N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide Snap fingers by the ear; Rhomberg’s test Swallow and say “ah” Use tongue depressor IX Glossopharyngeal Swallowing and voice XI Spinal Accessory Neck motion Should shrugging XII Hypoglossal Tongue movement and strength Stick out tongue and apply resistance with a depressor • Assess the patient's gross motor skills and balance. Note that these tests require that the patient be able to safely stand and walk. If the patient is unable to safely stand, this part of the exam should be deferred and the appropriate documentation should be includedin the chart. During these tests, be certain to stay close to the patient to prevent falls. o Walking gait: Have the patient walk across theroom.  Normal: Upright posture, steady gait, and maintaining balance without aids  Deviations from normal: Poor posture, staggering gait with little or no arm movement, or needing some sort of aid for ambulation o Heel-toe walking: Have the patient walk in a straight line placing the heel of one foot directly in front of the toes of the other foot.  Normal: Able to walk in a straight line, walking heel to toe.  Deviations from normal: Unable to maintain heel to toe gait. o Toe and heel walking: Have the patient walk across the room on his toes and return on his heels.  Normal: Able to walk on both toes and heels for a short distance  Deviations from normal: Unable to balance on toes or heels for several steps o Romberg Test: Have the patient stand with feet together and arms atside. Perform this test with eyes open and then with eyes closed.  Normal: The patient may sway slightly but can maintain an upright stance without moving her feet.  Deviations from normal: The patient is unable to maintain anupright stance without moving her feet. o One foot stance: Have the patient stand on one foot with eyes closed;then, have the patient stand on the other foot with eyes closed.  Normal: The patient is able to maintain balance for five seconds.  Deviations from normal: The patient is not able to maintain balance for five seconds. • Assess the patient's fine motor skills. o Finger to nose: Have the patient hold his arms straight out to his side atshoulder height and then alternate touching his nose with his index fingers. Repeat with eyes closed.  Normal: The patient is able to repeatedly touch nose with each finger.  Deviations from normal: The patient is not able to repeatedly touch nose with each finger. o Finger to nose and to nurse's finger: Have the patient touch his nose with his index finger Gag reflex VIII Acoustic X Vagus Hearing; balance

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