NUR 170 EXAM 2 Review Study Guide with
Complete Solutions
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!
Complete Solutions
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!
