1The nurse is assessing the range of motion (ROM) of a client's joints. What would the nurse use to assess flexion and extension of a joint if the client complains of pain on examination?
Goniometer
2A nurse is assessing a group of clients. The nurse identifies which of the following clients as being at the highest risk for developing osteoporosis?
63 year old female with late menarche and early menopause
3A client presents at the clinic with an enlarged, swollen, hot, and red metatarsophalangeal joint and bursa of the great toe. What medical diagnosis would the nurse suspect?
Gouty arthritis
4Bones contain yellow marrow that is composed mainly of
fat
5Increased lumbar curvature, which compensates for the enlarging uterus in pregnant women, is called what?
lordosis
6A client visits the clinic and tells the nurse that she has joint pain in her hands, especially in the morning. The nurse should assess the client further for signs and symptoms of
arthritis
7The external covering of the bone that contains osteoblasts and blood vessels is termed the
periosteum
8On inspection of the spine of a 79-year-old man, the nurse might expect to find a(n)
increased thoracic curve
9A nurse performs a nudge test to assess the gait of a client with Parkinson's disease. Which action by the nurse demonstrates the correct technique for performing this test? The nurse should stand:
at the back of the client and nudge the sternum
10The nurse is planning a presentation on osteoporosis to a group of high school students. Which of the following should the nurse plan to include in the presentation?
Moderate strenuous exercise tends to increase bone density.
11A nurse obtains an order to measure a client's leg length. How should a nurse correctly implement this order?
Measure from the anterior superior iliac spine to the medial malleolus
12A client visits the clinic and tells the nurse that after playing softball yesterday, he thinks his knee is “locking up.” The nurse should perform the McMurray test by asking the client to
flex the knee and hip while in a supine position.
13An adult client tells the nurse that he eats sardines every day. The nurse should instruct the client that a diet high in purines can contribute to
gouty arthritis
14When the client performs straight leg flexion, the client complains of pain that radiates down his leg. The nurse understands that this may indicate what?
Herniated disc
15The client tells the nurse that he has joint stiffness that is worse in the morning but improves as the day progresses. The nurse should assess the client for what musculoskeletal disorder?
Rheumatoid arthritis
16Skeletal muscles are attached to bones by
tendons
17Phil comes to the office with left “shoulder pain” that is markedly worse when his left arm is drawn across his chest (adduction). Which of the following is suspected?
Acromioclavicular joint involvement
18When examining a client with a rotator cuff tear, which of the following would the nurse expect to find?
A. Limitation of all shoulder motion
B. Chronic pain
C. Limited abduction
D. Sharp catches of pain with movement
C. Painful and limited abduction accompanied by muscle weakness and atrophy are seen with a rotator cuff tear. Chronic pain and limitation of all shoulder motion is seen with calcified tendonitis. Sharp catches of pain are associated with rotator cuff tendonitis.
19A client is diagnosed with osteomalacia. Which of the following would a nurse include in the client's teaching plan?
A. Decreasing purine intake can reduce the risk of osteomalacia.
B. An increased amount of vitamin C intake is recommended.
C. At least 20 minutes of sunlight each day is recommended
D. Reduce the amount of protein intake.
C. Sunlight will stimulate the body's production of vitamin D. Vitamin D deficiency can increase the incidence of osteomalacia. A decreased purine intake is suggested for gout. Increased vitamin C intake would be appropriate to promote bone and tissue healing. Adequate protein intake is needed to promote muscle tone and bone growth Question Format: Multiple Choice
20What would the nurse expect to find when examining a client with a herniated lumbar disc?
A. Rounded thoracic convexity
B. Lumbar lordosis
C. Flattened lumbar curve
D. Lateral curvature of the spine
C. In a client with a herniated lumbar disc, flattening of the lumbar curve may be seen. A rounded thoracic convexity or kyphosis is commonly seen in older adults. Lumbar lordosis or an exaggerated lumbar curve is often seen in pregnancy and obesity. Lateral curvature of the spine is seen with scoliosis.
21The nurse is performing an assessment on an adolescent client and notes a 45-degree flexion of the cervical spine. What should the nurse do next?
A. Assess the thoracic and lumbar spine.
B. Palpate the spinous processes.
C. Perform the Lasegue test.
D. Continue the exam because this curve is normal.
D. Normal flexion of the cervical spine is 45 degrees. Because the finding is normal, assessing the thoracic and lumbar spine, palpating the spinous processes, and performing the Lasegue test would be unnecessary.
22When asked to touch the ear to the shoulder, a client reports pain. Which of the following would the nurse do next?
A. Perform muscle strength against resistance.
B. Refer the client for further evaluation.
C. Flex and then hyperextend the neck
D. Palpate the paravertebal muscles for pain.
Answer: B
Rationale: Pain when touching the ear to the shoulder indicates a problem with lateral bending so the client should be referred for further evaluation. Performing muscle strength against resistance, flexing and then hyperextending the next, and palpating the paravertebral muscles for pain would not be performed next by the nurse because the client has a medical problem that requires diagnosis by a primary care provider.
23The nurse is caring for a client who reports low back pain. Which test would be most appropriate for the nurse to perform?
A. Lasegue
B. muscle leg strength
C. lateral bending of cervical spine
D. internal rotation of the shoulders
Answer: A
Rationale: Lasegue test, or straight leg raising, will check for a herniated nucleus pulposus, which is a cause of low back pain. Testing muscle leg strength, lateral bending of the cervical spine, or internal rotation of the shoulders would not be indicated.
24The nurse is assessing a client's ability to shrug her shoulders against resistance. The nurse is assessing which cranial nerve?
A. III
B. V
C. VII
D. XI
Answer: D
Rationale: Inability to shrug shoulders against resistance suggests a lesion of cranial nerve XI (spinal accessory nerve). Cranial nerve III is involved with extraocular eye movements. Cranial nerve V is involved with facial sensation. Cranial nerve VII is associated with facial muscles.
25After assessing a client's musculoskeletal system, the nurse is preparing to document the data gathered. Which of the following would the nurse document as objective data?
A. Denies pain in hips or legs
B. Complains of burning in lower back
C. Neck rotation limited to 50 degrees
D. History of osteoporosis
Neck rotation limited to 50 degrees
26After assessing a client's musculoskeletal system, the nurse is preparing to document the data gathered. Which of the following would the nurse document as objective data?
A. Denies pain in hips or legs
B. Complains of burning in lower back
C. Neck rotation limited to 50 degrees
D. History of osteoporosis
C. Rationale: Neck rotation limitation would be objective data because it was measurable and obtained during the physical examination. Client reports such as denial of pain, complaints of burning, and a history of osteoporosis are subjective data
27The nurse notes limitation in active range of motion of a client's right shoulder. What would the nurse to do next?
A. Test muscle strength.
B. Perform passive range of motion test.
C. Measure range of motion with a goniometer.
D. Ask the client which is the dominant side.
C. When limited range of motion is noted, the nurse should measure range of motion with a goniometer to provide information about the joint motion in degrees. Testing muscle strength may be done later once the measurement is obtained. Asking the client about his or her dominant side would be important to know when testing muscle strength, not joint motion. If the client cannot move the part against resistance when testing muscle strength, then the nurse would ask the client to move the part against gravity, and if not possible, attempt to passively move the part through its full range of motion.
28The nurse is preparing to palpate the anatomic snuffbox. At whichlocation would the nurse palpate?
A. At the anterior area of the sternoclavicular joint
B. At the posterior temporomandibular joint
C. At the olecranon process of the elbow
D. At the back of the wrist and extended thumb
D
29Inspection of a client's knee reveals swelling, and the nurse suspects that there is significant fluid in the knee. What test would the nurse perform to confirm the suspicion?
A. Phalen test
B. Tinel test
C. Ballottement test
D. Lasegue test
C
30When inspecting a client's feet, the nurse observes that the toes point inward. The nurse documents this finding as which of the following?
A. Hallus valgus
B. Pes varus
C. Verruca vulgaris
D. Pes cavus
Toes that point in are termed pes varus. Hallux valgus is noted as the great toe deviating laterally and possibly overlapping the second toe. Verruca vulgaris are painful warts that often occur under a callus. Pes cavus refers to feet with high arches.
31During the history, a young adult woman asks the nurse, "My mother has osteoporosis. What can I do to help reduce my risk?" Which response by the nurse would be most appropriate?
A. "Increase the amount of non-weight-bearing physical activity that you do."
B. "Keep your calcium intake at about 800 milligrams each day."
C. "Avoid being out in the sun for long periods of time."
D. "Avoid smoking and using alcohol."
D. Rationale: To reduce the risk of osteoporosis, the nurse should instruct the client to avoid smoking or alcohol consumption. The nurse should instruct the client to increase physical exercise or activity, especially weight-bearing activities; therefore, instructing the client to increase non-weight-bearing physical activity is not the nurse's most appropriate response. The nurse should instruct the client to consume approximately 1000 to 1500 mg of calcium daily; therefore, the recommendation of keeping the calcium intake at about 800 milligrams is too low. Avoiding long periods of sun exposure is not the most appropriate response, because the nurse should inform the client that sunlight can increase vitamin D levels to promote calcium absorption.
32A nursing student is preparing to demonstrate how to test the range of motion for the elbow. Which of the following would the student include? Select all that apply.
A. Flexion
B. Abduction
C. Extension
D. Rotation
E. Supination
F. Circumduction
A,C,E. When testing the range of motion of the elbow joint, the nurse would test flexion and extension, and supination and pronation of the forearm.
Abduction, rotation, and circumduction would be tested in the shoulder or the hip.
33The nurse is assessing a client’s range of motion of the lumbar spine. Which finding(s) require further follow-up by the nurse? Select all that apply.
A. Flexion of 60 degrees
B. Incremental movements while bending
C. Lumbar concavity flattening out
D. Spinal processes being in alignment
E. Unilateral exaggerated thoracic convexity
A,B,E. The findings of flexion of 60 degrees, incremental movement while bending, and unilateral exaggerated thoracic convexity are abnormal findings that require further follow- up by the nurse. The lumbar concavity flattening out and the spinal processes being in alignment are expected findings.
34A nurse is preparing a program on osteoporosis for a local women's group. What would the nurse cite as a risk factor?
A. Obesity
B. Multiparity (multiple births)
C. Smoking
D. African American ethnicity
(guessed)
C. Smoking is a risk factor for osteoporosis. Obesity, multiparity, and African American ethnicity are not noted risk factors for this disease.
35When testing muscle strength, a client has difficulty moving her right arm against resistance. What would the nurse to do next?
A. Move the part passively through its range of motion.
B. Ask the client to move the part against gravity.
C. Inspect by touch for a palpable contraction of the muscle.
D. Percuss the client's shoulder joint
B. If the client cannot move the part against resistance when testing muscle strength, then the nurse should ask the client to move the part against gravity and, if that is not possible, attempt to passively move the part through its full range of motion. Percussion is not indicated.
36Assessment reveals that a client has slight weakness with active range of motion against some resistance. How would the nurse document this finding?
A. 2/5
B. 3/5
C. 4/5
D. 5/5
C. Muscle strength is rated on a 5-point scale, with specific defining characteristics for each. Slight weakness with active motion against some resistance is 4 of 5 points. 2 of 5 points would indicate passive and poor range of motion. 3 of 5 points would indicate average weakness with active motion against gravity. 5 of 5 points would indicate normal findings, with active motion against full resistance.
37A nurse is providing health education about osteoporosis to a community group. What ethnicity is considered to be an independent risk factor for osteoporosis?
A. Caucasian
B. African American
C. South Asian
D. Native American
D
38During the nursing history of a newly admitted client, the nurse is reviewing a client's current medication regimen. What medication category creates a risk for decreased bone density?
A. Beta-adrenergic blockers
B. Corticosteroids
C. Nonsteroidal anti-inflammatories (NSAIDs)
D. Calcium channel blockers
Answer: B
Rationale: Steroids can deplete bone mass, thereby contributing to osteoporosis. This is not true of beta blockers, calcium channel blockers, or NSAIDs.
39The nurse is conducting a musculoskeletal assessment of an older adult client. What aspect of the client's medical history requires the nurse to alter the usual sequence or content of this assessment?
A. The client takes medications to treat hypertension.
B. The client suffered a fractured humerus 1 year earlier.
C. The client has a diagnosis of type 1 diabetes.
D. The client had a total hip replacement 2 years ago
D. If the client has had a total hip replacement, do not test ROM unless the physician gives permission to do so, due to the risk of dislocating the hip prosthesis. A 1-year-old arm fracture is likely to have healed fully and would not normally affect the content of the assessment. Diabetes can affect various aspects of the musculoskeletal system, but it does not likely require the nurse to modify the assessment. Antihypertensives are unlikely to affect assessment.
40The nurse is performing the bulge test during the assessment of a client's knee. This test will allow the nurse to make what determination?
A. Whether the client's swollen knee is caused by tissue swelling or by fluid accumulation
B. Whether the size of the client's knee changes throughout the joint's range of motion C. Whether swelling in the knee joint is a normal age-related change or a
pathological finding
D. Whether the client's knee joint is capable of adduction and abduction
A. The bulge test is used to determine if knee swelling is due to accumulation of fluid or soft tissue swelling. It does not address range of motion. Knee swelling is never considered to be an age-related change.
41Inspection of a client's foot reveals an enlarged, painful, inflamed bursa on the medial side of the foot. The nurse should make a referral for what health problem?
A. Osteomalacia
B. Hallux valgus
C. Pes planus
D. Gouty arthritis
B. Bunions are the characteristic sign of hallux valgus. They are not indicative of osteomalacia or gouty arthritis. Pes planus is flat feet.
42The nurse is planning the care of a 77-year-old woman who has recently been diagnosed with osteoporosis. What nursing diagnoses should the nurse address in the client's plan of care? Select all that apply.
A. Risk for injury related to osteoporosis
B. Risk for infection related to osteoporosis
C. Activity intolerance related to osteoporosis
D. Impaired physical mobility related to osteoporosis E. Disturbed sensory perception related to osteoporosis
A,C,D. Osteoporosis creates risks for injury, activity intolerance, and impaired mobility as consequences of musculoskeletal changes. The disease does not normally result in infection or impaired sensation.
43A nurse practitioner refers clients for osteoporosis screening according to the latest U.S. Preventive Services Task Force (USPSTF) recommendations. According to these recommendations, what client should be screen for osteoporosis?
A. A 71-year-old man who has type 2 diabetes
B. A 69-year-old woman with no major risk factors for osteoporosis
C. A 37-year-old woman who takes oral contraceptives
D. A 49-year-old African-American woman who is obese
B. USPSTF (2011) recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65- year-old white woman who has no additional risk factors. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men. Oral contraceptive use is a risk factor for osteoporosis, but screening is not recommended for 37-year-old clients. A 49-year-old African-American woman would similarly not be a candidate for routine screening.
44A nurse cares for a client who suffered a cerebrovascular accident and demonstrates the inability to speak clearly. The nurse recognizes that injury has occurred to what portion of the brain?
Broca's area
45A nurse is preparing to assess a client's cerebellar function. What aspect of neurological function should the nurse address?
Balance
46A client presents to the health care clinic with reports of difficulty swallowing. Which cranial nerves will provide the nurse with information related to the problem? Select all that apply.
Vagus
Abducens
Trochlear
Hypoglossal
Spinal accessory
Glossopharyngeal
vagus, hypoglossal, glossopharyngeal
47When testing sensory function of the trigeminal nerve (CN V), which of the following sensations would the nurse assess?
pain(with temperature) and light touch
48The diencephalon of the brain consists of the
thalmus and hypothalmus
49What should the nurse assess to test the function of the frontal lobe?
communication
50The _____ area integrates understanding of spoken and written words
wernicke
51the ______ area regulates verbal expression and writing ability
Broca
52Upon assessment, the nurse suspects the client is having a stroke. What symptoms might the nurse have found? Select all that apply.
Slurred speech
Severe headache
Left arm weakness
Tremors
Unsteady gait
first 3
53Which of the following would the nurse expect to assess if a client has a lesion of the sympathetic nervous system?
A. Bilateral dilated pupils
B. Unilateral dilated pupil
C. Argyll Robertson pupils
D. Constricted pupil unresponsive to light
D. A constricted pupil unresponsive to light or accommodation suggests a lesion of the sympathetic nervous system. Sympathetic nervous system stimulation would lead to bilateral dilated pupils. A unilaterally dilated pupil unresponsive to light or accommodation would suggest damage to cranial nerve
54A client complains of headaches each morning that disappear after getting out of bed. Which of the following would be most appropriate for the nurse to do?
A. Assess if the headaches are accompanied by dizziness.
B. Perform a complete neurologic exam.
C. Refer the client for immediate follow-up.
D. Ask if the client has ever had a seizure.
C. Morning headaches that subside after arising may be an early sign of increased intracranial pressure and require immediate evaluation. Asking about dizziness or seizures, and completing a neurologic exam would most likely occur with the additional follow-up.
55Which of the following assessment findings would lead the nurse to suspect that a client has Bell palsy?
A. Inability to detect sharp and dull stimuli
B. Inability to wrinkle the forehead
C. Closure of the affected eye from swelling
D. Muscle spasm of the lower face on the affected side
B. Inability to close the eyes, wrinkle the forehead, or raise the forehead, along with paralysis of the lower part of the face on the affected side, is seen with Bell palsy. Inability to detect sharp and dull stimuli is associated with lesions of the trigeminal nerve (CN V). Closure of the affected eye from swelling would suggest trauma. Paralysis, not muscle spasm, occurs with Bell palsy.
56When explaining how the nurse would test graphesthesia, which of the following would the nurse include?
A. Client will close the eyes and identify what number the nurse writes inthe palm of the client's hand with a blunt-ended object
B. The client is to identify the numbers of points felt when the nurse touches the client with the ends of two applicators at the same time.
C. The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred.
D. The nurse will briefly touch the client, and the client will need to identify where the touch occurred. (good guess)
A. Graphesthesia is the ability to identify what is being drawn on the client's body when the client's eyes are closed. Two-point discrimination is tested by having the client identify the number of points felts when touched with the ends of two applicators at the same time. Extinction is tested by simultaneously touching the client in the same area on both sides of the body at the same points and having the client identify the area touched. Point localization is tested by briefly touching the client and then asking the client to identify the points touched.
57The nurse is testing a client for Kernig sign. Which finding(s) should cause the nurse to suspect meningeal irritation? Select all that apply.
A. Pain when the knee is extended
B. Resistance to knee extension
C. Discomfort behind the knee with full extension D. Hips and knees remaining relaxed and motionless E. Able to easily bend head and neck forward
A,B. The nurse should suspect meningeal irritation if the client experiences pain when the knee is extended and resistance to knee extension when checking for Kernig sign. Discomfort behind the knee withfull extension during this assessment is normal for many clients. The hips and knees remaining motionless is considered a negative finding when checking for Brudzinski sign, not Kernig
sign. The client’s ability to easily bend the head and neck forward is an expected finding.
58During the Romberg test, a client is unable to stand with the feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would identify this as which of the following?
A. Spastic hemiparesis
B. Parkinsonian gait C. Scissors gait
D. Cerebellar ataxia
D. A wide-based, staggering, unsteady gait and positive Romberg's test (client unable to stand with feet together) suggests cerebellar ataxia. Spastic hemiparesis is characterized by a flexed arm held close to the body while the client drags the toes of the leg or circles it stiffly outward and forward. A Parkinsonian gait is a shuffling gait. A scissors gait is a short, stiff gait with the thighs overlapping each other with each step.
59When assessing a client's deep tendon reflexes, which technique would be most appropriate for the nurse to use?
A. Use the blunt end of the reflex hammer to strike a smaller area.
B. Strike the area slowly and methodically.
C. Hold the reflex hammer between the thumb and index finger. D. Percuss the area of the tendon to be struck for the reflex.
C. When eliciting deep tendon reflexes, the nurse should hold the reflex hammer between the thumb and index finger so that it swings freely. The nurse should use the pointed end to strike smaller areas and the blunt end to strike a wider area. The nurse should palpate the tendon to be used to elicit the reflex and use a rapid wrist movement to briskly strike the tendon.
60When preparing to test a client for meningeal irritation, what would the nurse to do first?
A. Check for evidence of fever and chills
B. Ensure no injury to the cervical spine
C. Position the client prone
D. Check for a Babinski reflex
B. Before testing a client for meningeal irritation, the nurse needs to ensure that there is no injury to cervical vertebrae or the cervical cord. Otherwise further injury could occur because testing involves flexing the neck. It is not necessary to check for fever or chills or a Babinski reflex. The client is positioned supine for these tests.
61During the health history a client reports a decrease in his ability to smell. During the physical assessment, the nurse would make sure to assess which cranial nerve?
A. CN I
B. CN II
C. CN VII D. CN IX
A. CN I (olfactory) would be evaluated to determine if the client was
experiencing a problem here related to his report of a decrease in smell.
Evaluation of CN II (optic) would be indicated if the client reported changes in vision. Evaluation of CN VII (facial) or IX (hypoglossal) would be indicated if the client reported a decrease in his ability to taste.
62When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk?
A. 42-year-old Caucasian woman who smokes
B. 68-year-old African American male with hypertension
C. 55-year-old Caucasian male who has a two beers a week D. 35-year-old African American male who has sleep apnea
B. Risk factors include older adulthood (risk doubling each decade after age 55), male sex, African American race, hypertension, smoking, chronic alcohol intake (more than 3 drinks per day), and sleep apnea. In the clients listed, the 68-year-old African American male with hypertension has the greatest risk due to his age, race, and hypertension. The other clients would be at risk, but the risk would be less.
63The nurse is teaching a group of students about the brain and spinal cord and asks the students, “What does the brain stem control?” Which response by the students requires further follow-up by the nurse?
A. Respiratory function
B. Heart rate
C. Equilibrium D. Reflex actions
C. The brain stem is responsible for various reflex actions. The medulla has centers that control and regulate respiratory function, heart rate and force, and blood pressure. The brain stem does not control equilibrium.
64A nurse is testing a client's deep tendon reflex. The nurse taps the tendon above the olecranon process. The nurse is assessing which reflex?
A. Brachioradialis
B. Triceps
C. Biceps D. Achilles
B. The nurse tests the triceps reflex by tapping the tendon above the olecranon process. The nurse tests the brachioradialis reflex by tapping the tendon at the radius about 2 inches above the wrist. The nurse tests the biceps reflex by placing the thumb over the biceps tendon and striking the thumb with the reflex hammer. The nurse tests the Achilles reflex by tapping the Achilles tendon at the posterior aspect of the ankle above the heel.
65Which of the following would lead the nurse to suspect meningeal irritation? A. Hips and knees remain relaxed and motionless when neck is flexed
B. Reports of decreased pain with flexion of the hips and knees
C. Discomfort behind the knee with full extension of the leg
D. Pain and flexion of the hips and knees with neck flexion
D. Pain and flexion of the hips and knees with neck flexion are positive Brudzinski signs and suggest meningeal irritation. Pain and increased resistance to extending the knee when the client's leg is flexed at both the hip and knee and then straightened is a positive Kernig sign, suggesting meningeal irritation. Discomfort behind the knee during full extension when testing for Kernig sign occurs in many normal people.
66While the nurse is assessing a client’s coordination, the client exhibits uncoordinated, jerky movements and is unable to touch either finger to the nose. Which condition should the nurse suspect?
A. Cerebellar disease
B. Vestibular dysfunction
C. Lower motor neuron disease
D. Extrapyramidal tract abnormalities (correct but guessed)
A
Rationale: The nurse would suspect cerebellar disease for a patient exhibiting uncoordinated, jerky movements and the inability to touch a finger to the nose. Vestibular dysfunction is associated with swaying and moving the feet apart to prevent a fall. Lower motor neuron disease would be suspected if the patient exhibited fasciculation (rapid twitching of resting muscle). The nurse would suspect extrapyramidal tract abnormalities if the client exhibited rigid muscles that resist passive movement.
67What would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident?
A. Inability to hear high-pitched sounds
B. Loss of tactile sensation
C. Difficulty speaking
D. Blurred vision
The frontal lobe contains Broca's area, which is responsible for speech. Injury to this area may lead to difficulty speaking. Difficulty with sounds would be associated with the temporal lobe. Loss of tactile sensation would be associated with the parietal lobe. Blurred vision would be associated with the occipital lobe.
68During a routine follow-up visit, the nurse is assessing a client who reports a sudden severe headache and inability to see out of the left eye. What would be most appropriate for the nurse to do?
A. Assess the client's coordination.
B. Assess the client's visual acuity.
C. Refer the client for immediate medical follow-up. D. Suggest that the client take a daily aspirin.
(review)
C
Rationale: A sudden, severe headache and inability to see out of one or both eyes are symptoms of a stroke and require immediate medical follow-up.
Assessing the client’s coordination and visual acuity may be performed later, but these are not the most appropriate actions at this time. The nurse should not suggest that the client take a daily aspirin, because the client should speak with a doctor prior to doing so.
69A nurse is having difficulty eliciting a patellar reflex during a client's neurological assessment. What would be most appropriate for the nurse to have the client do?
A. Lock the fingers together and pull against each other.
B. Clench the jaw tightly.
C. Squeeze a thigh with the opposite hand. D. Stretch the arms over head.
A. Having the client interlock the hands is a reinforcement technique that aids in enhancing the reflex response in the legs. Clenching the jaw or having the client squeeze one thigh with the opposite hand would be a reinforcement technique for testing arm reflexes. Stretching arms overhead would be inappropriate.
70What would be most appropriate for the nurse to do when assessing motor function of a client's trigeminal nerve?
A. Ask client to differentiate sharp and dull sensations on the face.
B. Have the client smile, frown, and wrinkle the forehead.
C. Palpate temporal and masseter muscles while client clenches the teeth. D. Assess dilatation of the client's pupils with direct light.
C. To test the motor function of the trigeminal nerve (CN V), the nurse asks the client to clench the teeth and palpates the temporal and masseter muscles for contraction. Touching the client's face for dullness or sharp sensations tests the sensory function of the trigeminal nerve. Having the client frown, smile, and wrinkle the forehead tests the motor function of the facial nerve (CN VII). Assessing pupillary dilation tests the oculomotor (CN III) nerve.
71The nurse is assessing a client who has a history of recurrent Bell palsy. Which findings suggest to the nurse that the client is experiencing a recurrence of this condition? Select all that apply.
A. Inability to detect sharp and dull stimuli
B. Inability to wrinkle the forehead
C. Closure of the affected eye from swelling
D. Muscle spasm of the lower face on the affected side
E. Inability to close the eyes
B, E. Inability to wrinkle the forehead or raise the forehead, close the eyes, along with paralysis of the lower part of the face on the affected side, is seen with Bell palsy. Inability to detect sharp and dull stimuli is associated with lesions of the trigeminal nerve (CN V). Closure of the affected eye from swelling would suggest trauma. Paralysis, not muscle spasm, occurs with Bell palsy.
72When assessing cranial nerves IX and X, what would the nurse consider as a normal finding?
A. Stationary soft palate on phonation
B. Deviation of uvula when client says "ah"
C. Asymmetrical soft palate
D. Uvula and soft palate rising bilaterally on phonation
D. Normal findings associated with testing CN IX and CN X include a uvula and soft palate rising bilaterally and symmetrically on phonation. A stationary or asymmetrical soft palate or deviation of the uvula would be considered an abnormal finding.
73The nurse is performing a point localization test on a client during a
neurological assessment. How shoulld the nurse perform this test?
A. The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object.
B. The client is asked to identify the number of points felt when the nurse touches
the client with the ends of two applicators at the same time.
C. The nurse will simultaneously touch the client in the same area on both sides of the
body, and the client will identify where the touch occurred.
D. The client will close the eyes. The nurse will then gently touch the client, and the client will identify where the touch occurred.
D. Point localization is tested by briefly touching the client and then asking the client to identify the points touched. Graphesthesia is the ability to identify what is being drawn on the client's body when the client's eyes are closed. Two-point discrimination is tested by having the client identify the number of points felts when touched with the ends of two applicators at the same time. Extinction is tested by simultaneously touching the client in the same area on both sides of the body at the same points and having the client identify the area touched.
74The nurse is performing the Romberg test on a client during a neurological assessment. How should the nurse perform this test? Place the following steps in the correct order.
A. Ask the client to stand erect with arms at the sides and the feet together.
B. Ask the client to close the eyes for 20 seconds.
C. Ask the client to stand on one foot and bend the knee on which the client is standing. D. Ask the client to hop on one foot.
E. Repeat on the opposite side.
A,B,C,D,E
75During a routine follow up visit, an older adult client asks the nurse, “I’ve noticed that my sense of smell has decreased over the years and I’m concerned about the cause.” What is the nurse’s best response?
A. “Over time the sense of smell decreases in some people, and this is normal.”
B. “Congenital problems may sometimes cause a loss of smell.”
C. “There may be a tumor or lesion present in the frontal lobe.”
D. “Injury of the nerve tissue at the top of the nose may be the cause.”
A. The statement, “Over time the sense of smell decreases in some
people, and this is normal,” is the nurse’s best response, because the sense of
smell may be decreased in some older adult clients. The statement, “Congenital problems may sometimes cause a loss of smell,” is correct, but the client reported a decrease the sense of smell over time, not an absence of the sense of smell since birth. The statement, “There may be a tumor or lesion present in the frontal lobe,” is not the best response, because although it references a potential cause of an inability to smell, the nurse does not have enough information based on the client’s statement to introduce this as a potential cause to the client.
76When reviewing the neural pathways, a group of students is identifying sensations that travel via the spinothalamic tract. Which sensations arecarried by this tract? Select all that apply.
A. Pain
B. Temperature C. Position
D. Vibration
E. Light touch
A,B,E. Sensations of pain, temperature, and crude and light touch travel by way of the spinothalamic tract, whereas sensations of position, vibration, and fine touch travel by way of the posterior columns.
77The nurse is assessing a 39-year-old woman who has a 20-year history of cigarette smoking. When reviewing the client's current medication administration record, what drug would the nurse identify as increasing the woman's risk of stroke?
A. Acetaminophen
B. A beta-adrenergic blocker C. ASA
D. An oral contraceptive
Answer: D
Rationale: The use of oral contraceptives, especially in smokers over 35, constitutes a significant risk factor for stroke. Acetaminophen, ASA, and beta blockers usually decrease an individual's risk of stroke.
78The nurse is conducting a focused neurological assessment of an 81-year-old client. When analyzing the assessment data, the nurse should be aware of what age-related neurological change?
A. Impaired judgment
B. Tremors accompanying intentional movements C. Loss of remote memory
D. Loss of sensation in distal extremities
Answer: B
Rationale: Older adults may experience intentional tremors (tremors that occur with intentional movements). Such tremors are not associated with disease.
Impairments in judgment, remote memory, and limb sensation are considered pathologic in clients of all ages and warrant further assessment.
79The nurse has positioned a client supine and asked her to perform the heel- to-shin test. An inability to run each heel smoothly down each shin should prompt the nurse to perform further assessment in what domain?
A. Balance and coordination
B. Light touch sensation C. Deep tendon reflexes D. Leg strength
Answer: A
Rationale: Deviation of the heel to one side or the other during the heel-to-shin test may be seen in cerebellar disease. As such, further assessment of balance and coordination is likely indicated. This assessment finding is not suggestive of deficits in reflexes, sensation, or strength.
80The nurse has placed her hands behind the client's head and flexed the client's neck forward as far as the client can tolerate. During the test, the client experiences leg pain and bends his knees. This assessment finding is suggestive of what health problem?
A. Ischemic stroke
B. Meningitis
C. Bell palsy
D. Brain stem lesion
B. Pain and flexion of the hips and knees during neck flexion are positive Brudzinski signs, suggesting meningeal inflammation. This finding is not suggestive of stroke, Bell palsy, or a brain stem lesion.
81The nurse is performing the Romberg test as part of a client's focused neurological assessment. What finding would constitute a positive Romberg test?
A. The client moves her feet apart to prevent herself from falling.
B. The client is unable to consistently touch her finger to her nose while her eyes are close. C. The client experiences pain during neck flexion and extension.
D. The client experiences pain when clenching her teeth.
A. The Romberg test assesses balance; swaying or repositioning during the test constitutes positive findings. The Romberg test does not address pain during neck flexion or teeth clenching. It does not require the client to touch the nose with a finger.
82The emergency department nurse's rapid assessment of a young adult client admitted unresponsive reveals fixed, constricted pupils bilaterally. The nurse should consider what possible cause for this assessment finding?
A. Recent narcotic use
B. Hemorrhagic stroke C. Recent seizure activity D. Cerebellar lesion
A. Narcotics can cause fixed, constricted pupils. This abnormal finding is not typically associated with stroke, seizures, or cerebellar lesions.
83Examination of a client's gait reveals that the client is stooped over when walking and that he slowly shuffles. As well, the client maintains a stiff posture when walking. The nurse should document what type of gait?
A. Scissors gait
B. Parkinsonian gait C. Spastic hemiparesis D. Foot drop
B. A parkinsonian gait is characterized by a shuffling gait with turns accomplished in a very stiff manner. The client also has a stooped-over posture with flexed hips and knees. A scissors gait involves thigh overlap. Spastic hemiparesis is characterized by dragging one toe. In foot drop, the client lifts the foot and knee high with each step, then slaps the foot down hard on the ground