NSG 305 Exam 3

A client tells the nurse, "My legs really hurt when I walk." What can the nurse say to this client in response? a. Maybe you have a lymph node infection in your groin. b. Does the pain go away when you stop walking? c. That means you have to walk more. d. Maybe you shouldn't walk as much and see if it improves.

b. Does the pain go away when you stop walking?

It is important that the nurse be knowledgeable about cardiac output in order to: a. Evaluate blood flow to peripheral tissues. b. Determine the electrical activity of the myocardium. c. Provide information on the immediate need for oxygen. d. Implement nutritional changes.

a. Evaluate blood flow to peripheral tissues. Rationale: Blood flow to the tissues is measured clinically as the cardiac output, and assists to predict tissue perfusion. Electrical activity is evaluated more effectively by EKG. While the cardiac output is important for perfusion and oxygenation of tissues, the oxygen saturation would provide more valuable information. Nutritional changes would be targeted to sodium and would depend on symptoms of disease.

A client comes into the clinic complaining of ear pain. During the examination, the nurse notes swelling directly in front of the client's right ear. Which lymph nodes should the nurse document as being edematous? a. Submental b. Preauricular c. Postauricular d. Occipital

b. Preauricular

eversion

turning outward

The cervical nodes drain the: A. upper arm and breast. B. hand and lower arm. C. external genitalia. D. head and neck.

D. head and neck.

Muscle strength rating 5

Full ROM against gravity, full resistance. Is 100% normal. You would say normal in your assessment.

When testing muscle strnght and the client cannot move the part against your resistance

ask the client to move the part against gravity

flexion

movement in which a limb is bent

rotation

turning around its own axis

inversion

turning inward

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 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.

The nurse is reviewing the orthopedist's physician assistant's progress notes and reads that McMurray's test was positive and Phalen's test was negative. The nurse interprets these findings as suggesting that the client may: A. have had an injury to the meniscus. B. have carpal tunnel syndrome. C. have osteoarthritis. D. have gouty arthritis.

A. have had an injury to the meniscus. In Phalen's test is positive if the client experiences numbness and burning in the fingers, otherwise the test is negative. The client may have developed carpal tunnel syndrome. McMurray's test is conducted while the client is reclining. The client is asked to turn a flexed knee toward the center of the body while the knee is stabilized with one hand, and pressure is applied to the lower leg with the other hand. If there is clicking or pain, the test is positive; otherwise, it is negative and suggests an injury to the meniscus.

Palpable inguinal lymph nodes are: A. normal if small (less than 1 cm), movable, and nontender. B. abnormal in adults but common in children and infants. C. normal if fixed and tender. D. abnormal and indicate the presence of malignant disease.

A. normal if small (less than 1 cm), movable, and nontender. Rationale: Inguinal lymph nodes may be palpable. This is a normal finding if the nodes are small (1 cm or less), movable, and nontender. Lymph nodes may be relatively large in children, and the superficial ones often are palpable even when the child is healthy.

6. When assessing for the presence of a herniated nucleus pulposus, the examiner would: A. raise each of the patient's legs straight while keeping the knee extended. B. ask the patient to bend over and touch the floor while keeping the legs straight. C. instruct the patient to do a knee bend. D. abduct and adduct the patient's legs while keeping the knee extended.

A. raise each of the patient's legs straight while keeping the knee extended. Rationale: A. The straight leg raising (Lasègue) test reproduces back and leg pain and helps confirm the presence of a herniated nucleus pulposus. The examiner raises each leg straight while keeping the knee in extension. B. To assess for a spinal curvature, the examiner will have the person will bend over and touch the toes with the knee in extension. C. Muscle extension can be assessed by instructing the person to rise from a squatting position without using the hands for support. D. To assess range of motion, the leg should be abducted and adducted with the knee extended.

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. Rationale: A. Crepitation is an audible and palpable crunching or grating that accompanies movement. It occurs when the articular surfaces in the joints are roughened. B. Crepitation is not the cracking noise heard when tendons or ligaments slip over bones during motion. C. Hyperflexion or hyperextension is assessed with range of motion. D. Bursitis is an inflamed bursa. Pain may occur with motion of the joint involved.

Stridor is a high-pitched, inspiratory crowing sound commonly associated with: A. upper airway obstruction. B. atelectasis. C. congestive heart failure. D. pneumothorax.

A. upper airway obstruction.

IF the client cannot move thier arm against gravity

Attempt to move the part passively through its full ROM.

Which of the following cardiac alterations occurs during pregnancy? A. An increase in cardiac output and blood pressure B. An increase in cardiac volume and a decrease in blood pressure C. An increased heart rate and increased blood pressure D. An increased stroke volume with decreased cardiac output

B. An increase in cardiac volume and a decrease in blood pressure

During a cardiovascular examination, a nurse in a provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following heart sounds is the nurse attempting to auscultate? (select all that apply) A. Ventricular gallop B. Closure of the mitral valve C. Closure of the pulmonic valve D. Closure of the tricuspid valve E. Murmur

B. Closure of the mitral valve D. Closure of the tricuspid valve

Increased tactile fremitus would be evident in an individual who has which of the following conditions? A. Emphysema B. Pneumonia C. Crepitus D. Pneumothorax

B. Pneumonia Rationale: Fremitus is a palpable vibration. Increased fremitus occurs with compression or consolidation of lung tissue (e.g., lobar pneumonia).

Which of the following best describes findings associated with fremitus? A. Fremitus is more pronounced on the anterior chest than on the posterior. B. The intensity of the fremitus decreases as you progress down the chest wall. C. A female will present with greater intensity of fremitus than a male. D. Increased fremitus is associated with an increase of air in the tissues of the lung.

B. The intensity of the fremitus decreases as you progress down the chest wall.

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. The person should flex or extend muscle groups for each joint while the examiner applies an opposing force.

A teenager in the third trimester asks the nurse at the prenatal clinic if pregnancy caused the curve in her spine. The nurse's best response is A. "Yes, and it will go away after you deliver." B. "Your back shows 'lordosis' which is an increase in the lumbar curve related to weight shift during pregnancy." C. "You need to see the physician today and tell him about your scoliosis." D. "It's not at all unusual for a young mother to develop kyphosis during pregnancy."

B. Your back shows 'lordosis' which is an increase in the lumbar curve related to weight shift during pregnancy. Lordosis, an increased lumbar curve, may be seen in obesity or pregnancy. Scoliosis, a lateral, S-shaped curvature of the spine is a functional disorder that is often congenital and appears during adolescence. It is a functional response to painful paravertebral muscles, herniated discs, or discrepancy in leg length. Kyphosis is an exaggerated thoracic curvature of the spine common in older adults. The nurse should respond, giving the client the correct term, and the explanation of the pain. The pain may or may not resolve with delivery.

Claudication is caused by: A. venous insufficiency. B. arterial insufficiency. C. varicose veins. D. stasis ulcerations.

B. arterial insufficiency.

Of the following statements, which identify age-related changes in the musculoskeletal system? (Select all that apply. ) A. increased calcium resorption B. decreased bone mass and minerals C. increased fibrous tissue D. decreased spinal column height

B. decreased bone mass and minerals C. increased fibrous tissue D. decreased spinal column height Age-related changes include decreased bone mass and minerals, decreased calcium reabsorption, decreased height due to spinal column shortening, and muscle fibers atrophy and fibrous tissue slowly replaces muscle tissue.

Why is osteoporosis more common as a person ages?

Bone resorption increases, calcium absorption decreases, and production of osteoblasts decreases.

The divisions of the spinal vertebrae include: A. Cervical, thoracic, scaphoid, sacral, and clavicular. B. Scapular, clavicular, lumbar, scaphoid, and fasciculi. C. Cervical, thoracic, lumbar, sacral, and coccygeal. D. Cervical, lumbar, iliac, synovial, and capsular.

C. Humans have 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3 to 4 coccygeal vertebrae.

A nurse in a provider's office is preparing to auscultate and percuss a client's thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A. Rhonchi B. Crackles C. Resonance D. Tactile fremitus E. Bronchovesicular sounds

C. Resonance D. Tactile fremitus E. Bronchovesicular sounds

Which of the following guidelines may be used to identify which heart sound is S1? A. S1 is louder than S2 at the base of the heart. B. S1 coincides with the A wave of the jugular venous pulse wave. C. S1 coincides with the carotid artery pulse. D. S1 coincides with the Q wave of the QRS electrocardiogram complex.

C. S1 coincides with the carotid artery pulse.

The patient has severe bilateral lower extremity edema. The most likely cause is: A. an infection of the right great toe. B. Raynaud phenomenon. C. heart failure. D. an aortic aneurysm.

C. heart failure.

The 8 year old client who fell while trying to mount a horse is admitted to the orthopedic clinic and is found to have compression fractures in lumbar vertebrae 4 and 5. When the child asks the nurse what "vertebrae" are, the nurse responds that they are: A. long bones that produce blood cells. B. cuboid bones that support the back. C. irregular hard bones that have spongy bones between them. D. curved bones that support the back.

C. irregular hard bones that have spongy bones between them Irregular bones such as vertebrae are of various shapes and are plates of compact bone with spongy bone between them. Flat bones are thin, flat, and consist of a layer of spongy bone between two thin layers of compact bone. Long bones (i.e., bones that are longer than they are wide), contain a shaft that contains marrow. Cuboid bones are spongy bone covered by compact bone.

When testing an individual for vocal resonance, the expected result of voice transmission is that: A. sounds are distinct and clearly identifiable. B. sounds increase as you move from the top to the bottom of the lung fields. C. sounds are muffled, soft, and indistinct. D. voice sounds are decreased in the presence of consolidation.

C. sounds are muffled, soft, and indistinct.

Arteriosclerosis refers to: A. a variation from the heart's normal rhythm. B. a sac formed by dilation in the arterial wall. C. thickening and loss of elasticity of the arterial walls. D. deposition of fatty plaques along the intima of the arteries.

C. thickening and loss of elasticity of the arterial walls.

Who are especially prone to development of osteoporosis?

Clients who are immobile or have a reduced intake of calcium and vitamin D

A nurse is working with an older client who has osteoporosis. The nurse understands that osteoporosis is more common in older people for which of the following reasons? Select all that apply. a) Increased incidence of arthritis b) Increased bone resorption c) Increased sun exposure d) Decreased osteoblast production e) Decreased calcium absorption f) Decreased intake of vitamin K

Correct response: • Increased bone resorption • Decreased calcium absorption • Decreased osteoblast production Explanation: Osteoporosis is more common as a person ages because that is a time when bone resorption increases, calcium absorption decreases, and production of osteoblasts decreases as well. Arthritis is not a risk factor for osteoporosis. It is not established that decreased intake of vitamin K or increased sun exposure are associated with advancing age, and even if it were, these are not risk factors associated with osteoporosis.

Which joint movement is a nurse testing when asking a client to move an extremity towards the body? a) Extension b) Abduction c) Flexion d) Adduction

Correct response: Adduction Explanation: Adduction is the movement towards the midline of the body. Flexion is bending the extremity at the joint and decreasing the angle of the joint. Extension is straightening the extremity at the joint and increasing the angle of the joint. Abduction is moving away from the midline of the body.

Which nutrient deficiency should a nurse recognize as placing a client at risk for osteoporosis? a) Calcium b) Protein c) Vitamin D d) Vitamin C

Correct response: Calcium Explanation: A calcium deficiency increases the risk osteoporosis. This causes the bones to become softer in nature because the rate at which bone is destroyed is occurring at a faster rate than new bone is made. Protein functions in muscle tone and growth. Vitamin C promotes healing of tissues and bones. Vitamin D deficiency causes osteomalacia, softening of the bones due to defective bone mineralization. Osteomalacia in children is known as rickets.

A client presents to the health care clinic with reports of onset of neck pain 3 days ago. The nurse recognizes that the most common cause of neck pain is what condition? a) Cervical disc degenerative disease b) Cervical strain c) Compression fractures d) Cervical spinal cord compression

Correct response: Cervical strain Explanation: The most common cause of neck pain is cervical strain. This can occur from sleeping in the wrong position, carrying a heavy load, or being in an automobile accident. Cervical disc degenerative disease is associated with impaired range of motion and pain that radiates to the back, shoulders, or arms. Cervical spinal cord compression causes neck pain with loss of sensation in the legs. Compression fractures of the neck may also cause loss of sensation in the legs if the spinal cord becomes compressed.

A client presents to the health care clinic with reports of onset of neck pain three (3) days ago. The nurse recognizes that the most common cause of neck pain is what condition? a) Cervical disc degenerative disease b) Cervical spinal cord compression c) Cervical strain d) Compression fractures

Correct response: Cervical strain Explanation: The most common cause of neck pain is cervical strain. This can occur from sleeping in the wrong position, carrying a heavy load, or being in an automobile accident. Cervical disc degenerative disease is associated with impaired range of motion and pain that radiates to the back, shoulders, or arms. Cervical spinal cord compression causes neck pain with loss of sensation in the legs. Compression fractures of the neck may also cause loss of sensation in the legs if the spinal cord becomes compressed.

When assessing a client's strength, it is necessary to a) Compare upper and lower extremities b) Assess the extremities at the same time c) Assess upper and lower extremities at the same time d) Compare one side to the other

Correct response: Compare one side to the other Explanation: When assessing muscle tone and strength, it is necessary to compare one side to the other. It is not necessary to compare the upper extremities to the lower extremities or to assess the upper and lower extremities.

A college age athlete presents to the clinic with pain in the tibiotalar joint. It is a hinge joint limited to flexion and extension. The terms used to describe these movements are what? a) Supination and pronation b) Adducting and abducting c) Dorsiflexion and plantar flexion d) Rotation and supination

Correct response: Dorsiflexion and plantar flexion Explanation: The terms used to describe the movements of the tibiotalar joint are dorsiflexion and plantar flexion. Adducting means to move a part of the body toward the midline. Abducting is moving a part of the body away from the midline. Supination is a motion where the foot or palm of the hand is moved to a surface up position. Pronation is a motion where the foot or palm of the hand is moved to a surface down position. Rotation is simply the movement of the joint. Rotation could be either internal or external in nature.

During palpation of the client's knee, the nurse compresses the suprapatellar pouch against the client's femur with one hand while feeling on each side of the patella with the opposite hand. For which of the following problems is the nurse assessing? a) Effusion in the knee joint b) Crepitus uteri flexion c) Osteoarthritis d) Ligament trauma

Correct response: Effusion in the knee joint Explanation: The balloon sign is indicative of a large effusion in the knee joint when fluid is palpable medial to the patella when the suprapatellar pouch is depressed. The presence of crepitus, osteoarthritis, or ligament damage is not directly suggested by a positive balloon sign. (less) This is the Ballottement test

Risk factors in which of the following areas are most readily changed to reduce the potential risk for falls? a) Environmental b) Cognitive c) Social d) Physiological

Correct response: Environmental Explanation: While adapting individuals' social, cognitive, and physiological circumstances can present challenges, modifications to address environmental threats to safety can often be made mo... (more) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 24: Assessing Musculoskeletal System, p. 515.

What range of motion is the nurse testing by asking a client to stoop to pick an object off the floor? a) Flexion b) Abduction c) Extension d) Rotation

Correct response: Flexion Explanation: Stooping is another term for bending. The client must be able to flex the thoracic and lumbar spines and flex the knees. Extension is straightening the extremity at the joint and increasing the angle of the joint. Abduction is moving away from the midline of the body. Rotation is turning the head to the right and then the left.

Which movement should the nurse instruct the client to perform to assess range of motion for the knee? a) Flexion b) Circumduction c) Rotation d) Abduction

Correct response: Flexion Explanation: The nurse should instruct the client to perform flexion to assess the range of motion for the client's knee. Circumduction, rotation, and abduction movements are not possible in the knees. Circumduction is the circular motion of the joint. Rotation involves turning the head to the right shoulder then back to midline and then turning the head to the left shoulder then back to midline. Abduction refers to moving away from the midline of the body. The knees are capable of performing only flexion and extension.

A client expresses to the nurse that he has a "giving in" or "locking" sensation in the knee. Which test should the nurse perform to elicit related findings of a possible tear in the meniscus of the client's knee? a) McMurray's b) Ballottement c) Phalen's d) Bulge

Correct response: McMurray's Explanation: The nurse should perform McMurray's test to confirm meniscal tear. Pain or clicking during the test is indicative of a torn meniscus of the knee. The Ballottement test and the Bulge test are done to detect the presence of fluid in the knee joint. Phalen's test is done to test carpal tunnel syndrome.

Which action by a nurse is a correct method for performing Tinel's test to determine the presence of carpel tunnel syndrome? a) Ask the client to bend the wrist down and back b) Palpate the hollow area on the back of the wrist c) Percuss lightly on the inner aspect of the wrist d) Perform wrist movements against resistance

Correct response: Percuss lightly on the inner aspect of the wrist Explanation: The nurse should tap at the inner aspect of the wrist to percuss the median nerve because the median nerve is located at the inner aspect of the wrist where it enters the carpal canal. Palpation of the hollow area on the back of the wrist is done to examine the anatomic snuffbox. Asking the client to bend the wrist down and back and performing wrist movements against resistance are done to assess range of motion and muscle strength.

The nurse is testing a client for carpal tunnel syndrome. The client flexes the wrists at an angle of 90° and holds the backs of the hands to each other for 60 seconds. The client tells the nurse that he is experiencing a burning pain as a result. Which test is the nurse performing on this patient? a) Tinel's b) Ballottement c) McMurray's d) Phalen's

Correct response: Phalen's Explanation: Phalen's test evaluates for carpal tunnel syndrome. The client flexes the wrists at an angle of 90° and holds the backs of the hands to each other for 60 seconds. Normal response is denial of any discomfort. Positive signs include numbness, burning, or pain. Tinel's sign is a test to assess for irritated nerves. It is performed by lightly percussing over the nerve to elicit a sensation or tingling in the distribution of the nerve. Ballottement is a test to assess for increased fluid in the knee joint. The McMurray test is used to test individuals for tears in the meniscus of the knee.

In assessing a client's temporomandibular joint (TMJ), the nurse asks the client to move the jaw forward. This movement is known as which of the following? a) Pronation b) Retraction c) Supination d) Protraction

Correct response: Protraction Explanation: Protraction is moving forward. Retraction is moving backward. Pronation is turning or facing downward. Supination is turning or facing upward. Pronation and supination are not possible at the TMJ.

The nurse is assessing a client with joint pain and is trying to decide whether it is inflammatory or non-inflammatory. Which of the following symptoms is consistent with an inflammatory process? a) Cool temperature b) Ecchymosis c) Nodules d) Tenderness

Correct response: Tenderness Explanation: Tenderness implies an inflammatory process along with increased temperature. Nodules and ecchymosis are not typically associated with inflammatory processes.

A nurse is testing the range of motion of a client's wrist for supination. Which movement will this involve? a) Moving the tips of the fingers away from the forearm b) Turning the palm of the hand downward c) Moving the tips of the fingers toward the forearm d) Turning the palm of the hand upward

Correct response: Turning the palm of the hand upward Explanation: Supination involves turning or facing upward, in this case turning the palm upward. Pronation involves turning or facing downward, in this case turning the palm downward. Flexion involves bending the extremity at the joint and decreasing the angle of the joint, in this case moving the tips of the fingers toward the forearm. Extension involves straightening the extremity at the joint and increasing the angle of the joint, in this case moving the tips of the fingers away from the forearm.

On inspection of the spine of a 79-year-old man, the nurse might expect to find a(n) a) increased thoracic curve b) decreased lumbar curve c) decreased cervical curve d) increased cervical curve

Correct response: increased thoracic curve Explanation: An exaggerated thoracic curve (kyphosis)is common with aging.

The nurse is going to test range of motion in a patient. To test extension of the triceps muscle, the nurse would instruct the patient to a) turn the palm down b) straighten the elbow c) turn the palm up d) bend the elbow

Correct response: straighten the elbow Explanation: The client should have full range of motion.

The knee joint is the articulation of three bones, the: A. femur, fibula, and patella. B. femur, radius, and olecranon process. C. fibula, tibia, and patella. D. femur, tibia, and patella.

D. The knee joint is the articulation of the femur, the tibia, and the patella.

In assessing the client at the clinic, the nurse perform's Phalen's test. The client states that the client feels numbness and burning in the fingers. The nurse recommends that the client: A. refrain from keeping the wrist flexed for more than a few seconds. B. wear articles of clothing that fit loosely around the arms. C. consider taking glucosamine sulfate, an over-the-counter supplement, to increase the synovial fluid in the wrist joint. D. report the finding to the physician since it is abnormal.

D. report the finding to the physician since it is abnormal. In Phalen's test, the client holds the wrist in acute flexion for 60 seconds. If the client experiences numbness and burning in the fingers, the client may have developed carpal tunnel syndrome and should be evaluated by the physician specifically for the disorder.

Lymphedema is: A. the indentation left after the examiner depresses the skin over swollen edematous tissue. B. a thickening and loss of elasticity of the arterial walls. C. an inflammation of the vein associated with thrombus formation. D. the swelling of an extremity caused by an obstructed lymph channel.

D. the swelling of an extremity caused by an obstructed lymph channel.

What type of drinks are associated with risk of osteoporosis?

Excessive consumption of alcohol or caffeine.

Muscle strength rating 4

Full ROM against gravity, some resistance. Is 75% normal. is considered GOOD in your assessment.. Slight weakness.

Muscle strength rating 3

Full ROM with gravity. Is 50% normal. is considered FAIR in your assessment.

If it is not possible to do ROM

Inspect and feel for a palpable contraction of the muscle while the client attempts to move it. come pare bilateral joints

The client presents with an exaggeration of the lumbar spine curve. The nurse interprets these findings as indicative of: a) Dowager's hump b) Scoliosis c) Lordosis d) Kyphosis

Lordosis Explanation: Lordosis is an exaggeration of the lumbar spine curve.

Muscle strength rating 0

No muscular contraction - paralysis. Is 0% normal. Is considered ZERO in your assessment.

Smoking increases the risk for what bone disease?

Osteoporosis

Muscle strength rating 2

Passive ROM (Gravity removed and assisted by examiner) - poor ROM. Is 25% normal.. Is considered POOR in your assessment.

Muscle strength rating 1

Slight flicker of contraction - severe weakness. Is 10% normal. Is considered TRACE in your assessment.

Which of the following assessments would be an important finding for a patient with arterial disease? a. Intermittent claudication with exercise b. Brownish discoloration around the ankles c. Non-pitting edema on the lower extremities d. Altered sensation to touch

a. Intermittent claudication with exercise Rationale: Intermittent claudication is a common finding in persons with arterial disease, usually due to progression of atherosclerosis and alteration of tissue perfusion to the extremities. In venous disease, valves of the veins in the extremities become incompetent, resulting in higher pressures than normal in the veins. The pressure is transmitted to the capillaries of the lower extremities, resulting in thickening and non-pitting edema of tissues around the ankles. Prolonged thickening results in the red blood cells' being pressed outside the capillaries. The cells eventually break down, resulting in collection of hemosiderin deposits being collected in the area. Altered sensation to touch would be due to neuropathic changes commonly found with diabetes mellitus.

An eight-month-pregnant client is worried about all of the swollen veins she has developed. What can the nurse tell the client about these veins? a. It's because of the uterus causing blood to back up. b. Maybe you should see a vascular surgeon. c. It's too bad that your legs look like that. d. Nothing. Phone the physician and report the finding.

a. It's because of the uterus causing blood to back up.

The nurse observes that a 79-year-old client with a history of pulmonary tuberculosis has a severe spinal deformity. Which of the following would most likely describe what the nurse has assessed? a. Kyphosis b. Lordosis c. Hallux Valgus d. Swan-neck deformity

a. Kyphosis

The nurse observes that a 79-year-old client with a history of pulmonary tuberculosis has a severe spinal deformity. Which of the following would most likely describe what the nurse has assessed? a. Kyphosis b. Lordosis c. Swan-neck deformity d. Hallux Valgus

a. Kyphosis

Which of the following are least likely to be early signs of cardiac problems in older persons? (Select all that apply.) a. Mental status changes b. Agitation c. Frequent falls d. Sudden changes in GI function

a. Mental status changes b. Agitation c. Frequent falls Rationale: Many cardiovascular functions are complicated in that they involve many other systems. Mental status changes, agitation, and falls can be early signs of cardiac problems in the older person. Changes in function in the GI system are not typical signs of a cardiac problem.

A 47-year-old female tells the nurse, "I'm sorry for my hairy legs. I shaved a few days ago and didn't have time this morning to do it again." What does this information mean to the nurse? a. The client has good peripheral extremity blood flow. b. The client needs to plan more time for self-care in the morning. c. The client has personal hygiene issues. d. The client needs instruction on safe hair removal.

a. The client has good peripheral extremity blood flow.

A 68-year-old client has lower extremity edema and thick skin discolored to a dark brown. The client complains of his legs "feeling full." Which of the following does this information suggest to the nurse? a. The client might have venous insufficiency. b. The client has a deep vein thrombosis. c. The client might have an arterial blood clot. d. The client has varicose veins.

a. The client might have venous insufficiency.

After examining a 75-year-old male client, the nurse writes down "barrel chest." What does this finding suggest? a. This is a change associated with aging. b. The client has osteoporosis. c. The client has long-standing respiratory disease. d. The client has a history of smoking.

a. This is a change associated with aging. Rationale: As individuals age, body functions change. The diameters of the thoracic cage change. The appearance of a barrel chest (kyphosis) can contribute to the decrease in thoracic excursion.

On auscultation, which finding suggests a right pneumothorax? a) Bilateral inspiratory and expiratory crackles b) Absence of breath sounds in the right thorax c) Inspiratory wheezes in the right thorax d) Bilateral pleural friction rub

b) Absence of breath sounds in the right thorax

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for a lung transplant. The nurse performs the initial physical assessment. Which signs and symptoms should the nurse expect to find? a) Decreased respiratory rate b) Dyspnea on exertion c) Barrel chest d) Shortened expiratory phase e) Clubbed fingers and toes f) Fever

b) Dyspnea on exertion c) Barrel chest e) Clubbed fingers and toes

The nurse is planning to assess the apex of a client's lungs. Which area of the body will the nurse be assessing? a. Right of the sternum, sixth intercostal space b. Above the clavicles c. Below the scapula d. Left of the sternum, third intercostal space

b. Above the clavicles Rationale: The apex of each lung is slightly superior to the inner third of the clavicle.

A client tells the nurse she has calf pain. Which of the following should the nurse do? a. Call the physician and prepare for a heparin infusion. b. Pull up on the client's toes to see if there's more pain. c. Walk with the client and ask her to rate the pain. d. Ask the client to walk around the examination room.

b. Pull up on the client's toes to see if there's more pain. Rationale: A positive Homan's sign could indicate a blood clot in the leg. This sign is unreliable and follow-up studies may be required to identify the presence of a clot.

A patient has been diagnosed with Right-Sided Congestive Heart Failure, and is confused about return of deoxygenated blood from the tissue. To clarify the confusion, which chamber of the heart receives blood from systemic circulation? a. Left atrium b. Right atrium c. Right ventricle d. Left ventricle

b. Right atrium Rationale: The right atrium is a thin-walled structure that receives deoxygenated blood from all the peripheral tissues by way of the superior and inferior vena cava and from the heart muscle by way of the coronary sinus.

The mother of a four-year-old child tells the nurse, "I think there's something wrong with him; his chest is round like a ball." Which of the following would be an appropriate response for the nurse to make to the mother? a. I see what you mean. That seems odd. b. The chest of a child appears round and is normal. c. I wouldn't worry about that. d. Did you tell the doctor about this?

b. The chest of a child appears round and is normal.

During the cardiac assessment, the nurse finds a client has jugular vein distention. What does this mean to the nurse? a. The client is dehydrated. b. The client could have fluid overload. c. The client is fine. d. The client has an infection.

b. The client could have fluid overload.

The nurse sees that the client will breathe deeply and then stop breathing for a short while. Which of the following does this observation suggest? a. This client has pneumonia. b. This is seen in aging people, people with heart failure, and people who have suffered brain damage. c. This client is hyperventilating. d. This client is in a diabetic coma.

b. This is seen in aging people, people with heart failure, and people who have suffered brain damage. Rationale: Cheyne-Stokes respirations are periods of deep breathing alternating with periods of apnea. Precipitating factors include aging, heart failure, uremia, brain damage, and drug-induced respiratory depression.

Why are women at risk for osteoporosis?

because of a menarche that begins late, or begin menopause early because of decreases estrogen levels

A 47-year-old client with a history of chronic back pain asks the nurse what she can do to reduce this pain. Which of the following can the nurse instruct the client? a. Learn to ignore the pain. b. Rest as much as possible. c. Help to reduce the pain with weight management and a physical activity program. d. Talk with a pain clinic doctor about pain management.

c. Help to reduce the pain with weight management and a physical activity program.

The nurse assesses ankle edema in a client. What can the nurse say to the client about this edema? a. It's caused by tight stockings. b. It's caused by a blood clot. c. It's caused by blood pooling in the legs. d. It's caused by an infection.

c. It's caused by blood pooling in the legs.

The nurse rates a client's biceps muscle strength as a 3. What does this rating mean? a. The client has full range of motion against gravity with full resistance. b. The client has full range of motion without gravity. c. The client has full range of motion with gravity. d. The client has full range of motion against gravity with moderate resistance.

c. The client has full range of motion with gravity.

The nurse rates a client's biceps muscle strength as a 3. What does this rating mean? a. The client has full range of motion against gravity with moderate resistance. b. The client has full range of motion without gravity. c. The client has full range of motion with gravity. d. The client has full range of motion against gravity with full resistance.

c. The client has full range of motion with gravity. Rationale: The rating of 3 of muscle strength is considered fair and means the client has full range of motion with gravity.

A client tells the nurse, "My legs are always cold." What significance does this information have to the nurse? a. The client smokes. b. The client has stasis ulcers. c. The client might have arterial insufficiency. d. The client has edema.

c. The client might have arterial insufficiency.

A client's blood pressure is 158/90 mm Hg. What does this reading suggest to the nurse? a. This client has prehypertension. b. This blood pressure is normal. c. This client has stage 1 hypertension. d. This client has stage 2 hypertension.

c. This client has stage 1 hypertension.

The neonatal nurse obtains a newborn's blood pressure as being 76/40 mm Hg. Which of the following should the nurse do with this information? a. Call for help as the baby is going to cardiac arrest. b. Ask another nurse to check the blood pressure because it is low. c. Write it down. This is a normal neonatal blood pressure. d. Call the physician.

c. Write it down. This is a normal neonatal blood pressure.

The nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? a) Nonproductive cough and normal temperature b) Sore throat and abdominal pain c) Hemoptysis and dysuria d) Dyspnea and wheezing

d) Dyspnea and wheezing

A client postoperative hip replacement is prescribed a pillow between the legs. Which position will this pillow serve for the client? a. Circumduction b. Adduction c. Flexion d. Abduction

d. Abduction

Modification of lifestyle behaviors to help manage hypertension does not include which of the following? a. Weight loss of even 10 pounds b. The DASH diet c. Fruits, vegetables, and whole grains d. Alcohol intake with meals

d. Alcohol intake with meals Rationale: Weight loss of even 10 pounds; fruits, vegetables, and whole grains; the DASH diet; and a daily exercise regimen will help reduce high blood pressure. Alcohol intake with meals should be reduced to help manage high blood pressure.

The nurse wants to further assess a client's radial pulse. What can be done to do this assessment? a. Conduct the Trendelenburg's test. b. Conduct the Babinski test. c. Conduct the manual compression test. d. Conduct the Allen's test.

d. Conduct the Allen's test.

A 47-year-old client says, "I don't want to develop osteoarthritis like both of my parents have." Which of the following can the nurse instruct this client? a. Calcium replacements will prevent the disorder. b. Nothing. The disorder is genetic. c. Taking over the counter analgesics will stop the progression of the disorder. d. Eating a well-balanced diet and regular exercise are the best defense.

d. Eating a well-balanced diet and regular exercise are the best defense.

Nurses can best help older clients prevent hypertension by teaching: a. Low-fat, low-cholesterol diets. b. The importance of exercise. c. How to handle stressful situations. d. How to maintain a normal blood pressure.

d. How to maintain a normal blood pressure. Rationale: Hypertension is a major risk factor for other cardiovascular conditions. In persons older than 50, systolic blood pressure greater than 140 mm Hg is a much more important cardiovascular disease risk factor than is diastolic blood pressure. The risk of cardiovascular disease, beginning at 115/75 mm Hg, doubles with each increment of 20/10 mm Hg. Answers 1, 2, and 3 are important elements to include in education of a patient with blood pressure elevation, and are included in the correct answer.

The nurse is preparing to assess a client's hip joints. Which of the following should the nurse expect to assess with this client? a. Slipping and gliding motion b. Flexion and extension only c. Rotation only d. Movement in all axes and planes

d. Movement in all axes and planes Rationale: In ball and socket joints, the ball-shaped head of one bone fits into the socket of another. This joint allows movement in all axes and planes, including rotation. The shoulder and hip joints are the only examples in the body.

A seven-month-pregnant female is sitting quietly in the waiting room, and her respiratory rate is 20 and shallow. What does this finding suggest to the nurse? a. She is using accessory muscles to breathe. b. She is in pending respiratory failure. c. She has a history of smoking. d. Nothing. This is normal.

d. Nothing. This is normal. Rationale: As the uterus enlarges during pregnancy, the pressure in the abdominal cavity also increases. As a result, diaphragmatic excursion is limited and can result in more rapid and shallow respirations.

In planning a patient education session, the nurse sees one area of focus for Healthy People 2010 is chronic obstructive pulmonary disease (COPD). Which of the following information should the nurse include in the education session to address this focus area? a. Identify those at risk c. Screening for environmental triggers d. Smoking cessation e. Develop action plans

d. Smoking cessation

An eight-month-pregnant female client tells the nurse, "I'm okay except I have a backache and I never had a backache before." Which of the following can the nurse instruct the client about this health concern? a. The baby's bottom is pressing on the spine. b. Once you develop a backache in pregnancy you will always have them. c. The baby's head is pressing on the spine. d. The center of gravity has shifted putting pressure on the lower spine.

d. The center of gravity has shifted putting pressure on the lower spine.

While palpating the posterior thorax of a client, the nurse notes increased fremitus. What does this finding suggest to the nurse? a. Nothing. This is a normal finding. b. The client has a thick chest wall. c. The client needs to speak up. d. The client could either have fluid in the lungs or have an infection.

d. The client could either have fluid in the lungs or have an infection.

A 33-year-old female client comes into the clinic with an edematous left calf that is painful to the touch, feels warm, and is red. Which of the following should be included in the focused interview of this client? a. How long have you had varicose veins? b. Have you had any facial swelling? c. Are you experiencing any emotional upset? d. What medications are you taking?

d. What medications are you taking?

what does the physical assessment include for musculoskeletal?

inspecting and palpating the joints, muscles, and bones, testing ROM. and assessing muscle strength

extension

movement in which a limb is placed in a straight position

circumduction

movement of a limb or extremity so that the distal end describes a circle while the proximal end remains fixed

abduction

movement of drawing away from the middle

adduction

movement of drawing toward the middle

pronation

movement that turns the palm down

supination

movement that turns the palm up

protraction

moving a body part such as jaw forward or anteriorly