NCLEX – Neurological Data Collection – LOA/LOC/VITALS/TEMP – Flashcards
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LOA
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level of alertness
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LOA is assessed by:
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1. speaking to pt 2. gently touch pt 3. painful stimuli (sternal rub/supraorbital pressure/trapezius squeeze)
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LOC
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Level of consciousness
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LOC is assessed by assessing clients behavior:
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- confusion - delirium - unconsciousness - stupor - coma
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Vital signs:
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- monitor BP/P changes which may indicate increased ICP
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Elevated temp increases:
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metabolic rate of the brain
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Elevated temp may indicate a dysfunction of the:
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- hypothalamus (or) - brain stem
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A slow rise in temp may indicate:
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infection
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Respiration types:
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- Cheyne-stokes - Neurologic hyperventilation - Apneustic - Ataxic - Cluster
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Cheyne-Stokes is:
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rhythmic with periods of apnea
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Chyene-Stokes can indicate:
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1. a metabolic dysfunction 2. dysfunction in the cerebral hemisphere 3. dysfunction in basal ganglia
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Basal ganglia helps:
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regulate motor function
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Basal ganglia participates in:
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1. motor output 2. limpic system input 3. oculomotor
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Brain cells that make the brain are called:
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neurons
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If brain neurons die the will:
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not be replaced
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Neurogenic hyperventilation is:
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regular deep and rapid, sustained respirations - at a rate of 25 bpm
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Neurogenic hyperventilation indicates a:
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disfunction in the : - low midbrain and - middle pons
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Apneustic is:
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irregular respirations with pauses at the end of inspiration and expiration
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Apneustic indicates a:
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dysfunction in the : - middle or - caudal pons
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Cluster breaths are:
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clusters of breaths with irregularly spaced paused
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Cluster breaths indicate a:
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dysfunction in the: - medulla - pons
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Pupils test:
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P E R R L A
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reactions to light are described as:
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- slow - brisk - fixed
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Unilateral pupil dilation indicates:
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compression of the III Cranial Nerve (occulomotor)
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Midposition fixed pupil indicates:
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midbrain injury
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Pinpoint fixed pupil indicates:
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pontine damage - pontine (pertaining to the pons in the brainstem)
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Motor function is:
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- muscle tone (strength and equality) - voluntary / involuntary movements - purposeful / nonpurposeful movements
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Posturing indicates:
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deterioration of the condition
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Types of posturing:
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1. Flexor (decorticate posturing) 2. Extensor (decerebrate posturing) 3. Flacid posturing
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Flexor (decorticate posturing) is when a:
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- pt flexes one or both arms on the chest - may extend legs stiffly
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Flexor (decorticate posturing) indicates a:
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- nonfunctioning cortex
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Extensor (decerebrate posturing) is when a pt:
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- stiffly extends one or both arms - possibly the legs
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Extensor (decerebrate posturing) indicates:
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- a brainstem lesion
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Flaccid posturing is when a pt displays:
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- no motor response in any extremity
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Babinski's Reflex is the:
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dorsiflexion of the ankle and great toe w.fanning of the other toes when firmly stroking the lateral aspect of the sole of the foot
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A Positive Babinski test indicates:
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a disruption of the pyramidal tract
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Corneal Reflex is the:
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loss of the blink reflex
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Loss of corneal reflex indicates:
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a dysfunction of cranial nerve V (trigeminal)
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Loss of the gag reflex indicates:
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a dysfunction of cranial nerves IX (glossalpharangeal) and X (vagus)
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prone position
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lying face down
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supine postion
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lying face up
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fowler's position
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- head of the patient's bed is raised 18-20" above the level - knees also elevated.
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semi-fowlers position
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- patient in an inclined position - upper half of the body raised - elevating the head of the bed approximately 30 degrees.
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trendelenburg position
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laying flat on the back (supine position) with the feet higher than the head
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reverse tredelenburg position
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laying flat on the back (supine position) with the head higher than the feet
