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Findings for the Neurological System - Chapter 24 Lesson
Terms in this set (51)
Cranial Nerve 1
sniff test - patient able to perceive odor in each nostril equally and identify it
Cranial Nerve 2
- visual acuity test: patient able to read letters at 20 feet away from Snellen chart
- confrontation test: patient's peripheral vision. corresponds to examiner's peripheral vision
- ophthalmologic examination: positive red reflex, retinal arteries and veins present, optic disc - margins well defined and color yellow to creamy pink with 1.5 mm diameter, macula -- fovea centralis located 2 disc diameters temporal to optic disc
when the plantar is elicited, the nurse should expect plantar flexion of the toes
nurse should expect slight movement of umbilicus toward each area of stimulation to be bilaterally equal
cremasteric reflex (male only)
the nurse should expect the testicle and scrotum to rise on the side of the thigh being stroked
contraction of biceps muscle - flexion of elbow
contraction of triceps muscle - extension of elbow
pronation of forearm and flexion of elbow
contraction of quadriceps muscle - extension of lower leg
contraction of gastrocnemius muscle - plantar flexion of foot
which finding is considered normal during assessment of the olfactory cranial nerve (CN 1)?
bilateral nares patent and able to identify odor
which finding is considered normal during assessment of the hypoglossal nerve (CN 7)?
tongue thrust is midline without fasciculations
which finding is considered normal during assessment of the biceps reflex?
flexion of elbow
which finding suggests a normal adult plantar reflex?
plantar flexion of the toes
which finding is expected when the finger-to-nose test is performed by a patient who has no neurological deficits?
finger-to-nose movement is accurate and smooth
in a patient with normal cerebellar function, which finding is expected when the patient performs the Romberg test?
balance maintained with slight swaying
during a neurological assessment of primary sensory function, which finding is considered normal when joint position is tested?
ability to identify joint position when moved
which finding reveals that the patient has intact cortical sensory function of stereognosis?
ability to recognize object in palm of hand
which finding is expected during assessment of the plantar reflex in an infant less than 12 months old?
dorsiflexion of big toes
which gait is observed in a newly walking child?
wide stance with some wobbling
which statement describes the expected gait in an aging adult?
shorter steps with less lifting of feet
progressive autoimmune disorder; demyelination of brain's white matter (infectious organism possible trigger)
inflammation of meninges around brain and spinal cord
sudden interruption of blood supply to part of brain from blood clot or rupture of intracranial blood vessel
post-infectious disorder causing acute neuromuscular paralysis
temporary acute paralysis or weakness of one side of face
slowly progressive degenerative disorder; lack of dopamine
neurotransmitter - decreased coordination and control of movements and ataxia
when evaluating the facial nerve (CN 7), which findings related to the patient's face would the nurse note as abnormal?
eyelids will not close, lower eyelid sags, facial skin creases disappear
which finding would the nurse note as abnormal when evaluating the hypoglossal nerve (CN 7)?
weak tongue thrust
the nurse would suspect that an infant has shaken baby syndrome based on which abnormal signs?
presence of seizures, altered level of consciousness
which neurologic findings are abnormal when observed in an infant?
exposed meningeal sac
during the heal-to-shin neurologic test, which findings suggest intact proprioception?
absence of tremors with movement, ability to maintain contact of heal with shin, ability to move heel along shin in straight path
the nurse uses the round portion of a tongue blade on the toe to test a patient's sense of superficial pain. which patient response indicates a normal finding?
"that feels dull and is not painful"
during a neurologic examination of a 3-month-old infant, which findings are related to the presence of primitive reflexes?
alternates flexion and extension of legs, grasps object strongly when placed in palm, moves head and opens mouth to external mouth stimulation when hungry
match the abnormal adult neurologic disorder with the abnormal finding.
1. multiple sclerosis
2. Guillain-Barre syndrome
3. Bell palsy
1. hypoactive deep tendon reflexes
2. hyperactive deep tendon reflexes
the pregnant patient is in her third trimester and has been diagnosed with intrapartum maternal lumboscral plexopathy as evidenced by which subjective symptom?
pain radiating from buttock to the leg
the adult patient has had a stroke as evidenced by which objective signs?
aphasia, altered level of consciousness, difficulty managing secretions
which findings are considered normal on assessment of the oculomotor, trochlear, and abducens cranial nerves?
palpebral fissures are symmetric, both pupils constrict with accommodation
which facial movements are expected on assessment of the facial nerve (CN 7)?
smile, show teeth, puff out cheeks, raise eyebrows
which findings are considered normal on assessment of the acoustic nerve (CN 7)?
sound from tuning fork is heard equally in both ears, air conduction of sound is greater than bone conduction of sound, individual is able to correctly repeat words whispered in both ears
the patient is found to have active, expected deep tendon reflexes. which score represents the expected deep tendon reflex finding?
which finding is considered normal on evaluation of the cremasteric reflex?
testicle and scrotum rise on the stroked side
which movement of the foot is expected when the achilles reflex is evaluated?
plantar flexion of the foot
which finding suggest normal balance while the patient is hopping on one foot with eyes open?
ability to hop for 5 seconds with good balance
when a patient's normal gait is being evaluated, which findings are expected and considered normal?
gait is smooth and rhythmic, arm swing is smooth and symmetric, trunk posture sways with gait
during the neurologic test for vibratory sensation, which normal finding is expected?
ability to feel a vibration in the joint
which statement describes the gait of an older child as compared with the gait of a newly walking child?
feet close together
which cranial nerve senses may be diminished in the older adult?
sense of sight, smell, hearing
which objective data suggests a child has cerebral palsy?
cognitive impairments, persistent primitive reflexes, exaggerated deep tendon reflexes
the older adult is newly diagnosed with parkinson disease and demonstrates which objective signs?
tremors, muscular rigidity, short shuffling steps
match the abnormal pediatric neurologic disorder with the abnormal finding
1. cerebral palsy
2. spina bifida
3. shaken baby syndrome
1. persistent primitive reflexes
2. loss of bowel control
3. retinal hemorrhages
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