N440 ICR concept UPDATED ACTUAL
Exam Questions and CORRECT Answers
risk factors for icr issues - CORRECT ANSWER - All populations are potentially at risk
for problems with ICR
Some populations are at higher risk
Degenerative pathology (higher incidence in the elderly population)
Injury related to ICR problems, commonly seen in adolescent and young adult age groups
TBI's (most commonly from falls and motor vehicle accidents)
Falls more of an issue with the very young and elderly population
MVA's are more prevalent in the young adult population
Personal risk factors
Age
HTN
DM
Smoking
Obesity
Cardiovascular disease
neurologic changes with age - CORRECT ANSWER - motor, sensory, cognitive, sleep
pattern, sleep deprivation changes
icr assessment questions - CORRECT ANSWER - patient's appearance and assess his or
her speech, affect and movement
Asking pertinent questions will provide clues to the examiner of ICR problems and will help to
focus the physical examination
Numbness, paralysis, tingling, neuralgia
Loss of consciousness, dizziness, fainting, confusion
Changes in recent or remote memory
,Changes in vision, hearing, balance, gait
Speech problems
Chewing/swallowing problems
Muscle weakness or loss of bowel or urinary control
Onset of unexplained tremors or other motion disturbances
Unexplained, severe headache
Vomiting
Symptom onset
History of head injury
icr testing tools - CORRECT ANSWER - Mental Status
Glasgow Coma Scale (GCS)
Cranial Nerves
Intracranial Pressure
Measurement of Cerebral Perfusion Pressure
NIH Stroke Scale
ICR Physical Assessment - CORRECT ANSWER - general appearance
skin
head, neck, extremities
raccoon eyes- bruises around eyes
battle sign- bruising behind ears, medical emergency
complete neurologic assessment - CORRECT ANSWER - a history and evaluation of
mental status (consciousness and cognition)
cranial nerves
mobility and motor (range, strength, posture, abnormal movements)
Deep tendon reflexes
, Sensation (pain, touch, temperature, vibration, and position)
Cerebellar function
what is included in a mental status assessment - CORRECT ANSWER - Emotional
responses
Mood
Cognitive functioning
Personality
How do we assess mental status?
Generally divided into assessment of consciousness and cognition
Cognition is intellectual function: long-term, memory recall and immediate
Alert, Lethargic, Stuporous, Coma
Cognitive functioning should be intact in the healthy elderly client, some changes may occur as
individuals grow older
When assessing an elderly patient's mental status it is essential to determine what - CORRECT
ANSWER - their baseline
what does lethargic mean - CORRECT ANSWER - easily aroused but drowsy
what does stuporous mean - CORRECT ANSWER - responds to painful stimuli
What does comatose mean? - CORRECT ANSWER - not responding to anything
During a client's neurologic assessment, the nurse finds that the client continues to be drowsy,
but is easily awakened. How does the nurse document this client's level of consciousness? -
CORRECT ANSWER - lethargic
How do you assess motor function? - CORRECT ANSWER - Observe for involuntary
tremors or movements
Exam Questions and CORRECT Answers
risk factors for icr issues - CORRECT ANSWER - All populations are potentially at risk
for problems with ICR
Some populations are at higher risk
Degenerative pathology (higher incidence in the elderly population)
Injury related to ICR problems, commonly seen in adolescent and young adult age groups
TBI's (most commonly from falls and motor vehicle accidents)
Falls more of an issue with the very young and elderly population
MVA's are more prevalent in the young adult population
Personal risk factors
Age
HTN
DM
Smoking
Obesity
Cardiovascular disease
neurologic changes with age - CORRECT ANSWER - motor, sensory, cognitive, sleep
pattern, sleep deprivation changes
icr assessment questions - CORRECT ANSWER - patient's appearance and assess his or
her speech, affect and movement
Asking pertinent questions will provide clues to the examiner of ICR problems and will help to
focus the physical examination
Numbness, paralysis, tingling, neuralgia
Loss of consciousness, dizziness, fainting, confusion
Changes in recent or remote memory
,Changes in vision, hearing, balance, gait
Speech problems
Chewing/swallowing problems
Muscle weakness or loss of bowel or urinary control
Onset of unexplained tremors or other motion disturbances
Unexplained, severe headache
Vomiting
Symptom onset
History of head injury
icr testing tools - CORRECT ANSWER - Mental Status
Glasgow Coma Scale (GCS)
Cranial Nerves
Intracranial Pressure
Measurement of Cerebral Perfusion Pressure
NIH Stroke Scale
ICR Physical Assessment - CORRECT ANSWER - general appearance
skin
head, neck, extremities
raccoon eyes- bruises around eyes
battle sign- bruising behind ears, medical emergency
complete neurologic assessment - CORRECT ANSWER - a history and evaluation of
mental status (consciousness and cognition)
cranial nerves
mobility and motor (range, strength, posture, abnormal movements)
Deep tendon reflexes
, Sensation (pain, touch, temperature, vibration, and position)
Cerebellar function
what is included in a mental status assessment - CORRECT ANSWER - Emotional
responses
Mood
Cognitive functioning
Personality
How do we assess mental status?
Generally divided into assessment of consciousness and cognition
Cognition is intellectual function: long-term, memory recall and immediate
Alert, Lethargic, Stuporous, Coma
Cognitive functioning should be intact in the healthy elderly client, some changes may occur as
individuals grow older
When assessing an elderly patient's mental status it is essential to determine what - CORRECT
ANSWER - their baseline
what does lethargic mean - CORRECT ANSWER - easily aroused but drowsy
what does stuporous mean - CORRECT ANSWER - responds to painful stimuli
What does comatose mean? - CORRECT ANSWER - not responding to anything
During a client's neurologic assessment, the nurse finds that the client continues to be drowsy,
but is easily awakened. How does the nurse document this client's level of consciousness? -
CORRECT ANSWER - lethargic
How do you assess motor function? - CORRECT ANSWER - Observe for involuntary
tremors or movements
