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Nursing 230 - Exam 3 Neurosensory I questions with complete solutions
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Nursing 230 - Exam 3 Neurosensory I questions with complete solutions
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Nursing 230 - Exam 3 Neurosensory I questions with complete solutionsNeuro Assessment Past Health History- Points to consider Correct Answer-1st Avoid suggesting certain symptoms or asking leading questions. 2nd Mode of onset (sudden or gradual) and the course of the illness. (time of onset, characteristics, symptoms, and progression)
3rd Do not always consider patient a valid historian. Obtain history from
someone who has firsthand knowledge of problems and complaints
Past Health History Correct Answer-Characteristics - sequence, duration, persistence
Onset- sudden/gradual
Associated disease or trauma
Clues- paralysis, autonomic signs
Muscle tremors, visual disturbances, speech, balance and coordination, Assess sensation (pain, touch), Meds (seizure, OTC, ophthalmic), Allergies, injury to head and back, Hx of invasive procedures, physiological distress, change in interpersonal relationships, interference
with ADL's
Focused Assessment- First Correct Answer-Past Health History
Neuro Assessment Correct Answer-assess LOC, responsive or purposeful movement, Glasgow Coma Scale; voluntary or involuntary movements of extremities; muscle tone and posture; pupils; swallowing and gag reflex
Mental Status and LOC Correct Answer-Indicates cerebral function and how patient is adapting to environment
LOC is single most important indicator in neurological function
Components of Mental Status and LOC Correct Answer-General appearance and behavior- Level of consciousness (awake, asleep, comatose), motor activity, body posture, dress and hygiene, facial expression, and speech
Cognition- Orientation to person, place, time
Mood and Affect- agitation, anger, depression, euphoria and appropriateness of these states.
Glasgow Coma Scale Correct Answer-A way to quantify the ambiguous/
subjective terms used to describe level of consciousness.
The scale is used to assess level of consciousness and reaction to stimuli in a neurologically impaired patient based on performance in three categories: eye opening, verbal response-performance, and motor responsiveness.
Glasgow Coma Scale (GCS) Correct Answer-15 points max: A/O eye opening 1-4, Verbal response 1-5, Motor Response 1-6, Used for ongoing Neurological assessment. Measures Eye Opening 4pts.
(Spontaneous, to voice, to pain, none) Verbal Response 5pts. ( Oriented, confused, inappropriate words, inappropriate sounds, none) and Motor
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