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N172: NEUROLOGY ASSESSMENT AND DISORDERS: TEST
QUESTIONS WITH CORRECT ANSWERS
What are the highest and lowest score for the Glasgow coma scale? What are the 3 responses? -- Answer ✔✔ Highest: 15 Lowest: 3
- eye opening
- Verbal response
- Motor response for eye opening on the Glasgow coma scale, what are the ratings? -- Answer ✔✔ 4: spontaneous
- Opening eyes to name or command 2: lack of opening eyes to previous stimuli but opening to pain 1: lack of opening to any stimulus U: unstageable for verbal response on the Glasgow coma scale, what are the ratings? -- Answer ✔✔ 5: appropriate orientation, conversant, correct ID of self, place, year, month 4: Confusion. Conversant, disorientation in 1 or more hemispheres 3: Inappropriate or disorganized use of words (cursing), lack of sustained conversation 2: Incomprehensible words, sounds (moaning) 1: lack of sound even with painful stimuli U: Untestable (patient with tracheostomy) for motor response on the Glasgow coma scale, what are the ratings? How would you test this? -- Answer ✔✔ 6: obedience of command 5: Localization of pain, lack of obedience but presence of attempts to remove offending stimulus (purposeful movement) 4: Flexion withdrawal, flexion of arm in response to pain w/o abnormal flexion posture (no posturing)
3: Abnormal flexion, flexing of arm at elbow and pronation (making a fist) = docorticate posturing 2: Abnormal extension, extension of arm at elbow usually with adduction and internal rotation of arm at shoulder = decerebrate posturing 1: Lack of response U: untestable Ask patient to "raise your arm, hold up 2 fingers" For GCS <5 w/o sedation, what should happen? If the score is <8, what is that considered? -- Answer ✔✔ contact One Legacy organ donation Coma How do we test for proprioception? (3) What is a (+) Romberg test? What does it indicate? What is ataxia? -- Answer ✔✔ Finger to nose: movements should be rapid, smooth, accurate Heel to shin: movement should be smooth, straight line Romberg: stand with feet touching and close eyes, mild sway = normal (+) Romberg: loss of balance, indicates vestibulocochlear (inner ear problem) or posterior spinal column disease Ataxia: balance issues Define stereognosis? Define Graphesthesia? -- Answer ✔✔ identify familiar object by touch and manipulation draw a number on palm of hand with a Q-tip, ask patient to identify it Describe the motor strength assessment and ratings out of 5? -- Answer ✔✔ 5/5: normal against gravity and resistance 4/5: Full ROM against mod resistance and gravity 3/5: Full ROM against gravity ONLY, not against resistance 2/5: extremity can move, NOT against gravity (can roll but not lift) 1/5: muscle contracts but extremity can’t move 0/5: no visible or palpable muscle contraction or movement of extremity
Beta-adrenergic receptors bid to beta-1 receptors in heart, regulate rate and force of contraction, Beta-2 receptors in lungs, arteries, liver, uterus (regulate bronchial diameter, arterial diameter, glycogenesis) Describe how GABA, dopamine, and serotonin work? -- Answer ✔✔ GABA: inhibits CNS function Dopamine: controls fine movement and emotions Serotonin: controls sleep, hunger, behavior, affects consciousness Describe what the following parts of the brain are responsible for? Thalamus Hypothalamus Epithalamus Midbrain Pons Medulla Oblongata Cerebellum Ventricles Meninges Circle of Willis Limbic system -- Answer ✔✔ Thalamus: sorting, processing, relaying station for input into cortical region Hypothalamus: regulation of temp, water metabolism, appetite, emotional expression, sleep-wake cycle, thirst Epithalamus: growth and development + pineal body Midbrain: auditory and visual reflexes Pons: controls respiration Medulla Oblongata: controls HR, BP, respiration, swallowing Cerebellum: coordination and balance, fine movements Ventricles: chamber filled with CSF fluid Meninges: covering of CNS composed of 3 connective tissue membranes Circle of Willis: circle of connected blood vessels that provides alternative routes for circulation to brain Limbic system: emotional and behavioral responses to environmental stimuli if the posterior (sensory) part of the spinal nerve is damaged, what happens?
if the anterior (motor) part of the spinal nerve is damaged, what happens? -- Answer ✔✔ loss of sensation flaccid paralysis ascending (sensory) pathways detect what sensations? descending (motor) pathways detect what sensations? -- Answer ✔✔ pain, temp, crude touch fine touch, position, vibration, muscle tone, gross movements if upper motor neurons are damaged, what happens? if lower motor neurons are damaged, what happens? -- Answer ✔✔ UMN: increased muscle tone, decreased muscle strength, decreased coordination and hyperactive reflexes LMN: decreased muscle tone, loss of reflexes Somatic reflexes result in what? Autonomic reflexes result in what? -- Answer ✔✔ skeletal muscle contraction activate cardiac and smooth muscle and glands Describe a reflex arc -- Answer ✔✔ Reflex conducted over a pathway composed of: receptor sensory neuron to carry afferent impulses to CNS integration center in spinal cord or brain Motor neuron to carry efferent impulses Effector (tissue responding by contracting or secreting) Describe spinal reflexes -- Answer ✔✔ somatic reflexes mediated by spinal cord occur w/o impulses traveling to and from brain spinal cord is the integration center Describe deep tendon reflexes If they are abnormal, what could that indicate? What are the 4 things DTRs depend on? -- Answer ✔✔ occur in response to muscle contraction > muscle will relax and lengthen Abnormal DTR: lesion of a spinal nerve
- intact sensory and motor nerve root
Pupil constriction, secretions, constriction of bronchioles, increased peristalsis and secretion of GI fluid What is encephalitis? What is the most common cause? S/sx? -- Answer ✔✔ inflammation of the brain parenchyma (brain tissue) and meninges usually caused by viruses, bacteria, fungi or parasites Mosquitos S/sx: fever, N/V, H/A, vertigo, confusion, stupor, focal neurological deficit, personality and behavior changes, seizures How do you assess for increased ICP? -- Answer ✔✔ increased SBP, decreased HR, N/V, dilated pupils, HA Which nerves regenerate? -- Answer ✔✔ glial cells what are the parts of the central nervous system and peripheral nervous system? -- Answer ✔✔ CNS: brain, spinal cord, CN I and CN II PNS: CN III-X12, spinal nerves, autonomic nervous system Where are 10 of the 12 CN located? -- Answer ✔✔ Brain stem CN IV, CN V and CN VI focus on what? -- Answer ✔✔ pupil response, eye movement, protective mechanisms Which medications would be withheld while doing a CN assessment? -- Answer ✔✔ sedative medication Name the 12 Cranial Nerves and how they would be tested -- Answer ✔✔ 1. Olfactory: smell
- Optic: visual acuity and fields TEST: cover one eye and ask how many fingers, visual threat for corneal reflex
- Oculomotor: extraocular eye movements, six cardinal fields of gaze TEST: PERRLA
- Trochlear: downward and inward eye movement TEST: PERRLA
- Trigeminal: jaw opening and clenching, sensory to cornea
TEST: corneal reflex
- Abducens: lateral eye movement TEST: PERRLA
- Facial: close eyes, facial muscles TEST: inspect facial symmetry, smiling, puffing cheeks, raising eyebrows, can you close your eyes? If not, needs an eye patch
- Auditory/Vestibulocochlear: hearing and equilibrium TEST: test hearing with whisper test or auditory test
- Glossopharyngeal: swallowing and phonation (speech), carotid reflex TEST: gag reflex and ability to swallow, carotid reflex: manually stimulate baroreceptors in carotid artery = decreased BP and HR
- Vagus: speech and swallowing, carotid reflex TEST: same as CN 9
- Spinal Accessory: turn head, shrug shoulders, same actions as phonation TEST: trapezius muscle strength by shrugging shoulders against resistance, turn head side to side
- Hypoglossal: speech sound and swallowing TEST: inspect tongue in mouth and while protruded Define the following terms: Alert Lethargic Delirium Obtunded Stuporous Comatose -- Answer ✔✔ Alert: responds immediately to minimal stimuli Lethargic: drowsy or inactive, needs increased stimuli Delirium: confusion w/disordered perception and attention span, anxiety w/motor and sensory excitement Obtunded: extremely lethargic Stuporous: needs vigorous and continuous external stimuli (sternal rub) Comatose: can’t follow any commands, vigorous stimuli (sternal rub) doesn't produce any voluntary process Define MS What group has highest prevalence? May be R/T what? Etiology?
- perform self-injection techniques, med given to prevent exacerbations of MS
- Cardiotoxicity (lifetime dose limit is given to prevent this) Urinary retention from a flaccid bladder Urinary frequency and urgency (spastic bladder) Muscle spasticity Describe the 4 categories of MS: Relapsing-remitting Primary-progressive Secondary-progressive Progressive-relapsing -- Answer ✔✔ Relapsing-remitting: relapses w/full recovery or sequelae and residual deficit on recovery (85%) Primary-progressive: slowly worsening neurologic: function from the beginning w/no distinct relapses or remissions (10%) Secondary-progressive: relapsing-remitting initial course, then progression with or without occasional relapses, minor remission, and plateaus (new tx may slow progression, after 10 years relapsing/remitting pts advance to this type) Progressive-relapsing: progressive disease from onset, with clear acute relapses, with or without full recovery; periods between relapses characterized by continuing progression (5%) Define Myasthenia Gravis Which antibody is responsible? What is the primary feature of this disease? What is the biggest concern and other complications? What do these patients need to be taught? Diagnostic tests? Which medications are given for tx, give examples? When should these medications be given? What immunosuppressive drugs and other tx are given for MG? What are the nursing priorities for MG patients? -- Answer ✔✔ Autoimmune disease where decreased # of available Ach (Acetylcholine) receptors leads to impaired neuromuscular transmission, muscle weakness, and fatigue IgG Fluctuating muscle weakness (neck, shoulders, hip, eye/lid - pitosis, speaking, swallowing, breathing
Biggest concern: Respiratory due to weakening of intercostal muscles, decreased diaphragm movement, SOB, poor gas exchange Complication: aspiration, nutritional deficit due to inability to chew and swallow and move tongue Frequent rest periods, muscles are strongest in the morning Diagnostic tests: Electromyography, Tensilon IV Test Medication: Anticholinesterase meds to enhance transmission of Ach at receptor site Pyridostigmine/Mestinon: most successful in MG patients Meostigmine Bromide/Prostigmin Give medication 1 hour before meals so they kick in prior to having to chew and swallow (aspiration risk) Immunosuppressive drugs: Glucocorticoids, cyclosporine/Sandimmune or azathioprine/Imuran for antirejection tx, IVIG (in myasthenic crisis), surgery for thymectomy to remove thymoma and T-cells, plasmapheresis Nursing Priorities: reduce patient fatigue, aspiration risk, avoid respiratory infection, adequate nutrition, prevention and recognition of crisis Describe a myasthenic crisis Symptoms? Dx? Primary goal? -- Answer ✔✔ severe exacerbation of MG due to under medicated or lack of responsiveness to anticholinesterase meds (need higher dose) Symptoms: increased weakness or paralysis, severe ocular or bulbar symptoms, failure of respiratory muscle groups to maintain ventilation Dx: IV edrophonium (Tensilon) Primary goal: maintain airway/avoid URI Describe how the Tensilon IV test works? What medication and tx is needed? -- Answer ✔✔ Tensilon IV test (edrophonium): short-acting anticholinesterase med Inject 2mg IV and observe for muscarinic effects: abdominal cramps, N/V/D, diaphoresis, pupil constriction, bradycardia, hypotension If NO muscarinic effects: give 8mg Tensilon IV after 30 seconds If s/sx R/T MG = significant improvement in muscle strength for 5 minutes Have Atropine IV (cholinergic antagonist) available (HR will drop), withhold anticholinergic meds when stable, provide respiratory support
neuron involvement and used as a last resort to provide extra 2-3 months off of vent and trach (monitor LFT - ALT and AST for liver toxicity) Describe how seizures are divided by the following ages: first 6 months 2 - 20 years 20 - 30 years After 50 years -- Answer ✔✔ First 6 months: severe birth injury, congenital defects involving CNS, infection 2 - 20 years: R/T birth injury, infection, trauma, genetics 20 - 30 years: R/T structural lesions such as trauma, brain tumor or vascular disease After 50 years: R/T stroke and metastatic brain tumors 30% of seizures are _______________ How do genetics determine seizures? Define seizure? Patho of seizures? If neuron firing spreads to whole brain, what is it called? How do seizures effect brain tissue? -- Answer ✔✔ ideopathic (unknown cause) Some families have a low threshold for seizure-producing stimuli (trauma, disease, high fever) Definition: a transient, uncontrolled electrical discharge of neurons in the brain (cerebral cortex) that interferes with normal function Patho: stimulus > neuron cell membrane depolarization > spontaneous, abnormal firing (area of seizure focus) Generalized seizure Increased metabolic demand: req more glucose and 02 = increased cerebral blood flow, if unmet = encephalopathy What are the 4 phases of a seizure? -- Answer ✔✔ 1. Prodromal: signs or activity that precedes a seizure
- Aural: sensory warning that is similar each time w/a seizure (change in hearing, smell, taste, vision)
- Ictal: actual seizure
- Postictal: recovery period after seizure (30-90min) where patient feels fuzzy, lightheaded, sleepy depressed
Define epilepsy What causes it? -- Answer ✔✔ Chronic, recurrent pattern of seizures Alcohol Epilepsy, electrolytes Infection, Inflammation Overdose Underdose Trauma Ischemia Psychiatric Stroke Also: lack of sleep, flashing lights, heavy exercise What is a generalized seizure? -- Answer ✔✔ both sides of brain no focal point of onset or warning beforehand altered consciousness can be convulsive or nonconvulsive What is a partial seizure? -- Answer ✔✔ begins in 1 place in the brain (seizure focus) and affect only PART of the brain may or may not alter consciousness or awareness Describe a Tonic-Clonic seizure -- Answer ✔✔ LOC and fall to the ground if upright Tonic phase: stiffening of body for 10-20 seconds Clonic phase: jerking of extremities for 30-40 seconds Cyanosis, excessive salivation, tongue or cheek biting, incontinence Post-ictal phase: tired/sleepy, sore muscles Back to normal in several hours - couple days No memory of seizure Describe tonic seizure Describe clonic seizure Describe atonic seizure Describe general-onset nonmotor (Absent) seizure Describe Myoclonic seizure -- Answer ✔✔ Tonic seizure: sudden increased tone of extensor muscles, can occur during sleep or affect both sides of body
Drug therapy is meant to do what for seizures? -- Answer ✔✔ ongoing seizure activity w/o return to consciousness between seizures any seizure > 5 min neurologic emergency Brain uses more energy than is supplied > neuron exhaustion > stop functioning > permanent brain damage Convulsive status epilepticus (tonic-clonic) due to ventilory insufficiency, hypoxemia, cardiac dysrhythmias, hyperthermia, fatality IV Ativan/Lorazepam 2-4mg Must be seizure free X3 months Continuous Video EEG: audio, video and telemetry along with EEG (hold meds, deprive of sleep, give ETOH to lower seizure threshold) Prevent NOT cure Why is it important to monitor serum drug levels for seizure meds? -- Answer ✔✔ If seizures continue or if frequency increases If med compliance is questioned Therapeutic ranges are only guides for therapy 33% require combo therapy Which medication is given in the acute setting w/status epilepticus? What are the side effects? -- Answer ✔✔ lorazepam (Ativan) 2-4mg or Diazepam (Valium) IVP PRN followed w/long-acting drugs phentoin or phenobarbital Side effects: sedation What is some general anti-seizure drug information? -- Answer ✔✔ abrupt withdrawal from long-term may precipitate seizures Weaning: must be seizure free for 2-5 years, normal nuero exam and EEG Common side effects: diploplia, drowsiness, ataxia, mental slowing, nystagmus, blood dyscrasias use the least amount possible R/T Side effects What is the most harmful side effect of Phenytoin/Dilantin? How is it minimized? -- Answer ✔✔ Gingival hyperplasia (excessive growth of gingival tissue) Minimized by good dental hygiene (regularly brush/floss and dental visits)
gingivectomy may be required hirsutism (woman grows a beard) What are the gerontological considerations for seizures? -- Answer ✔✔ increased incidence of new-onset seizures liver function decreased (phenytoin metabolized here) ensure no ETOH abuse Cognition may already be altered (phenobarbital and primidone/Mysoline have potential effects on cognitive function Newer drugs cause less side effects What are the best ways to prevent seizures? -- Answer ✔✔ Medication compliance Avoid precipitating factors: ETOH, fatigue, lack of sleep, excessive stress Seizure precautions: padded side rails, 02, suction readily available What are the nursing interventions during an acute seizure? -- Answer ✔✔ Lorazepam IV Observe/record seizure details Protect from injury (especially the head) DO NOT restrain DO NOT place anything in the mouth Turn onto side to keep airway open ABCs, have 02 and suction available Provide emotional support to patient and family (incontinence and job discrimination) What should be monitored during and after a seizure? -- Answer ✔✔ Time of onset, duration of seizure Precipitating factors (aura if any) Seizure activity: body parts involved; sequence; character of movements Autonomic signs: pupil size and reactivity, respirations, cyanosis, disphoresis, incontinence, salivations LOC during and after seizure: Check: arousability, duration of reduced consciousness, awareness of and memory of event and Nuero checks Q 1-2 hours in ICU, Q4 on epilepsy unit
Clinical manifestations: abrupt, intense, excruciating pain in lips, gums, cheek, forehead, side of nose May withdrawal socially, lead to depression and SI Can occur several times per day or weeks or months apart Triggers: brushing teeth, washing face, yawning, talking Diagnostics: H&P noting exact triggering stimulus Goal of care: relieve pain medically or surgically Meds: anti-seizure meds block nerve firing 1st line medication therapy: Carbamazepine/Tegretol (check CBC, LFTs), then Gabapentin/Neurontin and Baclofen/Lioresal, Tricyclic Antidepressants (Amitriptyline/Elavil), Opioids are not effective Other tx: Botox, biofeedback, acupuncture, nerve blocking w/local anesthetic Nursing MGMT: control triggers, moderate room temp w/o drafts, avoid stimulus to area (hygiene during peak analgesia, soft toothbrush), food easy to chew and not too hot or cold, if corneal reflex is impaired: need eye protection and artificial tears, encourage regular f/u to cope with illness and social withdrawal Explain Bell’s Palsy -- Answer ✔✔ peripheral facial paralysis caused by inflammation of Facial Nerve (CN 7) on one side of face and demyelination of the nerve, can recover after a few months Cause: unknown but could be R/T activation of herpes simplex virus (HSV-1) Onset: outbreak of herpes vesicles in or around the ear (raised and fluid-filled), flaccidity of affected side of face w/flattening of nasolabial fold, drooping of mouth and drooling, inability to close eyelid, max facial weakness in 2 days of onset Complications: withdrawal due to change in appearance, malnutrition, dehydration, corneal abrasion, facial spasms and contractures Collaborative Mgmt: PT/OT/external treatment (moist heat and gentle massage) Medications: Corticosteroids (acyclovir/Zovirax, valacyclovir/Valtrex, famciclovir/Famvir) Nutrition: SLP, chew on unaffected side but patient will still drool Education: oral hygiene, early recognition of HSV (report ear pain to HCP), analgesics, avoid extremes in temp and drafts Eye protection: dark glasses, artificial tears, eye shield Emotional support: body image problems due to "stroke-like" appearance (full recovery in 9 months) Explain Guillain-Barre syndrome -- Answer ✔✔ acute, rapidly progressing, ASCENDING, potentially fatal form of polyneuritis
ASCENDING, symmetric paralysis affecting cranial nerves and peripheral nerves Occurs after a viral infection (CMV, campylobacter jejuni/GI infection & Epstein Barr), surgery or trauma T cells attack own myelin > transmission along myelin sheath is slowed or stopped 3 stages: initial (1-4 weeks), Plateau (few days-weeks), Recovery (4-6 months) Clinical Manifestations: symmetrical ASCENDING limb paresis/paralysis that may progress to respiratory muscles and require intubation, ophthalmoplegia (paralysis of eyes), sensory loss, Hypotonia (reduced muscle tone), Areflexia (lack of reflexes), severe muscle involvement and respiratory muscle paralysis, HR and BP may fluctuate drastically PEAK WEAKNESS: 4 weeks Complications: Respiratory failure (check resp rate and depth and watch for drooling), intubation/mechanical ventilation PRN, UTIs, immobility (pneumonia, DVT risk) Diagnostics: H/P: any respiratory or GI infection over last 3 weeks? CSF fluid w/elevated PRO Collaborative Interventions: vent support (esp during acute phase), first 2 weeks of s/sx onset: plasmapheresis removes antibodies, IVIG over 5 days (doesn't work after 4 weeks past s/sx) Nursing MGMT: monitor for resp failure and infection, pulmonary toilet (bronchial hygiene/IS/TCDB and Chest PT), nutritional status: body wt, serum albumin, calorie intake (severe cases need TPN), urinary retention requires intermittent Cath vs indwelling Cath, PT/OT, emotional support Explain Parkinson's disease -- Answer ✔✔ slowness in the initiation and execution of movement (bradykinesia), increased muscle tone (rigidity), tremor at rest, gait disturbance Patho: decreased Dopamine R/T degeneration of substantia nigra of the midbrain, excitatory effects of Acetylcholine go unopposed > damage to basal ganglia (important for movement) of cerebral cortex Decreased dopamine = involuntary movement (shaking) Increased Ach = voluntary movement (rigidity) Lewy bodies (clumps of PRO) found in the brain Cause/Etiology: combo of environmental and genetics (15% have family hx), environmental risk factors: well water, living in a rural area, pesticides Secondary Parkinson's dx: decreased dopamine due to exposure to chemicals or drug induced (metoclopramide/Reglan), meth use
