
| What would cause ring in one's ears, or hearing loss? | Dysfunction of cranial nerve VIII (acoustic) |
| Dysfunction of which nerve(s) would cause changes in vision? | Mostly cranial nerve II (optic); Damage to III (oculomotor), IV (trochlear), or VI (abducens) would cause double or blurred vision |
| Damage to which nerves would affect one's ability to swallow? | IX (glossopharyngeal), X (vagus) or XII (hypoglossal) |
| Bowel and/or urinary control can be caused by damage to what? | Um...the book just says spinal cord. Lame, I know. |
| What might cause one to have tremors? | Degenerative neuro-disorders (think parkinson's), or cerebellar disease, or MS |
| What may cause loss of recent (24 hour) memory? | Amnesia, Korsakoff's syndrome, delirium, and/or dementia. |
| What may cause loss of remote (think longer-term) memory? | Cerebral cortex disorders. |
| What is a CVA? | A cerebrovascular accident; a stroke |
| T/F Peripheral neuropathy can be caused by a vitamin deficiency. | True: niacin, folic acid, vitamin B12 (all B-vitamins) |
| Which American minority is twice as likely to endure a CVA than caucasian? | African Americans |
| Describe the scale used to report reflex response. | 0 to 4+; 0 being no response, 2+ being normal, and 4+ being hyperactive |
| Describe the assessment of cranial nerve I (olfactory) | Ask client to identify familiar smell (e.g. soap) |
| Describe the assessment of cranial nerve II (optic) | Use the Snellen chart (bad vision/missing letters=bad); red-reflux with irregular margins (using opthalmoscope) may equal papilledema. |
| Describe examination of nerves III, IV, and VI | Watch for droopy eyelid (think Paris Hilton); or uncoordinated motion of eye. |
| Describe the elements of a quick "nero check" | LOC, pupillary, movement/strength of extremities, VS |
| Describe the muscle strength table | Scale of 0-5 5: Active against full resistance (normal) 4: Active motion against some resistance (slight weakness) 3: Active against gravity (poor ROM) 1: Slight flicker (severe weakness) 0: No response (paralysis) |
| Why is it important to assess LOC first? | LOC validates subjective information collected from client |
| How do you test for corneal reflex? (CN VII: facial) | Touch the eye with a "fine wisp of cotton" - eyes should blink bilaterally |
| How do you assess for proper motor function of CN V (trigeminal) | Ask client to clench teeth; palpate masseter muscles; both S/B clinched bilaterally. |
| What would you ask of a client to assess motor function of CN VII (facial)? | Have them make faces; smile, frown, wrinkle forehead, etc. |
| What are normal findings of an assessment of motor function of the CNs IX (glossopharyngeal) and X (vagus)? | Demonstrates unlabored swallowing, positive gag reflex, and rising of the uvula and soft palate on phonation (CN X only; say ahhhhh). |
| Describe the method for assessing the CN XI (spinal accessory) (hint: involves resistance) | S/B able to shrug shoulders (otherwise: paralysis), and turn head (otherwise PN disease) against resistance. |
| What would an assessment of CN XII (hypoglossal) test for? | Fasciculations/Arophy caused by PN disease. Watch for deviation of tongue to affected side. |
| What kind of tests would be appropriate when evaluating the function of CN VIII? | (CNVIII=acoustic/vestibululocochlear nerve) Weber test (bilatteral hearing); Rinne test (vibratory senses); hearing (air conduction) should be 2Xs longer than vibratory conduction. |
| What does AAOx4 (or A&Ox4) mean? | Alert, aware, and oriented X4 (person, place, time, situation) |
| T/F muscle atrophy is the result of inactivity, and is not a sign of neural defect. | Fasle: neural defect can cause inactivity, and muscle atrophy (p. 581) Muscle atrophy can be a sign of lower neuron disorders. |
| Q. Elizabeth demonstrates bizarre face, tongue, jaw, and lip movements. What is likely to be the cause of Elizabeth's symptoms? | A. Chronic psychosis, or prolonged use of psychotrophic drugs. |
| Q. Jason has slow movements in his lower extremities, as if he is trying to run while half submersed in a swimming pool. What is the cause? | A. Cerebral palsy. (could also cause slow, twisting movements in his face...bummer) |
| Q. John presents with a wide-based, staggering, unsteady gate. He also demonstrates a positive Rhomberg's test. What is his diagnosis? | John is presenting with cerebellar ataxia for one of two reasons: either John has cerebellar disease, or he is drunk. hopefully the latter. |
| Q. Jake presents with a shuffling gait. He turns in a very stiff manner, has a stooped-over posture with flexed hips and knees. What's Jakes problem? | A. Jake is either doing an impression of Bill Cosby dancing, or he is presenting with Parkinsonian Gait. Either way it's painful to watch. |
| Q. Scott emerges from his low-rider with a flexed arm held close to his body. As he ambulates, you notice that he his dragging the toe of one leg behind him. WTF is up w/ Scott? | A. Scott is suffering from one of two serious issues: either he is experiencing spastic hemiparesis, or he thinks he is a gangsta from the 2c. Either way, it's likely the result of a recent stroke. Poor Scott |
| What is Nystagmus, and what is it a S/S of? | Rhythmic oscillation of the eyes; issues with CNIII, IV, and/or VI |
| What is paralytic strabismus, and what is it a S/S of? | Paralysis of the CNs III, IV, and/or VI |
Created by:
scottheadrick
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