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The characteristics of somatic senses include discrimination of what senses?
➹➹➹ : touch, pressure, vibration, position, tickling, temperature, and pain
Characteristics of normal cognition
➹➹➹ : intelligence, reality perception, orientation, judgement, recall and recognition,
language sympathetic vs parasympathetic
➹➹➹ : sympathetic (fight or flight) and parasympathetic (rest and digest)
Cognition is
➹➹➹ : the systematic way in which a person thinks, reasons and uses language
What are some signs of normal cognition?
➹➹➹ : attention
memory learning communication intelligence
NUR 209 EXAM 2 (NEUROLOGICAL) EXAM
| QUESTIONS & 100% CORRECT
ANSWERS (VERIFIED) | LATEST UPDATE |
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reality perception (awareness of time and space) orientation (knowing who one is as a person) recall and recognition language (availability to convey needs) What is sensation?
➹➹➹ : the process by which our sensory receptors and nervous system receive and
represent stimulus energies from our environment special senses
➹➹➹ : nose, eyes, mouth, ears, skin
If a patient cant sense discomfort while in a position on the bed, they can develop
➹➹➹ : a bed sore
T/F Someone can have full motor function while having impaired sensory function
➹➹➹ : true
What are somatic senses?
➹➹➹ : touch
kinesthetic sensation- the ability to know the position of your body without having to actually look at your body visceral sensation- sensation of organs or that "warm fuzzy feeling" or the feeling of your stomach hurting What are 2 examples of disorganized thinking?
➹➹➹ : delusion- when a person has a firm belief in something
ex: bright lights/ use of oxygen/ having a roommate/ having a room close to the nurse's station can all cause sensory overload What is sensory deprivation ( hypoactive delirium)?
➹➹➹ : this is a lack of meaningful stimuli
ex: having a private room/ bandaged eyes (even if only one eye had surgery done on it, they cover both eyes to avoid sensory overload but covering both can lead to sensory deprivation)/ bed rest restriction/ being on isolation precaution Neurological Assessment: Normal Pattern Identification
➹➹➹ : Information should be gathered about the patient's usual cognitive, sensory,
and neurological function and its impact on daily living. You should assess LOC, level of attention and distraction, orientation, ability to use language, and memory. Assess level of consciousness
➹➹➹ : •Hypervigilant
•Alert- patient may be just waking up from a nap but they know where they are and etc •Lethargic- this is when patient is "drifting off" so they're just sleepy, NOT confused •Obtunded-kind of like a drunk & stupor so you might have to shake them. they are a little confused •Semi Coma- patient is not responding verbally but flinch when mild pain is applied •Coma- patient is not responding verbally and dont flinch when mild pain is applied
Assess Orientation to person, place, time, and situation
➹➹➹ : 1.What is your full name?
- Where are you right now?
- What is today's date?
- Tell me about the current situation What is the Pfieffer Mental Status?
➹➹➹ : its used to provide an objective assessment of cognition
•A score of 7 or less indicates significant cognitive impairment. What is the Mini-Mental State Examination?
➹➹➹ : To provide an objective assessment of cognition
•Scores of 20 or below indicates significant cognitive impairment What is the Glasgow Coma Scale?
➹➹➹ : To provide an objective assessment of consciousness
•Glasgow Coma Scale Scores of 13 - 15 correlate with mild brain injury, 9 - 12 with moderate brain injury, 3-8 with severe brain injury Cranial nerves acronym
➹➹➹ : Oh Oh Oh To Touch And Feel A Good Velvet SAH
What nerve is I and what does it do
➹➹➹ : oflactory nerve-> sense of smell
What nerve is XI and what does it do
➹➹➹ : Spinal accessory --> head and shoulder movement
have patient push shoulders against your hands/ have patient turn cheek against hand What nerve is XII and what does it do
➹➹➹ : hypoglosseal --> tongue position
(nerve groups) What does the saying "3,4,6 make your eyes do tricks" mean?
➹➹➹ : This means nerves III (oculomotor), IV (trochlear) and VI (abducens) are paired
together because they are responsible for extra ocular motor functions tests for these functions are PERLA and having patient follow your finger What two nerves are paired together for facial expressions and facial senses?
➹➹➹ : V (trigeminal) and VII (facial)
have patient smile with your fingers on cheeks , have patient make blowfish face or have them close eyes and feel dull/sharp pain What is used to test the VIII (acoustic) nerve?
➹➹➹ : Rinne test (tuning fork on top of head)
Weber test (tuning fork on side of ear) Whisper voice test
What group of nerves has to do with taste, swallowing, tongue movement, and movement of vocal cords?
➹➹➹ : IX (glossopharyngeal), X (Vagus), XII (hypoglossal)
What must you do for patients who are on aspiration precautions?
➹➹➹ : order a swallow assessment
encourage no talking while eating must have thick fluids, not thin must have soft foods T/F : the sensory pathway is different from the motor pathway
➹➹➹ : true
Are vital signs alone a good indicator of neurologic status?
➹➹➹ : no
Gait (tandem walk), Romberg Test (balance), Finger-to-nose and Rapid Alternating Movements all test what?
➹➹➹ : cerebellar function
Neurologic recheck consists of
➹➹➹ : Level of consciousness
Motor function Pupillary response Vital signs Glasgow Coma Scale (GCS)
Cerebellar ataxia
➹➹➹ : staggering, wide-based gait; difficulty with turns; uncoordinated movement
Peripheral neuropathy
➹➹➹ : damage to nerves in lower legs and hands as result of diabetes mellitus
C4 spinal injury
➹➹➹ : complete paralysis below the neck (tetraplegia)
C6 spinal injury
➹➹➹ : partial paralysis of lower arms and hands as well as the lower body
T6 injury
➹➹➹ : Paraplegia, results in paralysis below the chest
L1 injury
➹➹➹ : paraplegia, results in paralysis below the waist
Signs of stroke
➹➹➹ : Sudden numbness or weakness of the face, arm or leg, especially unilateral
Sudden trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, or loss of balance or coordination Sudden, severe headache with no known cause
The acronym FAST stands for
➹➹➹ : Facial drooping, Arm weakness, Speech difficulties and Time
ischemic stroke
➹➹➹ : a type of stroke that occurs when the flow of blood to the brain is blocked
Hemorrhagic stroke
➹➹➹ : occurs when a blood vessel in the brain leaks or ruptures; also known as a
bleed Modifiable risk factors for a stroke
➹➹➹ : • High blood pressure
- Atherosclerosis
- Heart disease
- Smoking or tobacco use
- Atrial fibrillation (Afib)
- Diabetes
- Overweight or Obesity
- Blood disorders
- Excessive alcohol
- Certain medications Non-modifiable risk factors for stroke
➹➹➹ : Age, family history, gender
Seizure patient safety
➹➹➹ : a seizure is a sudden surge in brain activity
- place patient on their side to maintain airway and suction prn
B. Hearing loss in older adults is expected, so medical attention is not necessary. C. Chronic conditions such as diabetes and hypertension need to be well controlled. D. Use of protective earwear in noisy work areas.
➹➹➹ : B.Hearing loss in older adults is expected, so medical attention is not
necessary. As a person ages, reflex response may diminish. FALSE TRUE
➹➹➹ : true
A health assessment using a body systems approach focuses on the pathophysiology involved within specific body systems. TRUE FALSE
➹➹➹ : true
is fluid accumulation in the tissues.
➹➹➹ : edema
If a patient has receptive aphasia, he or she understands and follows directions but is unable to effectively carry out verbal communication with the nurse. FALSE TRUE
➹➹➹ : False -- they dont understand the directions
Normal breath sounds are classified as bronchial, bronchovesicular, and
➹➹➹ : vesicular
can be tested by having the patient look at a closer object and then look at a distant object.
➹➹➹ : Accomodation
An otoscope is an instrument used to assess internal eye structures. FALSE TRUE
➹➹➹ : false -- its to look in the ears
There are major areas on the precordium for examining the heart.
➹➹➹ : four (remember APTM)
It can generally be assumed that if a medial pulse is present, the distal pulse in the same extremity is present as well. FALSE TRUE
➹➹➹ : false
Bowel sounds of frequency and loudness are called borborygmi.
➹➹➹ : increased
Among older adults, 50% of those older than 75 years have some form of loss.
➹➹➹ : hearing
Overstimulation can be prevented by preparing patients before procedures, using a technique called sensation
➹➹➹ : information
Vision, hearing, smell, and taste are termed senses.
➹➹➹ : special
The kinesthetic sense influences awareness of the placement and action of body parts. TRUE FALSE
➹➹➹ : true
is the time needed to think about, evaluate, and come to terms with the activity after it happens.
➹➹➹ : afterburn
Cognitive skills developed throughout life need to be practiced regularly to be maintained. FALSE TRUE
➹➹➹ : true
Receptive aphasia is characterized predominantly by problems with word-finding of a milder nature than expressive aphasia. FALSE
TRUE
➹➹➹ : false-- its worse than expressive aphasia
refers to a group of speech disorders that result from a disturbance of motor control, weakness, paralysis, or incoordination of the oral musculature.
➹➹➹ : dysarthria
The amount of stimuli in the environment, either increased or decreased, can influence cognition. FALSE TRUE
➹➹➹ : true
Delirium is a serious, persistent brain disease characterized by distortion of reality and difficulty processing information. FALSE TRUE
➹➹➹ : false
this the definition of delusions. delirium is acute and fluctuating brain organ dysfunction, presenting with a disturbance of consciousness with reduced ability to focus, sustain, or shift attention. Sensory receptors can be classified into groups.
➹➹➹ : three
A client with vision loss has begun buying large-print books. A client with hearing loss has learned to communicate using sign language. A client has learned to sleep through the frequent beeping of the intravenous pump.
➹➹➹ : A client has learned to sleep through the frequent beeping of the intravenous
pump. Explanation: Adaptation occurs when the body adapts to constant stimuli, such as the continuous beeping of a hospital device. Adaptation is not the same as compensation. Compensation is when the client learns sign language for the hearing loss, and uses large print books for visual changes After assessing a client, a nurse documents the state of awareness as confused. What part of the brain controls awareness? Reticular activating system Medulla Hypothalamus Cranial nerves
➹➹➹ : Reticular activating system
A client has an abrupt onset of a cluster of global changes in attention, cognition, and level of consciousness (LOC). What would be the most appropriate nursing diagnosis? Impaired Memory
Acute Confusion Ineffective Coping Chronic Confusion
➹➹➹ : Acute Confusion
this is the definition of acute confussion The neonatal intensive care unit (NICU) nurse is reviewing sensory development in the neonate. Which statement indicates to the preceptor that the nurse knows how to provide stimulation for these neonates? "Stimulation is not needed as the neural pathways are mature in the newborn." "The use of mobiles will stimulate visual sensation." "Rocking and changes of body position will help to stimulate visual sensations." "Medically fragile infants need constant light and visual stimulation."
➹➹➹ : "The use of mobiles will stimulate visual sensation."
Which is not a lifespan consideration for sensory perception? Toddlers explore their environment by seeing, hearing, touching, tasting, and smelling. School-age children learn to make independent responses based on what is perceived through the senses.
