• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

image

PLAY BUTTON

image

PLAY BUTTON

image

Progress

1/47

Click to flip

Card Range To Study

through

47 Cards in this Set

  • Front
  • Back
What is included in the assessment of appearence?
-dress
-hygiene
-grooming
-gait
-posture
What does assessing behavior include?
-actions and affect
-content and quality of speech
-LOC
When does the assessment begin?
upon entering the clients room
What is asked to assess mental status or LOC?
-What is your name
-Where are you
-What year is it
CN 1 is _____. Which controls the sense of _____.
-olfactory
-smell
What cranial nerves involve assessment of the eyes?
-CN2 optic
-CN3 oculomotor
-CN4 trochlear
-CN 6 abducens
Which cranial nerve involves assessment of the jaw bone while clinching ones teeth?
CN 5 trigeminal
Which cranial nerve controls the raising of eyebrows, clinching teeth, blowing out cheeks, and closing eyes tightly?
CN 7 facial
Which cranial nerve controls hearing?
CN 8 acoustic
These CN asks the client to say ahh, stick out your tongue, and take a sip of water?
CN 9 glossopharyngeal
CN 10 Vagus
CN 12 hypoglossal
What CN all ows the turing of the head from side to side and shrugging the shoulders?
CN 11 Spinal accessory
What documents a pupil that is WNL?
PERRLA
What is PERRLA?
Pupil equal round reactive to light and accommodation
With darkness pupils should?
dilate
With light pupils should?
constrict
Gait should be ____ and _____.
smooth and well balanced
Posture should be ____ and _____.
erect and symmetrical
Name the nine pulses
-temporal
-carotid
-apical
-brachial
-radial
-femoral
-popliteal
-posterior tibial
-dorsalis pedis
Which pulses cannot be palpated simultaneously?
carotid
Which fingers do you use to palpate pulses?
index and middle fingers
When assessing a client for the first time you should listen to which pulse for how long?
apical for 60 seconds
What safety mechanism does the nurse use when assessing the client?
have side rails down when assessing upper bodt and up while assessing lower body
Be mindful of the clients ____ while performing the assessment?
privacy
Which lower extremity pulse is palpated most often?
dorsalis pedis
What should be documented to articulate that tje pulses are WNL?
pulses are equal bilaterally
What are the four levels of consciousness?
-fully conscious AAOX4
-confused->disoriented to time place or person
-lethargic->oriented with slow, sluggish speech and mental processes
-obtunded->arouses to stimulation, but only will respond with one or two words
What is the Romberg test and what does it assess for?
-a neurological test that detects poor balance and assess coordination
How is the Romberg test performed?
have patient stand still with their heels together and remain still.
Then ask the patient to close their eyes, if they lose balance the test is positive
How do we assess the motor function and sensory perception of the radial nerve?
motor function-have client move wrist back and forth
sensory- touch space between thumb and forefinger
How do we assess the motor function and sensory perception of the median nerve?
motor function- have client perform thumb opposition with remaining 4 fingers
sensory- touch or stroke the tip of second finger
How do we assess the motor function and sensory perseption of the ulnar nerve?
motor- abduction of the fingersmake sure to spresad fingers apart
sensory- touch or stroke the tip of the 5th finger
What are the three nerves that checked in the lower extremities?
-femoral
-sciatic nerve-> tibial
-sciatic nerve-> peroneal
How do we assess motor and sensory function of the femoral nerve?
motor- haave client perform straight leg raise
sensory-stroke the anterior thigh
How do we assess motor and sensory function of the tibial nerve?
motor-have client plantar flex foot down
sensory-stroke the sole of the foot
How do we assess the motor and sensory function of peroneal nerve?
motor-have client dorsiflex foot up
sensory-stroke the web space between first and second toe
What is cranial nerve l and what does it control?
-olfactory
-smell
What is cranial nerve II and what does it control?
-optic
-vision
What is cranial nerve III and what does it control?
-oculomotor
-most eye movement, pupillary constriction, upper eyelid elevation
What is cranial nerve IV and what does it do?
-trochlear
-down and in eye movement
What is cranial nerve V and what does it do?
-trigeminal
-chewing, corneal reflex, face and scalp sensations
What is cranial nerve VI and what does it do?
-abducens
-lateral eye movement
What is cranial nerve VII and what does it do?
-facial
-expressions in forehead, eye, mouth, and taste
What is cranial nerve VIII and what does it do?
-acoustic
-hearing and balance
What is cranial nerve IX and what does it do?
-trochlear
-down and in eye movement
What does cranial nerve X and what does it do?
-vagus
-swallowing, gag reflex, talking
What is cranial nerve XI and what does it do?
-accessory
-shoulder movement and head rotation
What is cranial nerve XII and what does it do?
-hypoglossal
-tongue movement