Health Assessment Exam 3 test bank

A nurse is having difficulty eliciting a patellar reflex. Which of the following 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

Assessment reveals that an older client has osteomalacia. Which of the following would be most important to include in the client's teaching plan? A) Practice risk prevention for fractures. B) Keep exercise to a minimum to decrease pain. C) Minimize movements to maintain joint stability. D) The risk for arthritis increases with age.

a

During 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

During the physical exam, the nurse notes a very tender and painful, reddened, hot, and swollen metatarsophalangeal joint of the client's great toe. Which of the following would the nurse suspect? A) Gouty arthritis B) Rheumatoid arthritis C) Degenerative joint disease D) Plantar fasciitis

a

When assessing the elbow, a nurse asks a client to hold the arm out and turn the palm down. The nurse is testing which of the following? A) Pronation B) Flexion C) Rotation D) Supination

a

When 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 in the 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.

a

When testing the range of motion of the cervical spine, the nurse notes impaired range of motion and neck pain. A review of the client's history reveals fever, chills, and headache. Which of the following would the nurse suspect? A) Meningitis B) Cervical strain C) Compression fracture D) Cervical disc degeneration

a

Which of the following would the nurse interpret as a positive response to the Phalen test for a client suspected of having carpal tunnel syndrome? A) Numbness B) Atrophy of the thenar prominence C) No tingling D) Hard, painless Bouchard nodes

a

Which test would be most appropriate for the nurse to perform when a client complains of low back pain? A) Lasegue test B) Muscle leg strength C) Lateral bending of cervical spine D) Internal rotation of the shoulders

a

A nurse is preparing to perform a complete neurologic exam. Place the assessments in the most appropriate sequence for the nurse to perform them. A) Cranial nerves B) Reflexes C) Mental Status D) Motor/cerebellar function E) Sensory system

a b c d e

When reviewing the neural pathways, a group of students identify which of the following as sensations that travel via the spinothalamic tract. Select all that apply. A) Pain B) Temperature C) Position D) Vibration E) Light touch

a b e

A 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

nerve VI

abducens controls lateral eye movement

nerve VIII

acoustic hearing and balance

A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. Which of the following would the nurse do? A) Use a Snellen chart to test visual acuity. B) Ask a client to identify scents. C) Test extraocular eye movements. D) Perform the Weber test.

b

A 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

After teaching a group of students about the bones and their functions, the instructor determines that the teaching was successful when the students state that blood cells are produced in which of the following? A) Compact bone B) Red marrow C) Yellow marrow D) Spongy bone

b

The nurse is assessing a client's gait. Which finding would alert the nurse to the need for a referral for further evaluation. A) Weight evenly distributed B) Shuffling of feet C) Stands on heels and toes D) Arms swinging in opposition

b

When 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 paravertebral muscles for pain.

b

When documenting the findings of a neurologic assessment, which of the following would be most important? A) Verify the data before documenting. B) Describe the client's response. C) Label the client's behavior. D) Record objective data primarily.

b

When 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 with hypertension C) 55-year-old Caucasian male who has a two beers a week D) 35-year-old African American who has sleep apnea

b

When 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

b

When preparing to test a client for meningeal irritation, which of the following would be most important for 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

When testing muscle strength, a client has difficulty moving each extremity against resistance. Which of the following would the nurse 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) Compare bilateral findings.

b

Which of the following assessment findings would lead the nurse to suspect that a client has Bell's 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

While assessing the knee joint of a client, a nurse also explains about the typical motions associated with that joint. Which of the following would the nurse include? A) Circumduction B) Flexion C) Abduction D) Internal rotation

b

A 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

A 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

A female client tells the nurse that she has been diagnosed with systemic lupus erythematosus. The nurse would assess the client for which common complication? A) Diabetes mellitus B) Urinary tract infection C) Osteoporosis D) Early menopause

c

A group of students is reviewing information related to the major bones of the skeleton. The students demonstrate understanding of the material when they identify which of the following as part of the axial skeleton? A) Humerus B) Femur C) Vertebral column D) Carpals

c

A nurse is preparing a program on osteoporosis for a local women's group. Which of the following would the nurse include as a modifiable risk factor? A) Small-boned, thin frame B) Personal history of fractures C) Low estrogen levels D) Age

c

A nurse is testing the range of motion of the thoracic and lumbar spine. Which of the following would the nurse document as an abnormal finding? A) Flexion of 80 degrees B) Lateral bending of 35 degrees C) Hyperextension of 20 degrees D) Rotation of 30 degrees

c

After 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

After teaching a group of students about the brain and spinal cord, the instructor determines that the students demonstrate the need for additional teaching when they identify which of the following as being controlled by the brainstem? A) Respiratory function B) Heart rate C) Equilibrium D) Reflex actions

c

Assessment reveals that a client has slight weakness with active range of motion against some resistance. The nurse would document this as which of the following? A) 2/5 B) 3/5 C) 4/5 D) 5/5

c

Inspection of a client's knee reveals swelling, and the nurse suspects that there is significant fluid in the knee. Which of the following would the nurse use to confirm the suspicion? A) Phalen's test B) Tinel's test C) Ballottement test D) Lasegue's test

c

The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following? A) 1+ B) 2+ C) 3+ D) 4+

c

When 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 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

Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve? A) Ask client to differentiate sharp and dull sensations on client's face. B) Have the client smile, frown and wrinkle the forehead. C) Palpates temporal and masseter muscles while client clenches teeth. D) Assess dilatation of pupils with direct light.

c

Which of the following would be most appropriate when the nurse notes limitation in active range of motion of a client's right shoulder? 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

Which of the following 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

Which of the following would the nurse most likely expect to 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

c

A client complains of temporomandibular joint (TMJ) pain. Which of the following would the nurse most likely assess? A) Knife-like pain B) History of fracture C) Recent weight gain D) Difficulty chewing

d

A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment? A) Vital signs B) Neurologic system C) Cardiac function D) Coordination

d

A nurse asks a client to bring the hands together behind the head with the elbows flexed. The nurse is testing which of the following? A) Abduction B) Adduction C) Internal rotation D) External rotation

d

A nurse is preparing to assess a client's cerebellar function. Which of the following would the nurse expect to test? A) Remote memory B) Sensation C) Mental status exam D) Balance

d

During 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

During the history, a young adult woman tells 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 around 800 milligrams each day." C) "Avoid being out in the sun for long periods of time." D) "Try to avoid drinking too much coffee or other caffeinated fluids."

d

The 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

d

The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam? A) Romberg B) Tandem walking C) Gait D) Hop on one foot

d

The nurse is preparing to palpate the anatomic snuffbox. At which location 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

When a nursing instructor is describing the peripheral nervous system to a group of students, the instructor would explain that there are how many pairs of spinal nerves? A) 8 B) 11 C) 24 D) 31

d

When assessing cranial nerves IX and X, which of the following 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

d

Which of the following would be most appropriate to do when 45-degree flexion of the cervical spine is noted in an adolescent client? 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

Which 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

Which 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

nerve VII

facial salivary, taste, tears

nerve IX

glossopharyngeal taste on posterior, and gag reflux

nerve XII

hypoglossal tongue muscles

nerve III

oculomotor constricts pupils, elevates eyelids

nerve I

olfactory

nerve II

optic

nerve XI

spinal accesory neck and head muscles

nerve V

trigeminal pain, touch, temp, from face to brain. biting and chewing

nerve IV

trochlear contracts one eye muscle

nerve X

vagus