NEUROLOGIC

©Concept Media 2005

NEUROLOGIC ASSESSMENT

Series 106 MENTAL STATUS AND CRANIAL NERVE EVALUATIONS (106.1)

This Instructor’s Guide contains: Brief Description, Objectives, Discussion Questions, Pretest, Post-test, Answer Keys, Glossary, and Handouts for this program, Neurologic Assessment: Mental Status and Cranial Nerve Evaluations. The questions included in this Guide follow the NCLEX model. Institutions that have purchased this program from Concept Media have permission to duplicate any of the contents of this Instructor’s Guide for teaching purposes.


Neurologic Assessment: Mental Status and Cranial Nerve Evaluations

Program Description:

Mental Status and Cranial Nerve Evaluations, the first program in the four-part series Neurologic Assessment, uses real-time footage of a healthcare professional performing two of the components of a complete neurologic examination. It begins by describing various interviewing techniques that enable the provider to assess cerebral function. Methods include asking appropriate questions; listening to the patient’s responses for both content and use of language; observing his or her body language, affect, and movement; and noting his or her general demeanor and appearance. The second part of the program shows an evaluation of each of the 12 cranial nerves as well the patient’s normal responses to the various stimuli.

Objectives: Upon completion of this program, the learner will be able to:

1. Describe various interviewing techniques to use during a neurologic assessment.

2. List the components of a neurologic history.

3. Explain how to evaluate concentration, cognition, calculation, and memory during the interview process.

4. Compare and contrast afferent (sensory) and efferent (motor) nerves.

5. Identify the 12 cranial nerves.

- Cite which are afferent, efferent, and/or parasympathetic.

- State the function of each nerve.

6. Demonstrate a cranial nerve assessment.

7. Differentiate between normal and abnormal responses elicited when evaluating each of the cranial nerves.



Previewing Questions:

True or False 1. The spinal cord is part of the peripheral nervous system.

2. Mental status is an indicator of cerebral function.

3. During the interview process of a neurologic assessment, a healthcare provider should ask, “Have you had a recent sinus infection?”

4. Short-term memory can be checked by asking the patient his mother’s maiden name.

5. Having a patient count backward from 100 by 7s is a way to assess a patient’s cognitive ability as well as his concentration.

6. Looking at a patient’s clothing and grooming are part of an out-patient neurologic evaluation.

7. Efferent nerves direct movement to the skeletal muscles.

8. Cranial nerves can be either sensory or motor, but not both.

9. To check the first cranial nerve, ask the patient to identify an odor.

10. Asking a patient to read a Snellen Chart will evaluate his fifth cranial nerve.

11. If a light is shone only in one eye, the other pupil should also constrict.

12. PERLLA is used to document extra-ocular movements.

13. Taste is a function of both the seventh and ninth cranial nerves.

14. When a healthcare provider uses a soft, whispering voice to ask a patient to count to five, the examiner is checking the patient’s eighth cranial nerve.

15. About 20 percent of the population has a minimal or absent gag reflex.



Previewing Questions: Answer Key

Correct Answer Blacked Out 1. True False

2. True False

3. True False

4. True False

5. True False

6. True False

7. True False

8. True False

9. True False

10. True False

11. True False

12. True False

13. True False

14. True False

15. True False



Discussion Questions: 1. How can a healthcare provider assess neurologic status during an interview?

2. What elements comprise a neurologic assessment?

3. In what way do the cranial nerves impact our lives?



Post-Test Questions:

Match the following cranial nerves with their function:

1. Oculomotor

a. Salivation b. Shrugging shoulders c. Lens accommodation d. Speech e. Chewing

2. Trigeminal


3. Facial


4. Spinal Accessory


5. Hypoglossal




Post-Test Questions: continued 6. When doing a neurologic evaluation, the healthcare provider should ask about recent illnesses or

infections including:

a. West Nile virus. b. tooth abscess. c. sinus infection. d. b and c e. All of the above

7. At the beginning of the interview process, the patient should be told to remember three unrelated words. The purpose of this is to:

a. check his short-term memory later in the interview. b. distract him from the interview process. c. decrease his anxiety. d. a and c

8. Mental status can be checked by:

a. listening to the person speak, including his vocabulary, syntax, and flow of words. b. watching the person’s facial expressions for animation during conversation. c. looking for good eye contact while communicating. d. All of the above e. None of the above

9. Cranial nerves innervate the:

a. extremities. b. abdomen. c. thorax. d. b and c e. None of the above

Match the following cranial nerves:

10. Optic

a. Cranial Nerve VII b. Cranial Nerve IV c. Cranial Nerve VI d. Cranial Nerve X e. Cranial Nerve II



Post-Test Questions: continued 11. Facial


12. Vagus


13. Abducens


14. Trochlear


15. Normally, the eyelid should cover:

a. one-quarter of the eye. b. one-third of the eye. c. one-half of the eye.

16. To test the facial nerve:

a. place several drops of a sweet solution on the tongue and ask the patient to identify the taste. b. ask the patient to clench his teeth. c. look at the pupils and check their response to a light source. d. request that the patient stick out his tongue.



Post-Test Questions: continued 17. Which cranial nerve is responsible for maintaining balance?

a. First b. Eighth c. Third d. Tenth



Post-Test Questions Answer Key: 1. a b c d e

2. a b c d e

3. a b c d e

4. a b c d e

5. a b c d e

6. a b c d e

7. a b c d e

8. a b c d e

9. a b c d e

10. a b c d e

11. a b c d e

12. a b c d e

13. a b c d e

14. a b c d e

15. a b c d e

16. a b c d e

17. a b c d e



Glossary: Afferent nerve: nerve that carries impulses toward the central nervous system. Clonus: involuntary movement of rapidly alternating contraction and relaxation of a muscle. Coma: condition where a patient does not respond to either continuous or painful stimulation. He does not move except for reflex actions, and he does not verbalize. Consensual constriction: constriction of the pupil of the eye when a light is directly shone in the other eye. Decerebrate posturing: extensor posturing where a patient has clenched teeth, rigidly extended and hyperpronated arms, stiffly extended legs, and plantar extended feet. Decorticate posturing: flexor posturing where a patient’s arms, wrists, and fingers flex, his arms adduct, his legs stiffly extend and internally rotate, and his feet plantar extend. Dermatome, sensory: localized area of skin that is innervated by a segment of the spinal cord. Dilated pupil: pupil greater than 4 millimeters in diameter. Dorsal column nerves: detect proprioception, vibratory sensation, and light touch. The impulses travel from the periphery, entering the spinal cord and moving to the brainstem, where they cross to the opposite side terminating in the cerebral hemisphere on the opposite side of the body from where they began. Efferent nerve: nerve that carries impulses away from the central nervous system. Fasciculation: involuntary contractions or twitching of groups of muscle fibers. Graphesthesia: the sense by which letters or numbers are recognized when written on the skin with a dull-pointed object. Lethargy: drowsy state in which a patient can awaken, although not completely, to stimulation. He may also follow commands; however, his responses may be slow and inattentive. Lower motor neurons: nerve fibers which originate in the spinal cord and travel out of the central nervous system to muscles in the body.



Glossary: continued Obtundation: condition where a patient is difficult to arouse and needs constant stimulation to follow commands. He may verbally respond to stimuli with a few words, but will drift back to sleep when the stimulus is removed. PERRLA: acronym for pupils equal, round, reactive to light and accommodation.

Proprioception: perception of position, location, orientation, and movement of the body.

Reflex arc: route followed by nerve impulses to produce a reflex act, from the periphery through the afferent nerve to the nervous system, and back through the efferent nerve to an organ that produces an effect such as contraction or secretion.

Reinforcement: distraction technique (such as having a patient clench his teeth or hook his fingers together and then try to pull them apart) to elicit reflex activity in the upper or lower extremities. Spinothalamic nerves: detect crude touch, pain, and temperature. Impulses travel from the periphery, enter the spinal cord, and cross to the other side of the cord within one or two vertebral levels of their point of entry. They continue on that side up to the brain, terminating in the cerebral hemisphere on the opposite side of the body from where they began. Stereognosis: ability to recognize an object placed in the hands without looking at it. Stupor: state where a patient arouses to vigorous and continuous stimulation, which is typically painful in nature. He may moan briefly, but does not follow commands. His only response may be withdrawal from the painful stimulus. Subluxation: Incomplete or partial dislocation of a joint. Upper motor neurons: nerve fibers that start in the motor cortex of the brain and terminate within the medulla or spinal cord.



Handouts: CRANIAL NERVES

Number Nerve Function Structures Innervated I Olfactory Smell Olfactory bulb II Optic Vision Retina III Oculomotor Eyeball movement

Lens Accommodation 4 eyeball muscles and 1 eyelid muscle

Pupil constriction IV Trochlear Eyeball movement Superior oblique muscles V Trigeminal Sensations Face, scalp, teeth, lips, eyeballs, nose, throat lining General sensory from tongue Anterior 2/3 of tongue Proprioception Muscles of mastication Chewing Muscles of mastication VI Abducens Eyeball movement Lateral rectus muscle VII Facial Taste Face and scalp Proprioception Face and scalp Facial expressions Muscles of face Salivation and lacrimation Salivary and lacrimal glands VIII Acoustic Balance Vestibular apparatus (Vestibulocochlear) Hearing Cochlea IX Glossopharyngeal Taste Posterior 2/3 tongue Proprioception for swallowing Throat muscles Blood pressure receptors Carotid sinuses Swallowing and gag reflex Throat muscles Tear production Lacrimal glands Saliva production Parotid glands X Vagus Chemoreceptors Blood oxygen concentration, aortic bodies Pain receptors Respiratory and digestive tracts Sensations External ear, larynx, pharynx Taste Tongue Heart rate and stroke volume Pacemaker and ventricular muscles Peristalsis Smooth muscles of digestive tract Air flow Smooth muscles in bronchial tubes Speech and swallowing Muscles of larynx and pharynx XI Spinal Accessory Head rotation, upright position

Shrugging shoulders

Trapezius and sternocleidomastoid muscles

XII Hypoglossal Speech and swallowing Tongue and throat muscles



Handouts: continued SCORING FOR PUPIL REACTION TIME

Score Descriptor

4+ Brisk

3+ Less than brisk

2+ Slow

1+ Very sluggish

0 Absent

SCORING FOR STRENGTH OF REFLEX REACTION

Value Descriptor

0 Reflex absent

1+ Reflex slight, trace response or response brought on by reinforcement

2+ Reflex in lower half of normal range

3+ Reflex in upper half of normal range

4+ Reflex enhanced, more than normal, includes clonus

National Institute of Neurological Disorders and Stroke Scale



Handouts: continued SCORING OF MUSCLE STRENGTH

Value Descriptor

0 No muscle contraction

1+ Trace contraction, though not enough to move structure to which it is attached

2+ Voluntary movement which is not enough to overcome force of gravity

3+ Voluntary movement capable of overcoming gravity, but not applied resistance

4+ Voluntary movement capable of overcoming some resistance

5+ Normal strength

CONTINUUM OF LEVELS OF CONSCIOUSNESS

Full Consciousness Lethargy Obtundation Stupor Coma



Handouts: continued GLASGOW COMA SCALE

Category Criteria Score

Eye opening spontaneously 4

Eye opening to verbal response

3

Eye opening to pain 2

Eye Response

No eye opening 1

Oriented 5

Confused 4

Inappropriate words 3

Incomprehensible sounds 2

Verbal Response

No verbal response 1

Obeys commands 6

Localizing pain 5

Withdrawal from pain 4

Flexion to pain (decorticate posturing)

3

Extension to pain (decerebrate posturing)

2

Motor Response

No motor response 1

NEUROLOGIC

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