exam #3, practice questions
A NURSE ASKS A PT TO POINT TO OBJECTS & ASKS PT TO NAME THEM, TO READ SOME WORDS & ASKS THE PT TO RESPOND TO SIMPLE VERBAL AND WRITTEN COMMANDS. WHICH WOULD THIS BE ASSESSING? • 1. assessing language • 2. assessing orientation • 3. assessing recent memory • 4. assessing remote memory
ANSWER: 1. ASSESSING LANGUAGE
THE LATERAL VIEW OF THE SPINE DEMONSTRATES TWO TYPES OF CURVATURE ASSOCIATED WITH SPECIFIC DIVISIONS OF THE SPINAL COLUMNS. THE TWO TYPES ARE: • A. convex and concave. • B. convex and ellipsoid. • C. parabolic and concave. • D. parabolic and ellipsoid.
A. CONVEX AND CONCAVE.
THE NURSE IS CARING FOR A CLIENT AND WANTS TO ASSESS THE NEUROLOGIC FUNCTION. WHICH OF THE FOLLOWING WILL GIVE THE MOST INFORMATION? • 1. level of consciousness • 2. doll's eye's reflex • 3. Babinski reflex • 4. reaction to painful stimuli
ANSWER: 1 LOC • The most important and subtle changes are related to the client's level of consciousness, verbal ability, orientation, and ability to move to command.
THE NURSE IS CHECKING THE RANGE OF MOTION IN A PATIENT'S KNEE AND KNOWS THAT THE KNEE IS CAPABLE OF WHICH MOVEMENT(S)? • A) Flexion and extension • B) Supination and pronation • C) Circumduction • D) Inversion and eversion
A) FLEXION AND EXTENSION • The knee is a hinge joint, permitting flexion and extension of the lower leg on a single plane. The knee is not capable of the other movements listed. Page 572
WHICH OF THE FOLLOWING WOULD BE MOST IMPORTANT FOR A NURSE TO DO TO ENSURE THE ACCURACY OF INSPECTION DURING ASSESSMENT? • A)Compare bilateral body parts • B)Have 20/20 vision • C)Focus on selected body systems • D)Use touch judiciously
A)COMPARE BILATERAL BODY PARTS • With inspection, a comparison of bilateral body parts is necessary for recognizing abnormal findings
IN WHICH OF THE FOLLOWING ETHNIC GROUPS HAS THE LOWEST INCIDENCE OF OSTEOPOROSIS? • A. African Americans • B. Whites • C. Asians • D. American Indians
A. AFRICAN AMERICANS • African American adults have a decreased risk of fractures when compared to white adults, and Hispanic women have a decreased risk of fractures compared to white women. The difference in fracture rates may be traced to childhood, where African American and Hispanic children have shown significantly higher bone strength than white children show. There is greater bone density at specific bone sites in African American and Hispanic children.
MR. JENKINS IS A 43-YEAR-OLD PATIENT WHO GOES TO THE AMBULATORY HEALTH CENTER WITH COMPLAINTS OF MUSCLE PAIN. WHEN TESTING FOR MUSCLE STRENGTH, THE EXAMINER: • A. applies an opposing force against the individual's actions during ROM of a joint. • B. asks the individual to try to break the examiner's joint movements during ROM. • C. measures the degree of muscle tension developed during active extension and flexion of a joint. • D. can assume that if an individual has adequate active ROM that muscle strength is fully developed.
A. APPLIES AN OPPOSING FORCE AGAINST THE INDIVIDUAL'S ACTIONS DURING ROM OF A JOINT
THE NURSE ASKS THE CLIENT TO MOVE HIS EYES IN THE SHAPE OF AN H AND THEN IN A LARGE X. THE PORTION OF THE PHYSICAL ASSESSMENT THE NURSE IS COMPLETING WITH THIS CLIENT IS: • a. Assessing extraocular muscle movements • b. Assessing the optic nerve • c. Assessing the palpabrae • d. Assessing the red reflex
A. ASSESSING EXTRAOCULAR MUSCLE MOVEMENTS • Rationale: Each eye has six extrinsic or extraocular muscles (6 cardinal fields of gaze). They help hold the eye in place within the body orbit.
HEBERDEN'S AND BOUCHARD'S NODES ARE HARD AND NONTENDER AND ARE ASSOCIATED WITH: • A. osteoarthritis. • B. rheumatoid arthritis. • C. Dupuytren's contracture. • D. metacarpophalangeal bursitis.
A. OSTEOARTHRITIS.
THE MUSCULOSKELETAL SYSTEM FUNCTIONS INCLUDE: • A. protection and storage. • B. movement and elimination. • C. storage and control. • D. propulsion and preservation.
A. PROTECTION AND STORAGE. • The following are functions of the musculoskeletal system: provide support to stand erect; allow movement; to encase and protect the inner vital organs; to produce the red blood cells in the bone marrow; and as a reservoir for storage of essential minerals, such as calcium and phosphorus in the bones.
CREPITATION IS AN AUDIBLE SOUND THAT IS PRODUCED BY: • A. roughened articular surfaces moving over each other. • B. tendons or ligaments that slip over bones during motion. • C. joints that are stretched when placed in hyperflexion or hyperextension. • D. flexion and extension of an inflamed bursa.
A. ROUGHENED ARTICULAR SURFACES MOVING OVER EACH OTHER. • Crepitation is an audible and palpable crunching or grating that accompanies movement. It occurs when the articular surfaces in the joints are roughened.
WHEN ASSESSING A CHILD FOR STRABISMUS, THE NURSE SHOULD USE WHICH EYE TEST? • 1. the Snellen eye chart • 2. the cover-uncover test • 3. the opthalmoscope exam • 4. test of pupillary reaction
ANSWER: 2. COVER UNCOVER TEST • This test assesses coordination of eye muscle movement, In strabismus one muscle is weaker than the other and the eye wanders rather than focusing forward. A Snellen eye chart us used to determine visual acuity. an opthalmoscopic exam detects problems with interior structure of the eye. Pupillary reaction is the ability of the pupils to constrict in response to light.
THE NURSE IS PLANNING TO TEST THE FUNCTION OF THE TRIGEMINAL NERVE (CRANIAL NERVE V). THE NURSE WOULD GATHER WHICH OF THE FOLLOWING ITEMS TO PERFORM THE TEST? • 1. Tuning fork and audiometer • 2. Snellen chart, ophthalmoscope • 3. Flashlight, pupil size chart or millimeter ruler • 4. Safety pin, hot and cold water in test tubes, cotton wisp
ANSWER: 4 SAFETY PIN, HOT AND COLD WATER IN TEST TUBES, COTTON WISP • CN 5 is the trigeminal nerve-it is sensory and carries impulse of pain, touch, temperature from face to brain
A GLASGOW COMA SCALE SCORE OF 9-12 INDICATES WHAT? • 1. mild brain injury • 2. normal functioning • 3. severe brain injury • 4. moderate brain injury
ANSWER: 4. MODERATE BRAIN INJURY • <8 severe brain injury/coma • 9-12 moderate • >13 ok • 15 best score • range from 3-15
THE NURSE WOULD USE WHICH TEST TO EVALUATE A CLIENT'S MOTOR ABILITY AND FUNCTION AS PART OF A NEUROLOGICAL ASSESSMENT? • 1. Glasgow coma scale • 2. Abdominal reflex • 3. Babinski test • 4. Romberg test
ANSWER: 4. ROMBERG TEST • This is done when the nurse asks the pt to stand with eyes closed and feet together. There should be minimal swaying for up to 20 seconds. The Glasgow coma scale: assesses the pt's LOC. Abdominal assesses the upper and lower motor neurons. A positive Babinski indicates upper motor neuron disease.
A PATIENT IS COMPLAINING OF PAIN IN HIS JOINTS THAT IS WORSE IN THE MORNING, IS BETTER AFTER HE HAS MOVED AROUND FOR AWHILE, AND THEN GETS WORSE AGAIN IF HE SITS FOR LONG PERIODS OF TIME. THE NURSE SHOULD ASSESS FOR OTHER SIGNS OF WHAT PROBLEM? • A) Tendinitis • B) Osteoarthritis • C) Rheumatoid arthritis • D) Intermittent claudication
C. RHEUMATOID ARTHRITIS • Rheumatoid arthritis is worse in the morning when arising. Movement increases most joint pain, except in rheumatoid arthritis, in which movement decreases pain. The other options are not correct. Page 574-575
THE NURSE IS ASSESSING THE JOINTS OF A WOMAN WHO HAS STATED, "I HAVE A LONG FAMILY HISTORY OF ARTHRITIS, AND MY JOINTS HURT." THE NURSE SUSPECTS THAT SHE HAS OSTEOARTHRITIS. WHICH OF THESE ARE SYMPTOMS OF OSTEOARTHRITIS? SELECT ALL THAT APPLY. • A) Symmetric joint involvement • B) Asymmetric joint involvement • C) Pain with motion of affected joints • D) Affected joints are swollen with hard, bony protuberances • E) Affected joints may have heat, redness, and swelling
B) ASYMMETRIC JOINT INVOLVEMENT C) PAIN WITH MOTION OF AFFECTED JOINTS D) AFFECTED JOINTS ARE SWOLLEN WITH HARD, BONY PROTUBERANCES • Page: 608. In osteoarthritis, asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness, swelling with hard bony protuberances, pain with motion, and limitation of motion. The other options reflect signs of rheumatoid arthritis.
WHEN ASSESSING A PT EYE, WHICH INSTRUMENT WOULD THE NURSE USE TO VISUALIZE THE RETINA? • A) Otoscope • B) Ophthalmoscope • C) Stethoscope • D) Tuning Fork
B) OPHTHALMOSCOPE
WHEN TESTING FOR MUSCLE STRENGTH, THE EXAMINER SHOULD: • A. observe muscles for the degree of contraction when the individual lifts a heavy object. • B. apply an opposing force when the individual puts a joint in flexion or extension. • C. measure the degree of force that it takes to overcome joint flexion or extension. • D. estimate the degree of flexion and extension in each joint.
B. APPLY AN OPPOSING FORCE WHEN THE INDIVIDUAL PUTS A JOINT IN FLEXION OR EXTENSION. • The person should flex or extend muscle groups for each joint while the examiner applies an opposing force.
DURING THE ASSESSMENT OF A CLIENT, THE NURSE GENTLY TOUCHES THE TIP OF A STERILE COTTON SWAB IN THE CLIENT'S EYE. WHICH OF THE FOLLOWING WOULD BE CONSIDERED AN EXPECTED RESPONSE FOR THE CLIENT TO MAKE? • a. Begin sneezing. • b. Blink. • c. Scream in pain. • d. Swat the nurse's hand away.
B. BLINK. • Rationale: The extensive nerve endings in the cornea are responsible for the blink reflex.
IN THE SNELLEN CHART ASSESSMENT, THE NUMERATOR REPRESENTS THE • A. distance a "normal" person could read a particular line • B. distance that a person stands away from the chart • C. % of the # of letters a person can read on a line • D. # of feet that a person has to move forward to read a line
B. DISTANCE THAT A PERSON STANDS AWAY FROM THE CHART • the denominator is the distance a "normal" person could read a particular line
AT THE CONCLUSION OF AN EYE EXAMINATION, THE CLIENT LEARNS HE HAS PRESBYOPIA.WHAT CAN THE NURSE EXPLAIN TO THE CLIENT ABOUT THIS CONDITION? • a. It's inherited, and light focuses in front of the retina. • b. It's age-related, and it's harder for you to focus on close objects. • c. It's familial, and light is spread over a wide area. • d. It's inherited, and light focuses behind the retina.
B. IT'S AGE-RELATED, AND IT'S HARDER FOR YOU TO FOCUS ON CLOSE OBJECTS. • Rationale: Presbyopia is an age-related condition in which the lens of the eye loses the ability to accommodate. Light is focused behind the retina and focus on near objects becomes difficult.
A PATIENT IS BEING ASSESSED FOR RANGE OF JOINT MOVEMENT. THE NURSE ASKS HIM TO MOVE HIS ARM IN TOWARD THE CENTER OF HIS BODY. THIS MOVEMENT IS CALLED: • A) flexion. • B) abduction. • C) adduction. • D) extension.
C) ADDUCTION. • Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body. Flexion is bending a limb at a joint; extension is straightening a limb at a joint.
THE NURSE SUSPECTS THAT A PATIENT HAS CARPAL TUNNEL SYNDROME AND WANTS TO PERFORM THE PHALEN'S TEST. TO PERFORM THIS TEST, THE NURSE SHOULD INSTRUCT THE PATIENT TO: • A) dorsiflex the foot. • B) plantarflex the foot. • C) hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. • D) hyperextend the wrists with the palmar surface of both hands touching and wait for 60 seconds.
C) HOLD BOTH HANDS BACK TO BACK WHILE FLEXING THE WRISTS 90 DEGREES FOR 60 SECONDS. • For the Phalen's test, the nurse should ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. The Phalen's test reproduces numbness and burning in a person with carpal tunnel syndrome. The other actions are not correct for testing for carpal tunnel syndrome.
A PT VISUAL ACUITY IS ASSESSED AS 20/40 IN BOTH EYES USING THE SNELLEN CHART. THE NURSE INTERPRETS THIS FINDING AS WHICH OF THE FOLLOWING? • A)The pt can see twice as well as normal • B)The pt has double vision • C)The pt has less than normal vision • D)The pt has normal vision
C)THE PT HAS LESS THAN NORMAL VISION • the patient can see at 20 feet what most people can see at 40 feet
AN ABNORMAL SENSATION OF BURNING OR TINGLING IS BEST DESCRIBED AS: • A. paralysis. • B. paresis. • C. paresthesia. • D. paraphasia.
C. PARESTHESIA. • Paresthesia is an abnormal sensation such as burning or tingling.
THE NURSE ASSESSES A CLIENT'S VISION TO BE 20/150. THE CLIENT ASKS FOR AN EXPLANATION OF THE NUMBERS. WHICH OF THE FOLLOWING WOULD BE A CORRECT EXPLANATION FOR THE NURSE TO SAY TO THE CLIENT? • a. You are legally blind. • b. You see at 150 feet what a person with normal vision sees at 20 feet. • c. You see at 20 feet what a person with normal vision sees at 150 feet. • d. You might need surgery to correct the nystagmus.
C. YOU SEE AT 20 FEET WHAT A PERSON WITH NORMAL VISION SEES AT 150 FEET.
WHILE THE NURSE IS TAKING THE HISTORY OF A 68-YEAR-OLD PATIENT WHO SUSTAINED A HEAD INJURY 3 DAYS EARLIER, HE TELLS THE NURSE THAT HE IS ON A CRUISE SHIP AND IS 30 YEARS OLD. THE NURSE KNOWS THAT THIS FINDING IS INDICATIVE OF: • A) a great sense of humor. • B) uncooperative behavior. • C) inability to understand questions. • D) decreased level of consciousness.
D) DECREASED LEVEL OF CONSCIOUSNESS. • Pages: 660-661. A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.
WHICH OF THE FOLLOWING VALUES FOR VITAL SIGNS WOULD THE NURSE ADDRESS FIRST? • A) Heart rate = 72 beats per minute • B) Respiration rate = 28 breaths per minute • C) Blood pressure = 160/86 • D) Oxygen saturation by pulse oximetry = 89%
D) OXYGEN SATURATION BY PULSE OXIMETRY = 89% • low and means organs are not being perfused-can lead to the most damage the fastest-we want this >95%
WHEN THE NURSE ASKS A 68-YEAR-OLD PATIENT TO STAND WITH FEET TOGETHER AND ARMS AT HIS SIDE WITH HIS EYES CLOSED, HE STARTS TO SWAY AND MOVES HIS FEET FARTHER APART. THE NURSE WOULD DOCUMENT THIS FINDING AS A(N): • A) ataxia. • B) lack of coordination. • C) negative Homans' sign. • D) positive Romberg sign.
D) POSITIVE ROMBERG SIGN. • Page: 638. Abnormal findings for Romberg test include swaying, falling, and widening base of feet to avoid falling. Positive Romberg sign is loss of balance that is increased by closing of the eyes. Ataxia is uncoordinated or unsteady gait. Homans' sign is used to test the legs for deep vein thrombosis.
***musculoskeletal-neuro-mental status***
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