NUR 170
EXAM 2 STUDY GUIDE
Concepts Of Medical–Surgical Nursing
Galen College of Nursing
, NUR 170 EXAM 2 REVIEW
Assessment of the Nervous System –Ch. 41
Neuro Assessment—Medical hx- pg. 846 Chart 41-2
Evaluation of Mental Status— establishment of patient's norm regarding mental status
o Consciousness: the ability to be aware of the environment, an object, & oneself; LOC—
degree of alertness or amount of stimulation needed to engage in a patient's attention;
Alert: awake, engaged, & responsive (not oriented to person, place, or time) less
than alert is lethargic, drowsy but responsive; stuporous, arousable only with
vigorous or painful stimulation.
Coma: unconscious & cannot be aroused despite vigorous or noxious
stimulation.
o Cognition: evaluated in a rapid or focused manner using tests of memory & attention
that require verbal or written ability. Three types of memory can be tested: long-term
(remote), recall (recent), & immediate.
Mobility and Motor System Function—Range, strength, posture, abnormal movements, PERRLA
Report all decreases to the primary health care provider
Deep Tendon Reflexes and Sensation—Pain, touch, temp, vibration, position
Cerebellar Function—Gait, balance, coordination.
, Rapid Neuro Assessment—
NIHSS (National Institute of Health Stroke Scale)
o Critical focused assessment that gives quick and reliable information on the neuro status
of the patient.
GCS Establishes baseline data:
Highest score is 15
Critical Rescue—A decrease in 2 points or more in the GCS is clinically significant
and MD must be notified!
EXAM 2 STUDY GUIDE
Concepts Of Medical–Surgical Nursing
Galen College of Nursing
, NUR 170 EXAM 2 REVIEW
Assessment of the Nervous System –Ch. 41
Neuro Assessment—Medical hx- pg. 846 Chart 41-2
Evaluation of Mental Status— establishment of patient's norm regarding mental status
o Consciousness: the ability to be aware of the environment, an object, & oneself; LOC—
degree of alertness or amount of stimulation needed to engage in a patient's attention;
Alert: awake, engaged, & responsive (not oriented to person, place, or time) less
than alert is lethargic, drowsy but responsive; stuporous, arousable only with
vigorous or painful stimulation.
Coma: unconscious & cannot be aroused despite vigorous or noxious
stimulation.
o Cognition: evaluated in a rapid or focused manner using tests of memory & attention
that require verbal or written ability. Three types of memory can be tested: long-term
(remote), recall (recent), & immediate.
Mobility and Motor System Function—Range, strength, posture, abnormal movements, PERRLA
Report all decreases to the primary health care provider
Deep Tendon Reflexes and Sensation—Pain, touch, temp, vibration, position
Cerebellar Function—Gait, balance, coordination.
, Rapid Neuro Assessment—
NIHSS (National Institute of Health Stroke Scale)
o Critical focused assessment that gives quick and reliable information on the neuro status
of the patient.
GCS Establishes baseline data:
Highest score is 15
Critical Rescue—A decrease in 2 points or more in the GCS is clinically significant
and MD must be notified!
