Nursing Final Exam Study Guide

Final Exam Study Guide 1. Signs and symptoms and management of musculoskeletal sprains/strains/dislocations Sprains: often has redness and bruising over the affected joint, active and passive ROM is decreased, pain upon moving joint. X-ray to rule out fracture. Strain: affects muscles and tendon that connect a muscle to a bone. Pt usually complain of “pulled muscle” but can use affected limb Paresthesias: sensation of numbness, prickling, or tingling experienced in central and peripheral nerve lesions. First degree- stretching of ligamentous fibers Second degree- partial tear of part of the ligament with pain and swelling Third degreecomplete ligamentous separation -effects muscle or tendon that connects a muscle to a bone, complain of “pulled muscle,” severe cases cause inflammation, swelling, weakness and loss of functionsurgery may be needed Dislocation- complete separation of 2 bones that form a joint Very painful and cause immobility, need immediate medical attention Referral to orthopedics for possible surgery or reduction with application of cast or splint. Four cardinal signs of inflammation (swelling, pain, erythema, or warmth). 2. Signs and symptoms and management of spinal disorders (spondylosis, stenosis, etc.) Spinal stenosis: is the narrowing of one or more levels of lumbar spinal canal, subsequent compression of nerve roots. As many as 30% of the population may have had spinal stenosis after 60 yrs old, but only portion have symptoms Obesity is a predisposing factor Osteoporosis is predisposing factor Lumbar stenosis: 3. Recognition and immediate management of cauda equina syndrome Typically presents with leg weakness, saddle area anesthesia, bowel or bladder incontinence/retention, or impotence. 4. Maneuvers and expected findings with joint pain (knee, shoulder, wrist, etc.) Shoulder: Neck pain-Spurling’s. Shoulder pain-Apley scratch test(reaching the scapula). Internal and external flexion. Internal and external abduction. Pain with abduction= early supraspinatus tendinitis and subacromial bursitis=early rotator cuff injuries. Wrist and hand-allen’s test= radial and ulnar arteries. Phalens test=median nerve compression. Tinel’s sign assess for compression neuropathy – tapping over nerve. Finkelsteins test- de Quervains disease. Thumb between finger and point. Knee Pain= Mcmurray, apprehension sign, bulge sign, inspect/palpate to assess effusion. Lachman, drawer sign – ACL, Thumb test - PCL MCL, LCL test are valgus and varus Tennis elbow cup coffee cup sign CTS-NSAIDs not effective Achillies rupture – Thompson test Apley test that measures abduction and external rotation by having pt reach behind head to touch superior aspect of opposite scapula. For internal rotation an adduction n, pt reach behind the back and touch the inferior aspect of the opposite scapula. Pt should also get external and internal flexion w/ elbow flexed. Internal/external in abduction w/ shoulder at 90 degrees. Wrist: allen test which assess patency of radial and ulnar arteries and the arterial arch. Phalen’s test assess for median nerve compression. Tinel’s sign assess for compression neuropathy. Finkelstein’s test assess for de Quervain’s disease (have pt touch thumb into palm and make a fist. Test positive if moving wrist into ulnar deviation causes pain) 5. Initial assessment of FOOSH injury in correlation to anatomical location of radial head bone Fall on an outstretched hand: FOOSH - patients present after trauma with pain and swelling in the distal forearm or wrist. Numbness may be present if the medial nerve is affected. The mechanism of injury will often provide important clues to the diagnosis. The examination begins with gentle palpation to locate the area of point tenderness and includes a thorough neurovascular assessment. A radiograph of the wrist (including an oblique view) may be necessary to rule out fracture. Common fractures are the colles fracture of the distal radius and the navicular (scaphoid) fracture of the anatomical snuffbox. It is not unusual to have a navicular fracture missed on radiography, so an orthopedic referral should be provided when the presenting compliant is pain and trauma to the soft-tissue area of the anatomical snuffbox. 6. Assessment and management of Myofascial pain Myofascial pain: muscle pain that is purportedly caused by the development of “trigger points” within a muscle. Management: identifying and eliminating aggravating factors. Trigger point injections, (such as anesthetic or corticosteroids), dry needling (needle w/o med is inserted to deactivate the trigger point), massage therapy and the muscle relaxant tizanidine (can be temporarily used) 7. Health promotion activities to prevent sport related musculoskeletal injuries Protection may refer to preventing the injury from occurring or making it less severe by wearing protective gear, such as helmets, wrist pads, and kneepads. Maintain adequate hydration and proper diet while playing sports. Stretch before the activity. Stop when you are injured, do not “tough it out”. Reassurance: most injuries are self-limiting and improvement should occur in approx. 2 weeks Limitation of activity: immobilization of the injured area is appropriate during diagnostic phase. Bed rest should be limited to 2 days or less Physical therapy: may include heat or cold application with the goal of returning the pt to full function ASAP with minimal limitation Pain relief: NSAIDs are the first lie choice for pain relief. Long term use can lead to GI disease such as ulcers, gastritis and hemorrhage. Referral: pt should be referred to an orthopedic specialist if there is no relief with conventional methods Imaging studies: radiography, CT, and MRI are usually not indicated for acute musculoskeletal injuries 8. Osteopenia: is the thinning of bone mass that is commonly seen in people over the age 50 that have lower than average bone density but do not have osteoporosis. It is the precursor to osteoporosis. Caused by a level of T-scores in relation to the results of a dual-energy x-ray absorptiometry scan or DXA Scan, which measures the mineral content of bone. A T-score ranging from -1 to -2.5 would be classified as osteopenia. Patho: it occurs secondary to uncoupling of osteoclast-osteoblast activity resulting in a quantitative decrease in bone mass. Peak bone mass is typically achieved by males and females just prior to, or early-on in the 3rd decade of life. 9. Assessment and management of gout Assessment: thorough evaluation of the onset, characteristics and potentiating cause of gouty joint pain. Pt past medical history, including any joint or musculoskeletal trauma, along with family history. Management: goal is to terminate an acute attack, prevent future attacks, normalize hyperuricemia, and prevent potential complications of urate deposits. Management includes pharmacological treatment of acute attacks ad long term medical and pharmacological treatment of hyperuricemia. Acute management: generalized rest, elevation and immobilization of affected joints, and pharmacological treatments Subsequent management: pharmacological management, dietary modifications (purine rich foods, adequate fluid intake, and moderating etoh intake), and lifestyle modifications 10. Medication management for acute vs. chronic gout Acute management: pharmacological treatments (NSAIDs, colchicine, corticosteroids) Subsequent management: colchicine and NSAIDs may be continued in lower doses for up to 12 months after acute attack. Probenecid (uricosuric agent that blocks tubular reabsorption of filtered urate), allopurinol and febuxostat (xanthine oxidase inhibitors that lower plasma urate and urinary uric acid levels) IV drug krystexxa (uricase that is used to treat high serum uric acid levels that are refractory to other treatments. 11. Dietary restrictions for gout: moderation of purine rich foods such as all meats and seafood (especially organ meats such as liver, kidneys, and sweet breads), meat extracts and gravies, yeast and yeast extracts, beer and etoh beverages, beans, peas, lentils, oatmeal, spinach, asparagus, cauliflower, mushrooms, mussels, scallops, anchovies, herring, and sardines, trout, haddock, mackerel and tuna. 12. Signs and symptoms and management of thyroid disorders Hyperthyroidism: excessive secretions and synthesis of one or both of the thyroid hormones T4 and T3. Signs/symptoms: muscle atrophy, tremors, warm, flush, most skin, hyperpigmentation, fine and silky hair, urticaria, pruritus, vitiligo, corneal ulceration, increased exophthalmos, hyperactive reflexes, ST, elevated BP, sx of CHF, dysrhythmias, gynecomastia, enlarge thyroid. Management: Propylthiouracil (PTU) and methimazole (MMI) for meds. Emergency treatment includes IV hydration, thyroid blocking meds, beta adrenergic blockers and corticosteroids if signs of ophthalmopathy are present. Iodine blocks the release of stored thyroid hormones and glucocorticosteroids block the conversion of T4 to T3. Hypothyroidism: common treatable disorder in which there is a slow progression of thyroid hypofunction, followed by signs and symptoms indicating thyroid failure. Signs/symptoms: slowing of mental process, periorbital puffines, hypothermia, yellow skin, myxedema (facial pallor/swelling), dry, cool, rough skin, alopecia, dry, coarse, thick hair, ascites, large tongue, nonpitting edema, hyporeflexia, bradykinesia, bradycardia, cardiac enlargement, pleural effusion, decrease in fertility, hoarseness, hypoactive bowel sounds Management: typically treated medically, however surgery may be indicated for particularly large nonfunctional goiters that impair tracheoesophageal functioning. Usual medication is levothyroxine, but can be given combo therapy T3/T4 replacement therapy for those that does not respond to T4 replacement (Synthroid) alone. Armour thyroid (desiccated bovine thyroid) is still use today just not as much 13. Thyroid screening tests, confirmatory tests and monitoring Hyperthyroidism screening Initial: sensitive serum TSH assay, measurement of T4 and T3 levels. If pt is symptomatic or in high-risk category, such as family history or previous history of thyroid disease or autoimmune disorders, screening is appropriate. TSH level of less than 0.35 mIU/L usually accompanies an elevated FT4 >12.5 mcg/dL (which is preferred over T4) Subsequent testing: Thyroid scan, US, fine-needle biopsy and/or MRI. Hypothyroidism screening: Initial: although there are no universally accepted screening recommendations, American Thyroid Association recommends baseline screening at 35 especially high-risk patients (pregnant, older than 60, autoimmune disorder). No screening necessary for asymptomatic people before age 50, but some physicians chose to start at age 40. Diagnosis made by measuring TSH, but TSH and T4 used to monitor treatment. For primary hypo- it is low FT4 and elevated TSH. Subsequent testing: T3 levels, CBC b/c anemia is a frequent complication of hypothyroidism. Blood chem should b done to assess for alterations in serum electrolytes, BUN, creatine, serum osmolarity, and glucose. UA should be done with specific attention to the presence of protein. BP should be monitored since these pt tends to end up with HTN. 14. Risk factors for Hashimoto's & Grave’s disease Hashimoto’s: is an autoimmune (attacks thyroid cells) disorder. Underproduction of thyroid leading to hypothyroidism. Graves’s disease: autoimmune (attacks thyroid cells). Overproduction of thyroid leading to hyperthyroidism. This is 90% of hyperthyroidism 15. Risk factors for secondary obesity DM, HTN, CAD, CA, Skin infections, arthritis, GERD, stress incontinence, OSA, infertility, acute pancreatitis, gallbladder disease. 16. Macrocytic vs microcytic vs normocytic anemia (causes, symptoms, testing) Macrocytic anemia: anemia with an MCV equal to or greater than 100fL. Can be cause due to 1 of 4 reasons, vitamin B12 def., folate def., antimetabolite drugs such as methotrexate and miscellaneous etiologies (thiamine or pyridoxine-responsive anemias and Lesch-Nyhan syndrome, chronic etoh) Symptoms: Subjective include stomatitis, diarrhea, anorexia, peripheral neuropathies and malaise. Objective include pale or icteric mucosa, dry and cracked oropharynx, systolic injection murmur, tachycardia, tachypnea, diffuse abd tenderness. Testing: blood smear, reticulocytes may be low or normal in number, serum folate if folic acid deficiency is the cause, the schilling test (which is rarely use today) measures the ability of the small intestine to absorb vitamin B12 Microcytic anemia: based on small size of RBC. It is related to iron deficiency and the most common in the world. Symptoms: subjective include tachycardia, fatigue, SOB, dyspnea on exertion, palpitations, listlessness, poor concentration, anorexia, and dizziness. Objective include hemoglobin drops below, sallow-colored skin, pale mucous membranes, tachycardia, and tachypnea at rest. Possible prolonged blanching response in the nailbeds. Testing: CBC Normocytic anemia: anemia associated with normally sized RBCs (MCV 81-99 fL). At least half of all pts with an underlying chronic disease will develop normocytic anemia over the course of their illness Symptoms: Subjective depends on severity. Rarely presents with a moderate to severe anemia of less than 30% HCT, many pt with diagnosis do not report subjective findings. Objective are the same at microcytic (Objective include hemoglobin drops below, sallow-colored skin, pale mucous membranes, tachycardia, and tachypnea at rest. Possible prolonged blanching response in the nailbeds). Testing: initial testing begins with CBC, subsequent an absolute reticulocyte count 17. X-linked disorders in African American males Fragile x syndrome is the most common inherited form of intellectual disabilities and the most common single gene cause of autism. 18. Signs and symptoms of splenic sequestration: results when large numbers of sickled erythrocytes become lodged in the engorged, functional spleen during early childhood, resulting in severe anemia and potentially fatal hypovolemic shock, with a mortality of 10%-15%. Since this tends to be recurrent, splenectomy is often performed after the first episode Signs/symptoms: irritability, pain on left side of abdomen, weakness, tachycardia, splenomegaly, unusual sleepiness, pale, excessive thirst, tachypnea 19. Most accurate diagnostic testing for sickle cell anemia Peripheral blood smear (like done in newborn screening). Elevated reticulocyte count (>10% of the total erythrocyte count) is characteristically accompanied by the presence of Howell Jolly bodies, which are small remnants of nuclear material from hemolyzed erythrocytes that reflect hyposplenia from autoinfarction, as well as target cells. 20. Patient education for iron supplementation administration to improve efficacy Take at least 30 minutes before a meal or 2 hours before taking other medications. Avoid taking with milk, calcium and antacids, high fiber foods or caffeine. Some studies has suggested taking iron with orange juice or vitamin C supplementation to help improve absorption. 21. Risks, diagnosis and treatment of hematological disorders (normocytic, microcytic, macrocytic has been discussed previouslu) 22. Common types of leukemia: is a neoplastic disease of malignant hematopoietic stem cells that differentiate and proliferate according to specific lineage trajectories that distinguish the types of leukemia as either acute or chronic. Acute myelogenous leukemia (AML): may be seen in adults of all ages, but incidence increases after 40 years of age. Acute lymphoblastic leukemia (ALL): is the predominant form in children 2-15 with higher prevalence among children younger than 5 Chronic myelogenous leukemia (CML): strikes middle aged persons, with a median age onset of 42 years old. Chronic lymphocytic leukemia (CLL): more prevalent among adults older than 60 years of age, however may appear in persons of any age. Most common leukemia in Western developed countries with median age onset of 70. 23. Stages of chronic lymphocytic leukemia (CLL) Rai stage 0 low risk: lymphocytosis; no enlargement of the lymph nodes, spleen, or liver, RBC and PLT are near normal Rai stage I intermediate risk: lymphocytosis; enlarged lymph nodes; spleen and liver are not enlarged; RBC and PLT counts are near normal Rai stage II intermediate risk: lymphocytosis; enlarged spleen (and maybe enlarged liver); lymph nodes may or may not be enlarged; RBC and PLT counts are near normal Rai stage III high risk: lymphocytosis; lymph nodes, spleen, or liver may or may not be enlarged; RBC are low (anemia); PLT counts are near normal Rai stage IV high risk: lymphocytosis; enlarged lymph nodes, spleen, or liver; RBC may be low or near normal; PLT counts are low (thrombocytopenia) 24. Acute lymphoblastic leukemia (ALL) treatment in children and correlation with subsequent cancers in adulthood The main treatment with ALL is chemotherapy that is given in 3 phases: induction, consolidation, and maintenance. Treatment can take 2-3 years, most intense in the first few months. 95% of children with ALL enter remission after 1 month of induction treatment All children receive chemo through CSF to kill leukemia cells that have spread to the brain or spinal cord. There is a correlation with childhood cancers to adulthood cancers, and this increase if the childhood cancer occurs before age 15. The increased risk is related to a hereditary cancer syndrome, treatments that were performed that may have caused cancer-causing side effects, or due to risk related to age. Fam hx can also play a role. 25. Animal bites: more common in kids than adults. Can cause a range of injuries. Extremities is the common site for bites in older kids and adults. Predominant pathogen are oral flora of animal and human skin flora, so infection is usually from mixture of organisms. Can have serious clinical implications due to complication potential. Common pathogens include Pasteurell, Staph, Strep, Capnocytophaga canimorus Diagnostics: x-ray would indicate or rule out fracture, culture wound if sign of septic, pt immunocompromised or if ABX has failed Management: OTC or Toradol for severe pain Animal bites are highly infectious. Clean site with mild soap and water, 1% betadine. If you suspect rabbies, irrigate with 1% benzalkonium chloride Cat bites: Most involve upper extremities. Deep puncture wounds have particular concerns because cats have long, slender, sharp teeth. Can transmit Pasteurela and Bartonella henselae 26. The treatment and management of wounds and lacerations Infection with Pasteurella multocida characteristically develops rapidly following cat or dog bites with erythema, swelling, and intense pain evident as early as 12 to 24 hours after the bite. Blood cultures are warranted prior to ABX therapy for pt with an infected bite wound or any signs of systemic infection. Augumentin BID for 3-5 days is the treatment. Cefuroxine is an alternative with less reported GI issues. Allergy to PCN or cephalosporin, doxycycline or Bactrim DS is recommended. 27. Assessment and administration of tetanus vaccine for post exposure management Bite wounds are tetanus prone injuries. If pt has not received tetanus booster in the past 5 years, one should be administered. For those with absent or incomplete primary immunization, a proper dose of tetanus should be given. 28. Erectile dysfunction causes and treatments Causes: may be a result from combination of both physical and psychological or emotional (psychogenic) because etiologies are not mutually exclusive. A failure to generate the nerve impulses required to initiate an erection may be caused by a number of endocrinological or neurologic conditions or psychogenic. Maybe a result of failure to adequately fill penile blood vessels, most often arteriogenic in origin. Failure to retain blood in the penis, which is usually veno-occlusive in origin Loss of libido may indicate androgen deficiency arising from pituitary or testicular disease Medication are common causes of ED Neurologic disease, vascular disease, endocrine disorders, penile disorders, medications Treatments: includes behavioral based sex therapy and pharmacological Hormone therapy: parenteral agents (depo-testerone), oral agents (halotestin, android, methitest, testred, virilon), transdermal patch (androderm, testoderm), transdermal testosterone topical gel or solution (androgel, testim, axiron solution) Vasoactive therapy (drugs that decrease breakdown of 5-cyclic guanosine monophosphate): oral agents (Viagra, Levitra, Cialis, stendra), injectables (alprostadil), transurethral suppositories (alprostadil- muse) Vacuum constriction devices: insert penis into cylinder, then uses the pump to create a partial vacuum. Penile prostheses: can be surgically implanted into the penis Penile revascularization: experience is limited and some pt fail to have sufficient erection Low-intensity shock wave therapy 29. Drug of choice for treatment of priapism (persistent painful erection) Intracavernosal phenylephrine is the drug of choice if it has been less than 4 hours in duration. After 4 hours, aspiration combined with intracavernosal injection of a sympathomimetic drug is considered to be optimal treatment. 30. Hypospadias: relatively rare congenital condition (birth defect) where the opening of the penis is on the underside of the organ. Abnormal opening can form anywhere from just below the end of the penis to the scrotum. Usually requires surgical correction to restore the proper flow of urine. 31. Treatment of undescended testes (cryptorchidism) Usually corrected with surgery HCG injection could cause the testicle to move to your son’s scrotum, not usually recommended because it is much less effective than surgery. Should descend by age 2, if not surgery is needed before age 6 for proper maturation and hormone function. If both testes are missing or didn’t survive surgery, one may consider testicular prostheses 32. Varicocele vs testicular torsion vs hydrocele vs epididymitis Testicular torsion: a twisting or rotation of the testes around the spermatic cord, which is the blood supply to the testes. Lack of blood supply results in acute ischemia, this is an emergent situation. Ischemic necrosis will occur within 6 hours. The longer the time before help, the less the chance of viability. Hydrocele: a collection of peritoneal fluid within the scrotum between the two-layered sac that holds the testes and spermatic cord. It is also uncommon (<1% of adult men) but most occur in males > 40 years old. (When the scrotum is transilluminated with a penlight, the trapped fluid appears pink and yellow or red). Varicocele: is an abnormal degree of venous dilation in the vasculature above the testes. It is caused by weak walls and vascular engorgement in the spermatic cord. Incidence is around 10-20% and there is no particular age group who are predisposed to it and there is no particular age group. Pt cc that it feels like a bag of worms. Epididymitis: inflammation of the epididymis (back of the testicles that stores and carries sperm), can affect men of any age. Occur in those with history of UTI, unprotected sex, uncircumcised. Chlamydia is responsible for 2/3rd of the cases. Non sexual individuals, it is due to E-coli. SX: sudden onset unilateral scrotum pain, dysuria, painful, tender, fever and chills. Elevation of testes will relieve discomfort. Testicular Cancer: compared with other types of cancer, testicular cancer is rare and is highly treatable. Testicular cancer is the most common cancer in American males between the ages of 15 and 35. There is no clear cause and effect relationship for testicular cancer, but risk factors include: HIV infection, caucasian race; and history of cryptorchidism (undescended testes). Other risk factors that have been identified include: higher social status; being unmarried; and living in rural areas 33. Signs and symptoms of chronic vs acute prostatitis Acute prostatitis always associated with UTI and abrupt Urinary complaints: frequency, urgency, dysuria, nocturia, bladder-outlet obstruction Physical examination: warm, tense, boggy, very tender prostate Chronic bacterial prostatitis – **most common** • General complaints: symptoms often absent, perineal pain, low back pain, lower abdominal pain, scrotal pain, penile pain, pain on ejaculation • Urinary complaints: dysuria, irritative voiding • Physical examination: normal, boggy, or focally indurated prostate History of recurrent UTI Nonbacterial prostatitis – similar to chronic but no evidence of infection • General complaints: pelvic pain • Urinary complaints: irritative voiding, abnormal flow • Physical examination: similar to chronic bacterial prostatitis, tender on palpation Prostatodynia – s/s of prostatitis; no inflammation Common bacteria – E. coli and staph areus Obstructive symptoms: - what is obstructing? Prostate? What is it affecting? Weak stream Incomplete bladder emptying Dribbling Irritative symptoms: - if you have this, why what would be irritating? Urinary complaints – increased urgency, hesitancy, DRE results: Do not press hard can cause sepsis 34. Management and intervention for BPH Static obstruction BPH: direct obstruction of the bladder neck is caused by a build-up of prostatic tissue. Dynamic obstruction BPH: constriction of the bladder neck is caused by an increase in prostatic muscle tone through adrenergic stimulation. Forces the bladder to generate higher pressure than normal to achieve micturition. BPH testing: DRE, PSA, UA & UA culture to rule out infection or hematuria, urine cytology to exclude bladder cancer. Done should be done by urologist- urodynamic studies to identify difficulties in emptying the bladder, post-void residual urine test (PVR), cystoscopy. Meds: alpha 1-adrenergic antagonists relax the smooth muscle around the neck of the bladder such as tamsulosin, doxazosin, silodosin. Another medication 5-alpha reductase inhibitor that are commonly prescribed are finasteride and dutasteride. Things to avoid: etoh, caffeine, and highly seasoned foods which are known the irriate the bladder. Surgical: Transurethral resection of the prostate (TURP) is an option for those that is a candidate. 35. Assessment and management of prostate cancer Subjective: Usually asymptomatic early in the disease process and may even be asymptomatic in late stages of disease and lymphadenopathy Neurologic symptoms (e.g., an inability to perceive touch, pain, and temperature in the perineal or scrotal areas and a lack of sensation of bladder distention) occur with epidural metastasis and cord compression. Patient complaints can also include bladder-outlet symptoms or acute urinary retention with very large or locally extensive tumors, although these symptoms are most often due to BPH. OBJECTIVE: Prostate exam reveals palpable hard prostate. Nodules or induration may be noted as well. Late signs: hematuria, hemosperia Evaluation of contraction of the rectal sphincter in response to the bulbospongiosus (bulbocavernosus, Osinski) reflex in which the glans penis is squeezed should direct attention to a possible lesion at the level of the conus medullaris of the spinal cord. Differential diagnosis of musculoskeletal: trauma, infection, metabolic or circulatory disorders, tumors, synovial conditions, congenital or developmental problems, or degenerative disorders. Musculoskeletal complaint can be: acute or chronic in duration articular or non-articular in origin inflammatory (maybe infectious or idiopathic) or noninflammatory in nature localized or systemic in distribution Articular: structures include the synovium, synovial fluid, articular cartilage, intraarticular ligaments, joint capsule, and juxta-articular bone Non-articular: or periarticular structures are identified as supportive extra-articular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin Sprains: often has redness and bruising over the affected joint, active and passive ROM is decreased, pain upon moving joint Strain: affects muscles and tendon that connect a muscle to a bone. Pt usually complain of “pulled muscle” but can use affected limb Paresthesias: sensation of numbness, prickling, or tingling experienced in central and peripheral nerve lesions.