NSG 316 EXAM 2 Exam Questions Correct Answers New Update

NSG 316 EXAM 2 Exam Questions Correct Answers New Update Cranial Nerve I: Olfactory Test - Answer- test sense of smell with familiar odor Cranial Nerve II: Optic Test - Answer- test visual acuity and visual field with confrontation Confrontation Test - Answer- gross measure of peripheral vision -stand 2 fett from person -have patient cover one eye, then cover your own eye opposite 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 Confrontation Test: normal - Answer- 50 degrees upward 90 degrees temporal 70 degrees down 60 degrees nasal Cranial Nerve III, IV, VI: Oculomotor, Trochlear, Abducens Test - Answer- PERRLA 6 cardinal positions of gaze PERRLA - Answer- pupils equal, round, reactive to light (direct and consensual) and accommodation 6 cardinal positions of gaze - Answer- right & up right right & down left & up left left & down nystagmus - Answer- back-and-forth oscillation of the eyes nystagmus: amplitude - Answer- fine, medium or coarse movement nystagmus: frequency - Answer- constant or fades after few beats nystagmus: plane of movement - Answer- horizontal, vertical, rotary or combo Cranial Nerve V: Trigeminal Test - Answer- Motor: asking the client to clench her teeth while you palpate the masseter (muscle of mastication) 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 test? - Answer- CN V sensory, CN VII motor Corneal reflex test - Answer- -remove contacts, bring cotton wisp from side, lightly touch cornea NORMALLY: patient blinks bilaterally Cranial Nerve VII: Facial Test - Answer- Motor: have client smile, frown, puff out her cheeks, raise her eyebrows, close her eyes tightly Sensory: anterior 2/3 taste (sugar, salt, lemon juice) Cranial Nerve VIII: Vestibulocochlear Test - Answer- Whispered voice test Cranial Nerve IX & X: Glossopharyngeal and Vagus Test - Answer- Motor: open mouth say "ahh" & gag reflex NORMALLY: uvula and soft palate rise in midline Sensory: CN IX does posterior 1/3 taste Cranial Nerve XI: Accessory Test - Answer- shrug shoulders Cranial Nerve XII: Hypoglossal Test - Answer- say "light, tight, dynamite" screening neuro exam - Answer- perform on well persons who have no significant subjective findings complete neuro exam - Answer- perform on person with neuro concerns neuro recheck exam - Answer- perform on person with demonstrated neuro defect, who requires period ic assessment ansomia - Answer- Decrease or loss of smell occurs bilaterally hemianopsia; hemianopia - Answer- Defective vision or blindness in one half of the visual field ptosis - Answer- drooping eyelid paresthesias - Answer- tingling, prickling, "pins & needles" (sensory loss) diplopia - Answer- double vision dysphagia - Answer- difficulty swallowing What are the test to evaluate cerebellar function? - Answer- Balance Test (Gait) Romberg Test Rapid Alternating Movements (RAM) Balance Test (Gait) - Answer- -observe as the person walks 10 to 20 feet, turns and returns to the starting point NORMALLY: gait is smooth, rhythmic and effortless opposing arm swing is coordinating Romberg test - Answer- -ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed for ~20 seconds NORMALLY: patient can maintain posture and balance Rapid Alternating Movements (RAM) - Answer- pat the knees with both hands, turn hands over, then faster NORMALLY: done with equal turning and quick rhythmic pace flaccidity - Answer- decreased muscle tone (hypotonia), muscle feels limp, soft, flabby spasticity - Answer- increased muscle tone (hypertonia) rigidity - Answer- constant state of resistance; resists passive movement in any direction (dystonia) cogwheel rigidity - Answer- Increased tone is released by degrees during passive range of motion so it feels like small, regular jerks. paralysis - Answer- decreased or loss of motor power hemiplegia - Answer- Spastic or flaccid paralysis of one side of the body paraplegia - Answer- symmetric paralysis of both lower extremities quadriplegia - Answer- paralysis of all four extremities paresis - Answer- weakness of muscles rather than paralysis tic - Answer- involuntary, compulsive, repetitive twitching of a muscle group myoclonus - Answer- Rapid, sudden jerk or a short series of jerks at fairly regular intervals. (ex: hiccup)