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NSG 316 EXAM 2 – Questions With Proper Solutions

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Terms in this set (201)


Cranial Nerve I: Olfactory Test test sense of smell with familiar odor

Cranial Nerve II: Optic Test test visual acuity and visual field with confrontation

gross measure of peripheral vision
-stand 2 fett from person
-have patient cover one eye, then cover your own eye opposite
Confrontation Test to the persons covered one
-hold finger as target midline between you and patient, slowly
advance to periphery
-as person to say "now" as target is first seen

50 degrees upward
90 degrees temporal
Confrontation Test: normal
70 degrees down
60 degrees nasal

Cranial Nerve III, IV, VI: PERRLA
Oculomotor, Trochlear, 6 cardinal positions of gaze
Abducens Test

pupils equal, round, reactive to light (direct and consensual) and
PERRLA
accommodation

right & up
right
right & down
6 cardinal positions of gaze
left & up
left
left & down

nystagmus back-and-forth oscillation of the eyes

nystagmus: amplitude fine, medium or coarse movement

nystagmus: frequency constant or fades after few beats

nystagmus: plane of movement horizontal, vertical, rotary or combo

Motor: asking the client to clench her teeth while you palpate the
masseter (muscle of mastication)
Cranial Nerve V: Trigeminal Test Sensory- test light touch by having a client closer their eyes
while you toucher her face gently with a wisp of cotton, patient
identifies location

What does the corneal reflex CN V sensory, CN VII motor
test?

-remove contacts, bring cotton wisp from side, lightly touch
Corneal reflex test cornea
NORMALLY: patient blinks bilaterally

, Motor: have client smile, frown, puff out her cheeks, raise her
Cranial Nerve VII: Facial Test eyebrows, close her eyes tightly
Sensory: anterior 2/3 taste (sugar, salt, lemon juice)

Cranial Nerve VIII: Whispered voice test
Vestibulocochlear Test

Cranial Nerve IX & X: Motor: open mouth say "ahh" & gag reflex
Glossopharyngeal and Vagus NORMALLY: uvula and soft palate rise in midline
Test Sensory: CN IX does posterior 1/3 taste

Cranial Nerve XI: Accessory Test shrug shoulders

Cranial Nerve XII: Hypoglossal say "light, tight, dynamite"
Test

perform on well persons who have no significant subjective
screening neuro exam
findings

complete neuro exam perform on person with neuro concerns

perform on person with demonstrated neuro defect, who
neuro recheck exam
requires period ic assessment

ansomia Decrease or loss of smell occurs bilaterally

hemianopsia; hemianopia Defective vision or blindness in one half of the visual field

ptosis drooping eyelid

paresthesias tingling, prickling, "pins & needles" (sensory loss)

diplopia double vision

dysphagia difficulty swallowing

Balance Test (Gait)
What are the test to evaluate
Romberg Test
cerebellar function?
Rapid Alternating Movements (RAM)

-observe as the person walks 10 to 20 feet, turns and returns to
the starting point
Balance Test (Gait)
NORMALLY: gait is smooth, rhythmic and effortless opposing
arm swing is coordinating

-ask client to stand with feet at comfortable distance apart, arms
Romberg test at sides, and eyes closed for ~20 seconds
NORMALLY: patient can maintain posture and balance

Rapid Alternating Movements pat the knees with both hands, turn hands over, then faster
(RAM) NORMALLY: done with equal turning and quick rhythmic pace

decreased muscle tone (hypotonia), muscle feels limp, soft,
flaccidity
flabby

spasticity increased muscle tone (hypertonia)

constant state of resistance; resists passive movement in any
rigidity
direction (dystonia)

Increased tone is released by degrees during passive range of
cogwheel rigidity
motion so it feels like small, regular jerks.

paralysis decreased or loss of motor power

hemiplegia Spastic or flaccid paralysis of one side of the body

paraplegia symmetric paralysis of both lower extremities

quadriplegia paralysis of all four extremities

paresis weakness of muscles rather than paralysis

tic involuntary, compulsive, repetitive twitching of a muscle group

Rapid, sudden jerk or a short series of jerks at fairly regular
myoclonus
intervals. (ex: hiccup)

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