Anatomy and Physiology of the Central Nervous System, Exams of Medicine

Download Anatomy and Physiology of the Central Nervous System and more Exams Medicine in PDF only on Docsity!

NUR 2102_Neurological Assessment Exam Questions and Complete Solutions Graded A+ Denning [Date] [Course title]

Objectives - Answer: Utilizing a body systems approach, the student will: a. Apply anatomy, physiology, biology, chemistry, psychology, developmental psychology, and sociology concepts to the assessment of the neurological system of the adult b. Apply health history and physical examination principles for holistic assessment of the neurological system of the adult c. Conduct and document (EMR) a health history and physical examination of the adult while applying the principles of caring, therapeutic communication, interprofessional communication, and professionalism d. Utilize concepts of genetics and genomics when assessing the neurological system of the adult Objective Cont... - Answer: * Interpret common laboratory and diagnostic findings for the neurological system of the adult

• Based on national guidelines (Healthy People 2010/2020, AHRQ Clinical Prevention Guidelines, and other appropriate national standards), recommend the appropriate health promotion and clinical prevention strategies for the adult
• Assess self and patient scenarios utilizing the clinical reasoning model for the neurological system of the adult
• Identify and interpret common laboratory and diagnostic tests
• Demonstrate professionalism in the clinical simulation laboratory by: honoring confidentiality of scenarios and other's health histories; respecting other's self-determination and human dignity; and exhibiting integrity by abiding by laboratory guidelines, equipment use, and dress code
• Describe expected and unexpected findings in each body system to include ethnic, cultural, and age variations The Nervous System - Answer: * Central Nervous System
• Peripheral Nervous System
• Autonomic Nervus System Autonomic - Answer: regulates activities of internal organs such as the heart, lungs, blood vessels, digestive organs, and glands SNS = - Answer: activated during stress; flight for fight response

PNS = - Answer: controls vegetative function; functions associated with conserving energy such as decreasing heart rate and force of myocardial contraction; decreasing BP and respirations; stimulation of peristalsis Central Nervous System - Answer: * Brain and spinal cord Peripheral Nervous System - Answer: * Cranial and spinal nerves Autonomic Nervus System - Answer: * Sympathetic

• Parasympathetic A & P Review- Protective Structures: Skull Protects brain - Answer: * Foramen magnum is large oval opening at base of skull in occipital bone.

• Spinal cord extends through from medulla oblongata.

• Other foramina at base for entrance and exit of paired cranial nerves and cerebral blood vessels
• Meninges, three layers between skull and brain

• Dura mater, outer double layer
• Arachnoid, middle meningeal layer
• Pia mater, inner meningeal layer Between arachnoid and pia mater is subarachnoid space where cerebrospinal fluid (CSF) circulates. Meninges Image - Answer: Meninges: Subarachnoid Space - Answer: * Cerebrospinal fluid (CSF) circulates

A & P Review- Protective Structures: CSF is colorless, odorless fluid containing (6) - Answer: * Glucose

• Electrolytes
• Oxygen
• Water
• Carbon dioxide
• Leukocytes A & P Review- Brain - Answer: * Brain consists of cerebrum, diencephalon, cerebellum, and brainstem.
• Carotid arteries supply most of blood to brain, and branch off into posterior cerebral, middle cerebral, and anterior cerebral arteries.

• Remaining blood flows through two vertebral arteries and into posterior and anterior communicating arteries that supply blood through circle of Willis.
• Blood leaves brain through venous sinuses that empty into jugular veins. Carotid Arteries - Answer: supply most of blood to brain, and branch off into posterior cerebral, middle cerebral, and anterior cerebral arteries. Internal Structure of the Brain - Answer: Cerebrum - Answer: largest part of brain consisting of two hemispheres, each divided into four lobes: frontal lobe, parietal lobe, temporal lobe, and occipital lobe. Frontal Lobe - Answer: * contains primary motor cortex and functions related to voluntary motor activity

• also controls intellectual function, awareness of self, personality, and autonomic responses related to emotion.

Broca's area - Answer: contains left frontal lobe involved in formulation of words. Parietal Lobe - Answer: contains primary somesthetic (sensory) cortex that receives sensory input such as position, touch, shape, and texture of objects. Temporal lobe - Answer: * contains primary AUDITORY cortex.

• Wernicke's area
• Also interprets auditory, visual, and somatic sensory inputs that are stored in thought and memory Wernicke's area - Answer: located in left temporal lobe, responsible for comprehension of SPOKEN and WRITTEN language Occipital Lobe - Answer: contains primary visual cortex which receives and interprets VISUAL information Diencephalon - Answer: made up of thalamus,
• hypothalamus, epithalamus, and subthalamus. Hypothalamus important maintaining homeostasis Functions include regulation of body temperature, hunger, and thirst; formation of autonomic nervous system responses; and storage and secretion of hormones from pituitary gland. Hypothalamus - Answer: important maintaining homeostasis Hypothalamus Functions - Answer: * regulation of body

• temperature
• hunger
• thirst

• formation of autonomic nervous system responses
• Storage and secretion of hormones from pituitary gland Basal Ganglia - Answer: Function is balancing production of two neurotransmitters—acetylcholine and dopamine—that create smooth, coordinated voluntary movement Brainstem - Answer: made up of:
• midbrain
• pons,
• medulla oblongata

• Ten of twelve cranial nerves (CNs) originate from brainstem.

• Midbrain functions to relay stimuli concerning muscle movement to other brain structures

• Contains part of motor tract pathways that control reflex motor movements in response to visual and auditory stimuli
• Oculomotor nerve (CN III) and trochlear nerve (CN IV) originate in midbrain

• Pons relays impulses to brain centers and lower spinal nerves.

• CNs that originate in the pons are trigeminal (CN V), abducens (CN VI), facial (CN VII), and acoustic (CN VIII). Ex: hearing a car accident, crying baby, seeing smoke

Brainstem cont... - Answer: Medulla oblongata contains reflex centers for controlling involuntary functions such as breathing, sneezing, swallowing, coughing, vomiting, and vasoconstriction. Motor and sensory tracts from frontal and parietal lobes cross from one side to other in medulla; lesions on right side create abnormal movement and sensation on left side, and vice versa. Cranial nerves originating in medulla are glossopharyngeal (CN IX), vagus (CN X), spinal accessory (CN XI), and hypoglossal (CN XII). Cerebellum - Answer: * separated from cerebral cortex by tentorium cerebelli. Cerebellum Functions - Answer: * Coordinating movement

• equilibrium
• muscle tone
• proprioception

• Each cerebellar hemisphere controls movement for same (ipsilateral) side of body. Spinal Cord - Answer: * posterior (dorsal) column carries sensations of touch, deep pressure, vibration, position of joints, stereognosis, and two-point discrimination.

• Lateral spinothalamic tract carries fibers for sensations of light touch, pressure, temperature, and pain. Cranial Nerves - Answer: 12 pairs of cranial nerves
• Five pairs have only motor fibers.
• Three pairs have only sensory fibers.
• Four pairs have both motor and sensory fibers. Spinal Nerves - Answer: 31 pairs of spinal nerves emerge from spinal cord

Spinal Column - Answer: Reflex Arcs - Answer: tested by observing muscle movement in response to sensory stimuli.

• Deep tendon reflexes are responses to stimulation of tendon that stretches neuromuscular spindles of muscle group.

• Striking a deep tendon stimulates a sensory neuron that travels to spinal cord where it stimulates an interneuron, which stimulates a motor neuron to create movement.

• Superficial reflexes tested similarly.
• Each reflex corresponds to a specific spinal segment. Deep tendon reflexes are responses to - Answer: stimulation of tendon that stretches neuromuscular spindles of muscle group Superficial Reflexes - Answer: Upper Abdominal: T8, T9, and T Lower abdominal: T10, T11, and T Cremasteric: T12, L1, and L Plantar: L5, S1, and S Deep Reflexes - Answer: Biceps: C5 and C Brachioradial: C5 and C Triceps: C6, C7, and C Patellar: L2, L3, and L Achilles: S1 and S The Autonomic Nervous System - Answer: * Sympathetic Nervous System
• Parasympathetic Nervous System

Sympathetic Nervous System - Answer: Fight or flight Parasympathetic Nervous System - Answer: Dominates during calm, non-stressful times ANS - Sympathetic - Answer: * Sympathetic nervous system (SNS) arises from thoracolumbar segments of spinal cord and is activated during stress (the "fight-or-flight" response).

• SNS actions include:

• Increasing blood pressure and heart rate
• Vasoconstricting peripheral blood vessels
• Inhibiting gastrointestinal peristalsis
• Dilating bronchi ANS - Parasympathetic - Answer: * Parasympathetic nervous system (PNS) arises from craniosacral segments of spinal cord and controls vegetative functions ("breed and feed").

• PNS actions associated with conserving energy such as:

• Decreasing heart rate and force of myocardial contraction
• Decreasing blood pressure and respiration
• Stimulating gastrointestinal peristalsis Neurotransmitters - Answer: * Communicate messages from one neuron to another or from a neuron to a specific target tissue

• Excite or inhibit the target cell's activity
• Usually MULTIPLE neurotransmitters at work in the neural synapse Examples- dopamine, serotonin, GABA,

Epinephrine, and many others Functional Organization of the Brain - Answer: * Localization of function

• Multiple systems can overlap
• Can be assessed by various techniques (e.g., physiology, imaging, neurological exam, neuropsychological exam, post mortem) Brain lateralization - Answer: the two halves of the human brain are not exactly alike Functional specializations - Answer: some functions have neural mechanisms are localized primarily in one hemisphere Lateralization: Left Brain - Answer: Logical Sequential Rational Analytical Objective Looks at parts Lateralization: Right Brain - Answer: Random Intuitive Holistic Synthesizing

Subjective Looks at wholes Damage to Broca's aphasia - Answer: * Prevents a person from producing SPEECH

• Person can understand language
• Words are not properly formed
• Speech is slow and slurred Damage to Wernicke's aphasia - Answer: * Loss of the ability to UNDERSTAND language
• Person can speak clearly, but the words that are put together make no sense. This way of speaking has been called "word salad" because it appears that the words are all mixed up like the vegetables in a salad. Components of Neurological Exam - Answer: Health History
• Prenatal or birth events
• Exposures
• Illnesses
• Injuries
• Clinical manifestations or symptoms
• Family History
• Mental Status
• Cranial Nerves
• Motor System
• Sensory System
• Reflexes

Health History - Focused Neuro - Answer: * Prenatal or birth events

• Exposures (toxins, drugs)
• Illnesses (Epstein-Barr, Bell's Palsy, Rocky Mountain Spotted Fever, Lyme disease, encephalitis, etc.)
• Injuries (concussion, closed head, etc.)
• Clinical manifestations or symptoms: Abnormal sensation Dizziness Visual or sensory disturbances Tremors or other motor tics Pain Weakness Seizures Clinical manifestations or symptoms: - Answer: * Abnormal sensation
• Dizziness
• Visual or sensory disturbances
• Tremors or other motor tics
• Pain
• Weakness
• Seizures Family History - Answer: Diseases:
• Amyotrophic Lateral Sclerosis
• Parkinson's

• Multiple Sclerosis
• Seizure disorders
• Tumors
• Tourette syndrome
• Myasthenia Gravis
• Migraine
• Neurofibromatosis
• Guillain-Barré Syndrome
• Alzheimer's disease
• Muscular Dystrophy American Academy of Neurology - Answer: * Mental Status
• Cranial Nerves
• Motor System
• Sensory System
• Reflexes Mental Status - Answer: * Level of alertness, appropriate responses
• Orientation Motor System - Answer: * Strength
• Gait
• Coordination Sensory System - Answer: * Light touch,
• Pain/temperature
• Proprioception Reflexes - Answer: * DTRs-biceps, patellar, Achilles

• plantar Mental Status Cont... - Answer: * Orientation --If orientation is a concern during history, determine if oriented to time, place, person. ----Date and time is first orientation to disappear. Only a problem if remains disoriented after being reoriented ----Place is second orientation to disappear. ----Person is last orientation to disappear. --Orientations returns in opposite order in which is lost.
• Appearance, general behavior, mood
• Thought content, memory, recall
• Intellectual/functional ability Level of Consciousness (LOC) - Answer: Altered level of consciousness
• Nurse can determine if client alert and oriented by way questions are answered during interview.
• Change in level of consciousness (LOC) is earliest and most sensitive indicator of alterations in cerebral function. ---Awareness is higher level function controlled by reticular activating system. ---Wakefulness is controlled by brainstem. ---When client's awareness cannot be assessed because unconscious, arousal is assessed.

LOC (Arousal) - Answer: * Alertness

• Lethargy
• Obtunded
• Stupor
• Coma Lethargy - Answer: a lack of energy and enthusiasm. Obtunded - Answer: dull the sensitivity of; blunt; deaden Stupor - Answer: a state of near-unconsciousness or insensibility. Coma - Answer: a state of deep unconsciousness that lasts for a prolonged or indefinite period, caused especially by severe injury or illness. LOC - Answer: * Glasgow Coma Scale: assess LOC using 15-point scale.
• Assess for best response to eye opening, motor response, and verbal response.
• Determine stimulation/pain required to elicit response. ---Only time acceptable to inflict pain on client Glasgow Coma Scale - Answer: Cranial Nerves (12) - Answer: Relay Messages Between Brain to Head and Neck I: Olfactory II: Optic III: Oculomotor

IV: Trochlear V: Trigeminal VI: Abducens VII: Facial VIII- Acoustic IX- Glossopharyngeal X- Vagus XI- Spinal Accessory XII- Hypoglossal Olfactory - Answer: I: Smell Optic - Answer: II: vision; Snellen chart; peripheral vision Oculomotor - Answer: III: eye movement Trochlear - Answer: IV: eye movement Trigeminal - Answer: V: face sensations, movement Abducens - Answer: VI: eye movement (CN III, IV, VI test together) Facial - Answer: VII: movement and taste Acoustic - Answer: VIII: (Auditory)- hearing (Weber, Rinne, Whisper test), balance Glossopharyngeal - Answer: IX: taste, gag, phonation Vagus - Answer: X: phonation, swallowing, autonomic fibers to digestive tract, heart, lungs

Spinal Accessory - Answer: XI: shoulder and neck movement Hypoglossal - Answer: XII: tongue movement Cranial Nerves (12) (remember method) - Answer: On Old Olympus Towering Tops, A Fin And German Viewed Some Hops Abnormalities of Cranial Nerves - Answer: I- anosmia II- defect in vision (central or peripheral) III, IV, VI- pupil abnormalities, EOM abnormalities V- absent touch & pain, no blink, weakness of masseter or temporals muscles VII- asymmetrical facial movements, loss of taste VIII- decrease or loss of hearing

IX & X- uvula deviates to one side, no gag, hoarse or brassy voice, dysphagia XI- absent movement of sternomastoid or trapezius muscles XII- tongue deviates to one side , slow rate of movement Cranial Nerves: Type - Answer: Some Say Marry Money But My Brother Says Bad Business to Marry Money Dizziness - Answer: When the room is spinning Cranial Nerves Image - Answer: Motor System - Answer: * Includes brain and spinal cord motor pathways

• Includes all major muscle groups distal and proximal
• Muscle tone, strength, symmetry

• Unusual movements, fasciculations, tics, twitching Gait - Answer: * Walking or ambulating requires coordination of multiple voluntary and involuntary functions
• Strength, coordination, symmetry, balance, stance, speed, stride length, arm movement, foot placement, initiation & cessation Cerebellum - Answer: Cerebellum responsible for voluntary movement and motor coordination Cerebellum: Tests for Balance - Answer: * Romberg test (client standing)—feet together, arms at side, eyes open/closed
• Pronator drift
• Eyes closed, stand on one foot
• Tandem walking (heal toe)
• Hop on one foot, then other
• Knee bends
• Walk on toes/heels Pronator drift - Answer: Cerebellum:

Tests for Coordination - Answer: * Tests for coordination of upper extremity ---Rapid pronation/supination on thighs ---Alternately touch nose with index fingers (eyes closed) ---Touch each finger to thumb in rapid sequence ---Move index finger between nose and examiner finger

• Tests for coordination of lower extremity Heel to shin of opposite leg Sensory System (peripheral nerves) - Answer: Assess for sensation.
• Areas routinely assessed are the hands, lower arms, abdomen, lower legs, and feet
• Flex muscles, then resist against opposite force
• Dermatome map to identify spinal nerve providing sensation
• Light touch with cotton tipped swab
• Vibration using tuning fork on bony prominence; feel vibration and when it stops
• Kinesthetic sensation (proprioception) by moving finger/toe up/down
• Stereognosis
• Two-point discrimination
• Graphesthesia

Dermatome Map - Answer: Stereognosis - Answer: Close eyes and see if Pt can tell what object is in hand. Graphesthesia - Answer: Reflexes: Babinski - Answer: Also called Plantar reflex

• stroke bottom of foot heal to toe; note big toe movement- EXPECTED FINDING- plantar flexion
• if toes fan upward-UNEXPECTED FINDING- indicates CNS dysfunction, present before 2 years of age Deep Tendon Reflexes - Answer: Reflex-involuntary action in response to impulse sent to CNS *Often first sign of dysfunction
• Deep tendon reflexes - muscle stretch reflexes respond to stretching tendons
• Rated as normal, hypo-reflexic, hyper-reflexic
• Scored as: 0 1+ 2+ 3+ 4+

Reflex Score - Answer: Scoring Deep Tendon Reflexes: 0 = - Answer: No response Scoring Deep Tendon Reflexes: 1 = - Answer: Sluggish or diminished Scoring Deep Tendon Reflexes: 2 = - Answer: Active or Expected Response Scoring Deep Tendon Reflexes: 3 = - Answer: Slightly hyperactive, more brisk than normal; Not necessarily pathologic Meningeal Signs - Answer: * Neck Mobility

• Brudzinski's Sign
• Kernig's Sign Scoring Deep Tendon Reflexes: 4 = - Answer: Brisk, hyperactive with intermittent clonus associated with disease Meningeal Signs: Neck Mobility - Answer:

Meningeal Signs: Brudzinski's Sign - Answer: Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed Meningeal Signs: Kernig's Sign - Answer: an indication usually present in meningitis that consists of pain and resistance on attempting to extend the leg at the knee with the thigh flexed at the hip. Diagnostic Evaluation - Answer: * CT Scan

• Positron Emission Tomography
• Magnetic Resonance Imaging
• Lumbar Puncture
• Cerebral Angiography
• Myelography
• Noninvasive Carotid Flow Studies
• Transcranial Doppler
• EEG
• EMG
• Nerve Conduction Studies Sample Documentation - Answer: * Mental Status: alert, relaxed, and cooperative. Thought processes coherent. Client oriented to person, place, and time.
• Cranial Nerves: I- deferred; CN II-XII- intact.
• Motor: Good muscle bulk and tone. Strength 5/5 throughout. Cerebellar- RAMs, F to N, H to S, intact. Gait steady with normal base. Romberg- maintains balance with eyes closed. No pronator drift.
• Sensory: light touch, position, and vibration intact.

• Reflexes: 2+ and symmetric with plantar flexion of bilateral feet. Pediatric Considerations - Answer: * Timing and mastery of developmental milestones can reveal much information
• Loss of abilities after achievement of milestones is a red flag
• Failure of reflexes to extinguish (disappear) can also be a red flag
• There are several differences in assessment of system for infants and young children. ----Infants' sensation and cranial nerves are assessed by observation. ----Unique reflexes are assessed in infants. ----Children's motor development is compared with standardized tables of normal age and sequences of motor development. ----Assessment of older children and adolescent follows same procedures and reveals similar expected findings. Geriatric Considerations Factors to consider: - Answer: * General health and nutritional status
• History of head injury, trauma, or neurological disease
• Smoking history
• Substance use/abuse
• Educational level

• Social support Geriatric Considerations - Answer: * Decrease in taste & smell
• Decrease in muscle bulk
• Senile tremors
• Dyskinesias
• More deliberate movements
• Longer recall
• Loss of vibration sense at the ankle level
• Decrease position sense
• DTRs less brisk
• Some decline in memory and cognition is expected
• Sensory processing may diminish with aging
• Rapid or dramatic declines, or significant personality changes are red flags
• Tests for balance and gait are often assessed for older adults to identify those at risk for falls. Dyskinesias - Answer: Reduced ability to preform voluntary movements.