Neuro Assessment Essentials
This type of aphasia is characterized by fluent speech with made-up words and poor comprehension.
What is Wernicke’s (receptive) aphasia?
This term refers to the degree of competence a person shows in emotional, psychological, and intellectual functioning.
What is mental status?
This action must always be completed before identifying the client or beginning any part of the assessment.
What is performing hand hygiene?
This outermost layer of the skin contains no blood supply and prevents water loss.
What is the epidermis?
This part of the assessment begins the moment the nurse first sees the client and includes posture, grooming, and behavior.
What is the general survey?
This orientation area is usually the first to be disrupted when assessing mental status.
What is orientation to time?
This orientation is the first to be lost when a client is experiencing altered mental status.
What is orientation to time?
During orientation assessment, the nurse must check person, place, time, and this type of memory.
What is remote memory?
These glands become active at puberty, secrete an odorless fluid, and are responsible for body odor after bacterial breakdown.
What are apocrine sweat glands?
When checking level of consciousness, this orientation element is usually assessed first along with person and place.
What is orientation to time?
This cerebellar test requires the client to touch their own nose and then the nurse’s finger repeatedly.
What is the finger-to-finger (or finger-to-nose) test?
A client describes constant worrying, muscle tension, and irritability. These findings are associated with this common mental health condition.
What is anxiety?
When assessing the pupils, the nurse must evaluate four key characteristics: size, shape, reaction to light, and this bilateral response.
What is the consensual response?
A lesion described as “round with central clearing” is classified using this shape term.
What is annular?
During respiratory assessment, the nurse inspects for this essential characteristic, meaning both sides of the chest rise evenly.
What is symmetrical chest expansion?
This sensory pathway transmits pain and temperature sensations to the brain.
What is the spinothalamic tract?
Repeated checking, cleaning, or counting rituals that the client feels driven to perform are characteristic of this disorder.
What is obsessive-compulsive disorder (OCD)?
During abdominal assessment, bowel sounds must be auscultated beginning in this quadrant and moving clockwise.
What is the right lower quadrant (RLQ)?
This condition presents as clustered, painful vesicles arranged along a nerve line.
What is herpes zoster (shingles)?
This test, performed by compressing the nailbed and observing color return, evaluates peripheral perfusion.
What is the capillary refill test?
This motor neuron lesion produces increased muscle tone, spasticity, and hyperactive reflexes.
What is an upper motor neuron (UMN) lesion?
Acute onset of fluctuating attention, impaired memory, rapid emotional shifts, and altered awareness describes this condition, which is a medical emergency.
What is delirium?
When assessing skin turgor in the extremities portion of the exam, the nurse should check this anatomical area instead of the hand.
What is the back of the forearm or the clavicular area?
This tool is used to evaluate potentially malignant skin lesions and includes Asymmetry, Border, Color, Diameter, and Evolution.
What is the ABCDE mnemonic?
During abdominal assessment, this technique must always be performed first—before auscultation, palpation, or percussion.
What is inspection?