Term
| What are the 4 main headings of the full mental status examination? |
|
Definition
| Appearance, Behavior, Cognition, Thought Process ABC-T |
|
|
Term
| The mini-mental status exam only focuses on _____ function? |
|
Definition
|
|
Term
| The mini-cog consists of __-item _____ test and a _____-drawing test. This tests the person's _______ function? |
|
Definition
| 3, recall, clock, executive |
|
|
Term
| 3 areas you should assess to test the level of orientation? |
|
Definition
|
|
Term
| Which level of orientation is lost first? |
|
Definition
|
|
Term
| which level of orientation is lost last? |
|
Definition
|
|
Term
| Executive functions includes: |
|
Definition
| planning, abstract thinking, organizing |
|
|
Term
| How many component's are there to the neurological assessment, and what are they? |
|
Definition
| 5: mental status, cranial nerve function, motor function, sensory function, reflexes |
|
|
Term
| Name 5 tests that assess coordination of the lower extremities: |
|
Definition
| rapidly tap your feet, shallow knee bends, rapidly extend and flex your toes, heel to shin test, hop on one foot. |
|
|
Term
| Name 3 tests that assess coordination of the upper extremities: |
|
Definition
| finger to nose, finger to finger, rapid alternating movements. |
|
|
Term
| Name 2 tests that assess tactile discrimination: |
|
Definition
| sterognosis, graphesthesia. |
|
|
Term
| how is stereognosis performed? |
|
Definition
| have pt. close their eyes, place a familiar object in their hand, and see if they can recognize it. |
|
|
Term
| how is graphesthesia performed? |
|
Definition
| have pt. close their eyes, trace a number or letter on their hand and see if they can recognize what it was. |
|
|
Term
| Name 2 reinforcement strategies that can be used to enhance the deep tendon reflexes if you're having difficulting assessing them for the arm and for the leg: |
|
Definition
Arm: clench teeth, tighten leg muscles
Leg: tighten biceps, clasp fingers together and try to pull apart. |
|
|
Term
| What reflex are you assessing when you observe Knee Extension: |
|
Definition
|
|
Term
| What reflex are you assessing when you observe elbow flexion: |
|
Definition
|
|
Term
| What reflex are you assessing when you observe plantar flexion: |
|
Definition
|
|
Term
| What reflex are you assessing when you observe supination of wrist: |
|
Definition
|
|
Term
| What reflex are you assessing when you observe elbow extension: |
|
Definition
|
|
Term
| what grade would you assign to DTR's when they elicit an expected response? |
|
Definition
|
|
Term
| ______is a set of rapid, rhythmic contractions of the same muscle seen while performing DTRs. |
|
Definition
|
|
Term
| Name 8 tests used to assess the intactness of the sensory portion of the nervous system: |
|
Definition
| light touch, two-point discrimination, pain, temperature, vibration, position sense( proprioception), extinction, point localization |
|
|
Term
| what sensation can you defer from testing if the patient's pain sensation is intact? |
|
Definition
|
|
Term
| What 2 sensory tests are not repeated at proximal sites if they are intact distally? |
|
Definition
| vibration & proprioception |
|
|
Term
| What 2 tests are used to do a meningeal assessment? |
|
Definition
| Kernigs sign & brudzinski's sign |
|
|
Term
| How is Kernig's sign performed? |
|
Definition
| Leg flexed: the extension will cause severe neck pain |
|
|
Term
| How is Brudzinski's sign performed: |
|
Definition
| put chin to chest; pt. will pull knees up to prevent pain in the neck |
|
|
Term
|
Definition
| prolonged arching of the back, with head and heels bent backward. indicative of meningeal irritation |
|
|
Term
| Cranial Nerve I: name, what test it performs? |
|
Definition
| olfactory, smell coffee/vanilla |
|
|
Term
| Cranial Nerve II: name, what test it performs? |
|
Definition
|
|
Term
| Cranial Nerve III: name, what test it performs? |
|
Definition
| oculomotor, pupillary reaction |
|
|
Term
| Cranial Nerve IV: name, what test it performs? |
|
Definition
| trochlear, downward eye movement |
|
|
Term
| Cranial Nerve V: name, what test it performs? |
|
Definition
| trigeminal, Light touch on face/chew |
|
|
Term
| Cranial Nerve VI: name, what test it performs? |
|
Definition
| abducent, lateral eye movement |
|
|
Term
| Cranial Nerve VII: name, what test it performs? |
|
Definition
| facial, taste on anterior portion of tongue/ facial expressions |
|
|
Term
| Cranial Nerve VIII: name, what test it performs? |
|
Definition
| acoustic, test hearing,/equillibrium |
|
|
Term
| Cranial Nerve IX: name, what test it performs? |
|
Definition
| glossopharyngeal, taste on posterior portion of tongue. gag reflex |
|
|
Term
| Cranial Nerve X: name, what test it performs? |
|
Definition
|
|
Term
| Cranial Nerve XI: name, what test it performs? |
|
Definition
| spinoaccessory, shoulder muscle strength |
|
|
Term
| Cranial Nerve XII: name, what test it performs? |
|
Definition
| hypoglossal, ROM of tongue |
|
|
Term
| Name 4 levels of altered consciousness and the type of stimuli necessary to elicit a response: |
|
Definition
lethargic-light touch, say their name normally
obtunded-yell neame, shake vigorously
stuporous-noxious stimuli, pinch, sternum rub
comatose-no stimuli will arouse pt. |
|
|
Term
| an abnormal upper extremity flexor posture is referred to as: |
|
Definition
|
|
Term
| an abnormal upper extremity extensor posture is referred to as: |
|
Definition
| decerebrate- worse than decorticate (more serious) |
|
|
Term
| Name 4 examples of central noxious stimuli: |
|
Definition
| sternal rub, supraorbital pressure, pinch and twist trapezius, mandibular pressure |
|
|
Term
| name 1 example of peripheral noxious stimuli: |
|
Definition
|
|
Term
| When you assess the plantar reflex in an adult, what is the expected response: |
|
Definition
| adults curl toes, children 2 and under spread toes |
|
|
Term
| When you assess the plantar reflex in an adult, what is the abnormal response: |
|
Definition
| adults spread toes, children 2 and under curl toes |
|
|
Term
|
Definition
| refers to abnormal pitch or volume of voice |
|
|
Term
|
Definition
| refers to distorted speech volume |
|
|
Term
|
Definition
| refers to the inability to write |
|
|
Term
|
Definition
| refers to the inability to grasp the meaning of written words or sentences |
|
|
Term
| ____ or ____ affect is where topics vary but there remains an absence of expression-face remains immobile |
|
Definition
|
|
Term
| _____ is the feeling that one lost their identity |
|
Definition
|
|
Term
| ______is simultaneous opposing emotions toward a person, object or idea |
|
Definition
|
|
Term
| _____is a rapid shift of emotions |
|
Definition
|
|
Term
| what type of aphasia is the most common and severe? |
|
Definition
|
|
Term
| type of aphasia that the person can understand language, but is unable to express themselves is ____ or ____ aphasia. |
|
Definition
|
|
Term
| the affectedarea is the _______language area called the Broca's or ____ _____ cortex. |
|
Definition
|
|
Term
| Type of aphasia where the person has difficulty understanding what is being said to them is: |
|
Definition
|
|
Term
| The affected area is the _____ language area called the Wernicke's area or _____ ____ cortex. |
|
Definition
| posterior, association auditory |
|
|
Term
| The glascow coma scale assess what but NOT what? |
|
Definition
|
|
Term
| what 3 parameters are assessed with the glascow coma scale: |
|
Definition
| eye opening, verbal response, best motor response |
|
|
Term
| Glascow scores can range from ___ to ___ and a score less than ___ is indicative of a coma? |
|
Definition
|
|
Term
| name 3 superficial reflexes: |
|
Definition
| abdominal, plantar, and cremasteric |
|
|
Term
| name 5 protective reflexes: |
|
Definition
| gag, cough, sneeze, swallow, blink |
|
|
Term
|
Definition
| lack of coordinated action of the muscle group |
|
|
Term
|
Definition
| person exhibits impaired judgement related to distance and speed of movement |
|
|
Term
|
Definition
| term used for individuals that perform poorly with rapid alternating movements. |
|
|
Term
| Gait dysfunction: Steppage means: |
|
Definition
| lifts knee/ foot high and slaps it down hard |
|
|
Term
| Gait dysfunction: festinating(parkinsonian) means: |
|
Definition
| stooped posture, short and shuffling steps; has difficulty starting and stopping |
|
|
Term
| Gait dysfunction:spastic hemiparesis |
|
Definition
| leg is stiff and extended; toe is dragged in a semicircle and arm is immobile against body |
|
|
Term
| Gait dysfunction: cerebellar ataxia |
|
Definition
| wise based gait and has difficulty turning |
|
|
Term
| Gait dysfunction: scissors |
|
Definition
| looks like they are holding something between their knees |
|
|
Term
| Gait dysfunction: waddling |
|
Definition
| opposite hip drops as person takes a step due to weak hip muscles |
|
|
Term
|
Definition
| meaning only known to person |
|
|
Term
|
Definition
| excessive, irrelevant detail |
|
|
Term
|
Definition
| combining words with no connection |
|
|
Term
|
Definition
| covering up gaps in memory |
|
|
Term
|
Definition
| unwanted, repetitive behavior |
|
|
Term
|
Definition
|
|
Term
|
Definition
| jumps from 1 topic to next |
|
|
Term
|
Definition
| misinterpretations of real stimuli |
|
|
Term
|
Definition
|
|
Term
|
Definition
| false sensory perceptions |
|
|
Term
|
Definition
| wormlike-involves distal limbs |
|
|
Term
|
Definition
| rapid, sudden jerks at regular intervals |
|
|
Term
|
Definition
| persistent, strong irrational fear of an object or situation |
|
|
Term
|
Definition
| unwanted, persistent thoughts or impulses |
|
|
Term
|
Definition
| substituting when cannot think of the exact name of an object |
|
|
Term
|
Definition
| word choice based on sound |
|
|
Term
|
Definition
| involuntary, compulsive, repetitive twitching of a muscle group |
|
|
Term
|
Definition
| rapid, continuous twitching of resting muscle groups without moving limb |
|
|
Term
|
Definition
| feels a pain sensation when touched |
|
|
Term
|
Definition
| feels pain from non painful stimuli |
|
|
Term
| What 3 cranial nerves are used for extra ocular eye movements: |
|
Definition
| III oculomotor, IV trochlear, VI abducens |
|
|
Term
|
Definition
| fixed, dilated pupil Disorder of CN III oculomotor |
|
|
Term
|
Definition
| fixed, constricted pupil disorder of CN III oculomotor |
|
|
Term
|
Definition
| one pupil constricted the other is dilated Disorder of CN III oculomotor |
|
|
Term
|
Definition
| absence of smell, disorder of CN I olfactory |
|
|
Term
| ptosis/ Horner;s syndrome |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| fixed eye movement, one eye moves inward |
|
|
Term
|
Definition
| fixed eye movement, one eye moves outward |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| older adult sensory hearing loss |
|
|
Term
|
Definition
| obstruction in ear CNVIII acoustic disorder |
|
|
Term
| sensorineural hearing loss |
|
Definition
| Cranial Nerve VIII acoustic damage, damage to something in ear |
|
|
Term
| what test can help locate the liver borders? |
|
Definition
|
|
Term
| What is the livers expected size range on the midclavicular line: |
|
Definition
|
|
Term
| What palpation technique should be used when assessing a liver on someone with an obese abdomen? |
|
Definition
|
|
Term
| an alternative method of palpating the liver is: |
|
Definition
|
|
Term
| what is the expected perscussion note you should elicit which directly over the liver and spleen |
|
Definition
|
|
Term
| what type of percussin is performed when attempting to check for tenderness in the liver and kidney areas: |
|
Definition
|
|
Term
|
Definition
| temporary ( ex: ticklish) |
|
|
Term
|
Definition
| continuous ( very "board-like abdomen) |
|
|
Term
| What 3 movements should you look for when inspecting the abdomen: |
|
Definition
| respiratory, aortic pulsations, peristaltic waves |
|
|
Term
| After inspection what technique must you perform before you palpate and why? |
|
Definition
| Auscultation, because you need to listen before you palpate so you do not stimulate the bowel sounds |
|
|
Term
| how long should you listen before you can document BS are absent? |
|
Definition
|
|
Term
| Name 4 special test that are helpful in identifying ascites: |
|
Definition
| fluid wave, shifting dullness, puddle sign, ballottment |
|
|
Term
| what test must be done to obtain a definitive diagnosis of ascites: |
|
Definition
|
|
Term
| Test done is cholecystitis is expected: |
|
Definition
| Murphy's sign or inspiratory arrest |
|
|
Term
| 7 F's that refer to the major causes of abdominal distension |
|
Definition
| fat, feces, fetus, fibroids tumor, fatal growth, flatulence, fluid |
|
|
Term
| 4 terms used to describe the abdominal contours |
|
Definition
| flat, rounded, scaphoid, protruberant |
|
|
Term
| what contour is seen in infants during both supine and standing positions |
|
Definition
|
|
Term
| when a spleen enlarged is moves ____ and toward the______ |
|
Definition
| inferiorly & anteriorly, medial |
|
|
Term
| in addition to the abdominal aorta what 3 arteries for you auscultate to rule out bruits: |
|
Definition
|
|
Term
| what abd. quadrant do you begin at when you are assessing BS? |
|
Definition
|
|
Term
| what abd. quadrant is a mass of feces most commonly palpated or percussed? |
|
Definition
|
|
Term
| Normoactive BS consists of __ to __ sounds/min. |
|
Definition
|
|
Term
| what type of BS can be caused by narcotic analgesics and anesthesia, as well as, late bowel obstruction. |
|
Definition
|
|
Term
| what type of BS are heard in individuals with diarrhea or can be a sign of an early bowel obstruction |
|
Definition
|
|
Term
|
Definition
| audbile loud gurgling sounds heard from the stomach or intestine |
|
|
Term
| Cullen's sign is located around the _____ and indicative of ___-peritoneal bleed |
|
Definition
|
|
Term
| Grey-Turner's sign is located around the _____ and is indicative of ____-peritoneal bleed |
|
Definition
|
|
Term
|
Definition
| midline longitudinal ridge caused by separation of the abdominal rectus muscle ( the ridge is noted when pt raises their head while supine) |
|
|
Term
|
Definition
| bulge that is not visible until person stands |
|
|
Term
|
Definition
| palpable bulge only felt when person stands |
|
|
Term
|
Definition
| common in premature infants and resolves on its own |
|
|
Term
|
Definition
| a serious psychosocial disorder that includes voluntary starving and extreme weight loss |
|
|
Term
| when percussing over the symphysis pubis, you note that it is distended due to a full bladder. because of this, you will hear a ____ percussion note. |
|
Definition
|
|
Term
| pregnant women experience prolonged gastric emptying which can lead to____ |
|
Definition
|
|
Term
| drug metabolism in the liver of an older adult ______ |
|
Definition
|
|
Term
| _____sign is used to rule of peritoneal irritation |
|
Definition
|
|
Term
| _____dullness will not detect less than 300ml of fluid |
|
Definition
|
|
Term
| A _____ _____ is related to a pyloric obstruction and marked peristalsis with projectile vomiting is associated with pyloric stenosis. |
|
Definition
|
|
Term
| individuals experiencing abdominal pain, bloating and flatulence after consuming dairy products, should avoid _____ since they are showing signs of intolerance. Because of they lack the enzyme _____. |
|
Definition
|
|
Term
| black tarry stools are due to ____ blood, also referred to a _____ This is seen is ____ GI tract bleeding. Black, nontarry stools can occur from what supplement? |
|
Definition
| occult,melena,upper, Iron |
|
|
Term
| Upon palpation, ____ ____ occurs when the person is ticklisj, but___ _____ os a protective mechanism when peritoneum is inflamed. |
|
Definition
| voluntary guarding, involuntary ridigity(guarding) |
|
|
Term
| frank blood in stools occurs with _____ GI bleeding. |
|
Definition
|
|
Term
| What 4 vitamins/minerals can be lacking in an older adult due to reduction of gastric acid secreting. |
|
Definition
| b12, calcium, iron, folic acid |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| originates from inferior vena cava (IVC) soft continuous pulsating sound, there is an obstruction in the portal vein |
|
|
Term
|
Definition
|
|
Term
|
Definition
| purple-blue with cushing's (stretch marks) |
|
|
Term
|
Definition
|
|
Term
|
Definition
| hepatitis ( barium can also cause this) |
|
|
Term
|
Definition
| indicates peritoneal inflammation |
|
|
Term
|
Definition
|
|
Term
|
Definition
| projectile vomiting and marked peristalsis |
|
|
Term
|
Definition
|
|
Term
|
Definition
| burning, painful urination |
|
|
Term
|
Definition
| turbulent blood flow; aortic stenosis, arterial stenosis |
|
|
Term
|
Definition
| normal percussion note of the abdomen |
|
|
Term
| how to percuss the vertical span of the liver: |
|
Definition
| place hand at umbilicus and percuss upward until you hear a change in tone, mark it, then percuss downward from 4th ICS, note when change in tone, and measure the distance between the 2 points |
|
|
Term
| splenic percussion sign: (-) and (+) sign means: |
|
Definition
| (-) good (+) splenomegaly |
|
|
Term
| cutaneous hypersensitivity test |
|
Definition
| lift piece of skin from abdomen and it will cause pain if pt has peritonitis. |
|
|
Term
|
Definition
| difficulty breathing while lying supine; have to raise head of bed |
|
|
Term
|
Definition
| top of lung; lies against thoracic cavity |
|
|
Term
|
Definition
| bottom of lung; lies against the diaphragm |
|
|
Term
|
Definition
| at the xyphoid process and end of ribs where diaphragm is |
|
|
Term
| what nerve innervates the diaphragm |
|
Definition
|
|
Term
| pleural fluid is between what to layers: |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| Left Lung characteristics: |
|
Definition
| composed of 2 lobes, longer than the right lung to compensate for the heart |
|
|
Term
| right lung characteristics: |
|
Definition
| composed of 3 lobes( superior,middle,inferior lobes), shorter than left lung but broader to compensate the hearts placement and shorter to compensate the livers placement. |
|
|
Term
| Distance between the trachea and SCM should be ____ on both sides. |
|
Definition
|
|
Term
| when palpating the trachea,a tracheal shift to the unaffected or healthy side is indicative of: |
|
Definition
| enlarged thyroid, tension pneumothorax, atelectasis |
|
|
Term
| when palpating the trachea,a tracheal shift toward the affected side is indicative of: |
|
Definition
|
|
Term
| dry cough is indicative of: |
|
Definition
|
|
Term
| moist cough is indicative of: |
|
Definition
|
|
Term
| gradual SOB is indicative of: |
|
Definition
|
|
Term
| sudden SOB is indicative of: |
|
Definition
| asthma, trauma, spontaneous pneumothorax |
|
|
Term
| Sputum Color Characteristics: White or clear |
|
Definition
|
|
Term
| Sputum Color Characteristics: yellow or green |
|
Definition
|
|
Term
| Sputum Color Characteristics: black |
|
Definition
|
|
Term
| Sputum Color Characteristics:pink and frothy |
|
Definition
|
|
Term
| Sputum Color Characteristics:rust colored |
|
Definition
|
|
Term
| Sputum Color Characteristics:hemoptysis |
|
Definition
|
|
Term
| Sputum Color Characteristics: frank blood |
|
Definition
|
|
Term
| Expected finding of respirations: Rate,Rhythm, Depth, Effort, Sound are: |
|
Definition
| 10-20 breaths/min, even(regular), 500-800ml (tital volume,amount of air), effortless, quiet. HR-RR 4:1 |
|
|
Term
| an infrequent sigh helps what: |
|
Definition
|
|
Term
|
Definition
| rapid-shallow: hypermetabolic & hypoxic state |
|
|
Term
|
Definition
| slow & regular: excessive ICP d/t brain injury, certain drug OD(CNS depressants) |
|
|
Term
|
Definition
| absence: hernia of the brainstem 2 degree traumatic brain injury |
|
|
Term
|
Definition
| may indicate emotional dysfunction and may lead to hyperventilation resulting in dizziness. |
|
|
Term
|
Definition
| rapid & Deep (increase in rate & depth): extreme exertion/emotions-compensatory, mechanism for metabolic acidosis- Primary cause of Respiratory Alkalosis. |
|
|
Term
|
Definition
| slow shallow (irregular): prolonged bedrest-obesity-pain-overdose of narcotics/anesthetics. Primary cause of respiratory acidosis. |
|
|
Term
|
Definition
| 4 respiratory cycles followed by period of apnea. irregular pattern. Seen ins meningitis, brain abcess & encephalitis. |
|
|
Term
|
Definition
| regular rhythm increase in rate & depth, then apnea, then decrease in rate & depth. most common in heart failure. expected in infants and aging person during sleep |
|
|
Term
|
Definition
| prolonged gasping during inspiration, very short expiration phase, then apnea. |
|
|
Term
|
Definition
| variable rhythm. indicative of impending death. |
|
|
Term
| How to palpate thorax posteriorly: |
|
Definition
| thumbs pinch skin @ middle of back and pt takes a deep breath in. |
|
|
Term
| How to palpate thorax anteriorly: |
|
Definition
| hands at costal thorax, thumbs pointed toward xyphoid process and pt takes a deep breath in. |
|
|
Term
|
Definition
| increase more than 5 cm, assymetrical, one side higher than the other, indicative of atelectasis, hemothorax, pneumothorax |
|
|
Term
|
Definition
| less than 3 cm indicative of emphysema or fractured ribs. |
|
|
Term
|
Definition
| indicative of asthma, pleural effusion, emphysema |
|
|
Term
|
Definition
| indicative of pneumonia, atelectasis |
|
|
Term
| What level is the diaphragm on expiration: |
|
Definition
|
|
Term
| What level is the diaphragm on inspiration: |
|
Definition
|
|
Term
| Location of Broncho vesicular sound Anteriorly and posteriorly> |
|
Definition
Anteriorly: 1st & 2nd interspaces
posteriorly: between scapula |
|
|
Term
| not pathologic,popping/cracking sound, only last for a few breaths or after a cough, alveoli sections not fully aerated will deflate slightly and accumulate secretions.Sounds occur when these sections re-expand after a few deep breaths. Common in older adults or bedridden persons. |
|
Definition
|
|
