Test Bank For Critical Care Nursing- A Holistic Approach 11th
Edition By Patricia G. Morton; Dorrie K. Fontaine
help family members solve problems by: - ANSWER: • verbalize the immediate
problem
• identify support systems
• recall how they handled stress in the past
*Such assistance helps family members to focus on the present
issue. It also allows them to solve problems and regain a sense of
control over their lives.*
Medical futility - ANSWER: *treatment that's hopeless* or interventions
that aren't likely to benefit the patient even though they may appear to be effective
H&H Q's - ANSWER: • Do you have headaches? How often do you have them?
What precipitates them?
• Do you ever feel dizzy? How often do you feel this
way? What seems to precipitate the episodes?
• Do you ever feel a tingling or prickling sensation or numbness?
If so, where?
• Have you ever had seizures or tremors? Have you ever had
weakness or paralysis in your arms or legs?
• Do you have trouble urinating, walking, speaking, understanding
others, reading, or writing?
• How's your memory and ability to concentrate?
Mental Status Q's - ANSWER: What's your name? *person*
What's your mother's name? *other ppl*
What year is it? *time*
Where are you now? *place*
How old are you? *memory*
Where were you born? *remote memory*
What did you have for breakfast? *recent memory*
Who's Pres of the U.S. now? *general knowledge*
Can you count backward from 20 to 1? *Attn span &*
*calculation skills*
Steps to arousal - ANSWER: 1. auditory
2. tactile
3. painful
Assess for dysarthria - ANSWER: (=diff forming words)
Ask pt to repeat "no ifs, ands, or buts"
,CN I Assess - ANSWER: Check the patency of each nostril. Then instruct the patient to
close his eyes. Occlude one nostril, and hold a familiar, pungent-smelling substance
under the patient's nose and ask him to identify it.
Repeat this with the other nostril.
CN II Assess - ANSWER: Do this by asking the patient to read a newspaper,
starting with large headlines and moving to small print.
CN III, IV, VI Assess - ANSWER: Check pupil size, pupil shape, and pupillary response
to light. When assessing pupil size, look for trends, such as a gradual increase in the
size of one pupil or appearance of unequal pupils.
Ask the patient to follow your finger through six cardinal positions of gaze. (assess
the patient for nystagmus, or involuntary eye movement,
and the ability to hold gaze in that particular position.)
CN V Assess - ANSWER: Gently touch the right and left sides of the
patient's forehead with a cotton ball while his eyes are closed. Instruct him to tell
you the moment the cotton touches each area. Compare the patient's responses on
both sides. Repeat the technique on the right and left cheek and on the right and left
jaw.
Next, repeat the entire procedure using a sharp object, such as the tip of a safety
pin. Ask the patient to describe and compare both sensations.
To assess the motor function, ask the patient to clench his teeth while you palpate
his temporal and masseter muscles.
Corneal reflex.
CN VII Assess - ANSWER: Ask pt to:
• wrinkle his forehead
• raise and lower his eyebrows
• smile to show his teeth
• puff out his cheeks.
Also, with the patient's eyes tightly closed, attempt to open his eyelids. As you
conduct each part of this test, look for symmetry.
CN VIII Assess - ANSWER: Ask the patient to cover one ear. Then stand on the
opposite side and whisper a few words. Find out whether the patient can repeat
what you said. Test the other ear in the same way.
To test the vestibular portion of the acoustic nerve, observe the patient for
nystagmus and disturbed balance. Note reports of the room spinning or dizzines.
, CN IX & X Assess - ANSWER: • The glossopharyngeal nerve is responsible for
swallowing, salivating, and taste perception on the
posterior one-third of the tongue.
• The vagus nerve controls swallowing and is
responsible for voice quality.
Assess these nerves, first, by listening to
the patient's voice.
Then check the gag reflex by touching the tip of a tongue blade against the posterior
pharynx and asking the patient to open wide and say "ah." Watch for the
symmetrical upward movement of the soft palate and uvula and for the midline
position of the uvula.
CN XI Assess - ANSWER: Press down on the patient's shoulders while he
attempts to shrug against this resistance. Note shoulder strength and symmetry
while inspecting and palpating the trapezius muscles.
Apply resistance from one side while the patient tries to return his head to midline
position.
Look for neck strength. Repeat on the other side.
CN XII Assess - ANSWER: Ask the patient to stick out his tongue. Look for any
deviation from the midline, atrophy, or fasciculations.
Test tongue strength by asking the patient to push his tongue against his cheek as
you apply resistance. Observe the tongue for symmetry.
Test the patient's speech by asking him to repeat the sentence, "Round the rugged
rock that ragged rascal ran."
Stereognosis - ANSWER: the ability to discriminate the shape, size, weight,
texture, and form of an object by touching and manipulating it
Graphesthesia - ANSWER: ability to identify something by tactile sense (ID drawn
number on pt's hand)
Extinction - ANSWER: the failure to perceive touch on one side
Point localization - ANSWER: have the patient close his eyes, touch one of
his limbs, and then ask where you touched him
2-Point localization - ANSWER: touch the patient simultaneously in two contralateral
areas and note whether he can identify touch on both sides.
Pronator Drift Test - ANSWER: ask the patient to extend both arms, palms up. Have
him close his eyes and maintain this position
Edition By Patricia G. Morton; Dorrie K. Fontaine
help family members solve problems by: - ANSWER: • verbalize the immediate
problem
• identify support systems
• recall how they handled stress in the past
*Such assistance helps family members to focus on the present
issue. It also allows them to solve problems and regain a sense of
control over their lives.*
Medical futility - ANSWER: *treatment that's hopeless* or interventions
that aren't likely to benefit the patient even though they may appear to be effective
H&H Q's - ANSWER: • Do you have headaches? How often do you have them?
What precipitates them?
• Do you ever feel dizzy? How often do you feel this
way? What seems to precipitate the episodes?
• Do you ever feel a tingling or prickling sensation or numbness?
If so, where?
• Have you ever had seizures or tremors? Have you ever had
weakness or paralysis in your arms or legs?
• Do you have trouble urinating, walking, speaking, understanding
others, reading, or writing?
• How's your memory and ability to concentrate?
Mental Status Q's - ANSWER: What's your name? *person*
What's your mother's name? *other ppl*
What year is it? *time*
Where are you now? *place*
How old are you? *memory*
Where were you born? *remote memory*
What did you have for breakfast? *recent memory*
Who's Pres of the U.S. now? *general knowledge*
Can you count backward from 20 to 1? *Attn span &*
*calculation skills*
Steps to arousal - ANSWER: 1. auditory
2. tactile
3. painful
Assess for dysarthria - ANSWER: (=diff forming words)
Ask pt to repeat "no ifs, ands, or buts"
,CN I Assess - ANSWER: Check the patency of each nostril. Then instruct the patient to
close his eyes. Occlude one nostril, and hold a familiar, pungent-smelling substance
under the patient's nose and ask him to identify it.
Repeat this with the other nostril.
CN II Assess - ANSWER: Do this by asking the patient to read a newspaper,
starting with large headlines and moving to small print.
CN III, IV, VI Assess - ANSWER: Check pupil size, pupil shape, and pupillary response
to light. When assessing pupil size, look for trends, such as a gradual increase in the
size of one pupil or appearance of unequal pupils.
Ask the patient to follow your finger through six cardinal positions of gaze. (assess
the patient for nystagmus, or involuntary eye movement,
and the ability to hold gaze in that particular position.)
CN V Assess - ANSWER: Gently touch the right and left sides of the
patient's forehead with a cotton ball while his eyes are closed. Instruct him to tell
you the moment the cotton touches each area. Compare the patient's responses on
both sides. Repeat the technique on the right and left cheek and on the right and left
jaw.
Next, repeat the entire procedure using a sharp object, such as the tip of a safety
pin. Ask the patient to describe and compare both sensations.
To assess the motor function, ask the patient to clench his teeth while you palpate
his temporal and masseter muscles.
Corneal reflex.
CN VII Assess - ANSWER: Ask pt to:
• wrinkle his forehead
• raise and lower his eyebrows
• smile to show his teeth
• puff out his cheeks.
Also, with the patient's eyes tightly closed, attempt to open his eyelids. As you
conduct each part of this test, look for symmetry.
CN VIII Assess - ANSWER: Ask the patient to cover one ear. Then stand on the
opposite side and whisper a few words. Find out whether the patient can repeat
what you said. Test the other ear in the same way.
To test the vestibular portion of the acoustic nerve, observe the patient for
nystagmus and disturbed balance. Note reports of the room spinning or dizzines.
, CN IX & X Assess - ANSWER: • The glossopharyngeal nerve is responsible for
swallowing, salivating, and taste perception on the
posterior one-third of the tongue.
• The vagus nerve controls swallowing and is
responsible for voice quality.
Assess these nerves, first, by listening to
the patient's voice.
Then check the gag reflex by touching the tip of a tongue blade against the posterior
pharynx and asking the patient to open wide and say "ah." Watch for the
symmetrical upward movement of the soft palate and uvula and for the midline
position of the uvula.
CN XI Assess - ANSWER: Press down on the patient's shoulders while he
attempts to shrug against this resistance. Note shoulder strength and symmetry
while inspecting and palpating the trapezius muscles.
Apply resistance from one side while the patient tries to return his head to midline
position.
Look for neck strength. Repeat on the other side.
CN XII Assess - ANSWER: Ask the patient to stick out his tongue. Look for any
deviation from the midline, atrophy, or fasciculations.
Test tongue strength by asking the patient to push his tongue against his cheek as
you apply resistance. Observe the tongue for symmetry.
Test the patient's speech by asking him to repeat the sentence, "Round the rugged
rock that ragged rascal ran."
Stereognosis - ANSWER: the ability to discriminate the shape, size, weight,
texture, and form of an object by touching and manipulating it
Graphesthesia - ANSWER: ability to identify something by tactile sense (ID drawn
number on pt's hand)
Extinction - ANSWER: the failure to perceive touch on one side
Point localization - ANSWER: have the patient close his eyes, touch one of
his limbs, and then ask where you touched him
2-Point localization - ANSWER: touch the patient simultaneously in two contralateral
areas and note whether he can identify touch on both sides.
Pronator Drift Test - ANSWER: ask the patient to extend both arms, palms up. Have
him close his eyes and maintain this position
