NUR 2180 Physical Assessment Module 8 Quiz Study Guide Latest Updated 2022,100% CORRECT

NUR 2180 Physical Assessment Module 8 Quiz Study Guide Latest Updated 2022 1. Know what to assess cerebellar function if the patient states they are unsteady on their feet o Balance 2. Understand how to assess the different deep tendon reflexes o The action is a brisk strike at the tendon insertion. Do not allow the hammer to rest on the skin after the strike. You will be testing the triceps, biceps, brachioradialis, patellar, and Achilles in this manner. The briskness of the response is graded on a 0-4+ scale with 2+ being considered normal; 1+ and 3+ are low normal and high normal, respectively. 3. Understand the all of the cranial nerves and what body parts they assess so you are aware of what nerve to assess if “the patient says they are having inability to move …”, or if a question asks you specifically about a body part or function being checked and what cranial nerve is being assessed 4. Understand the Babinski response/reflex o If you see the toes splay and the large toe dorsiflex, it is a Babinski response, which indicates upper motor neuron dysfunction. 5. Understand the components of the Glascow Coma Scale and what it is used for o The Glasgow Coma Scale is used to determine a client’s level of consciousness in a quantitative manner. It is based on three components – eye opening, verbal response, and motor response. The highest score a client can be given is 15 which would be normal, the lowest is 3. A score of 7 or lower indicates a coma. 6. Know the routine components of a neurological recheck exam o 1) the level of consciousness –are they oriented to person, place, and time? o 2) motor function – can they follow commands and testing of strength? o 3) pupillary response – are the pupils equal in size and shape and do they respond to light? o 4) vital signs – although changes in the vital signs would occur late in the case of increased intracranial pressure. 7. Understand the assessments for evaluating cerebellar function o finger to nose (client touches the examiner’s finger and then touches their nose; the examiner moves their finger around as this is performed) o heel to shin (client moves heel up and down the shin of the opposite leg) o tandem (or heel to toe) walk (client’s toes of back foot touch the heel of the front foot as client walks in a straight line) o rapid alternating fingers (client touches each finger of one hand to the thumb as quickly as they can, test both hands) o rapid alternating hands (client touches first the palm and then the back of the hand against their thigh as quickly as they can; can do this with both hands simultaneously). 8. Understand the normal responses for assessing muscle tone o Test the client’s strength in their arms, legs, and neck. Also, check muscle tone, which is done with passive range of motion. Ask the person to relax as much as possible and move the limbs into different positions. Normally there will still be sense of slight resistance as this action is performed. 9. Understand what stereognosis is o The mental perception of depth or three-dimensionality by the senses, usually in reference to the ability to perceive the form of solid objects by touch. o Stereognosis tests determine whether the parietal lobe of the brain is intact. Typically, these tests involved having the patient identify common objects (e.g. keys, comb, safety pins) placed in their hand without any visual cues. 10. Know the deep tendon reflexes and response expected for each o For the triceps reflex (C7, C8), support the upper arm allowing the lower arm to dangle downward, have the client relax the arm (this is often difficult for them), and strike just above the elbow in the small indentation there. You should see the lower arm extend from the elbow and swing away from the body. o The biceps reflex (C5, C6) is elicited with indirect percussion. You will support the elbow, place your thumb over the biceps tendon and push down on it to stretch it. Then strike your thumb with the reflex hammer. The biceps will contract which will pull the lower arm upwards. o For the brachioradialis (C5, C6) (to remember the name note that it is between the places we palpate the brachial and radial arteries), support the lower arm or let it rest on the client’s leg. Strike about 4 cm above the styloid process. The reaction should be flexion at the elbow and the hand turning palm upward. o Patellar (L3, L4) is done most easily by having the client sit with their leg dangling. Palpate the patella and locate just below it. This is the location to strike with the hammer. The normal reaction is the leg extending at the knee. o Achilles (S1, S2) tendon reflex is mostly easily tested with the client sitting and legs dangling. Locate the Achilles tendon which is a cordlike structure running up the back of the heel to the calf. Hold the foot so that it is at a right angle to the leg and strike the tendon with the reflex hammer. Watch the calf for contraction. The normal response is the foot plantar flexing into your supporting hand. As noted in the picture above, this reflex can also be elicited by positioning the client as above if they are unable to sit upright. o The plantar reflex is performed by using the end of the hammer in a stroking action up the lateral aspect of the sole and across the ball of the foot. Normally you will observe plantar flexion toes in anyone over age 2 years. Sometimes you will see no response even in normal people so consider the whole picture. If you see the toes splay and the large toe dorsiflex, it is a Babinski response, which indicates upper motor neuron dysfunction. 11. Understand what the Romberg test is and how to determine positive and negative signs o The Romberg test is typically performed by having the client stand with their feet together, hands at their side, first with their eyes open and, then if they can maintain their balance, with their eyes closed. Have them maintain this position for approximately 20 seconds. Normally a person with their eyes closed can maintain that position with only a slight sway, however if the client loses their balance with the eyes closed, this is a positive Romberg sign and indicates a cerebellar lesion or a problem with vestibular function. 12. Understand the scale used to assess reflexes (1+ - 4+) and what they represent o The briskness of the response is graded on a 0-4+ scale with 2+ being considered normal; 1+ and 3+ are low normal and high normal, respectively. 13. Understand what graphesthesia is and what it assesses o Graphesthesia, also called graphagnosia, is the ability to recognize symbols when they are traced on the skin. “Graph” means writing and “esthesia” means sensing.