EAQ: 22&23
What characteristic feature does the nurse observe in a child with "pigeon toes?"
"Pigeon toes" is a condition in which the toes point inward while walking. Therefore, the child with "pigeon toes" tends to walk on the lateral side of the foot, and the longitudinal arch appears higher than normal. The child with genu varum tends to walk with a waddling gait. The child with "flatfeet" takes a broad-based stance. The child with genu valgum tends to stand with ankles apart and the knees touching.
The nurse is assessing a patient who has a sensory cortex lesion. The nurse instructs the patient to close the eyes and places a key in the patient's hand. The nurse finds that the patient is unable to identify the object by touch. Which clinical sign does the patient's response indicate?
A normal individual will be able to identify the object by touch, without seeing it. The patient with a sensory cortex lesion may have a decreased sensory perception. Astereognosis refer to the patient's inability to identify the object by touch. Rapid and rhythmic contractions of the same muscles indicate clonus. An abnormal, asymmetrical head or neck position is a sign of torticollis. Overactive or overresponsive reflexes indicate hyperreflexia in the patient.
A patient is given a score of 3 on the Glasgow Coma Scale. What does this score indicate?
A score of 7 or less on the Glasgow Coma Scale (GCS) indicates that the patient is in a comatose condition; a score of 3 is given to a patient who is totally unresponsive. A fully alert patient should have a GCS score of 15. The GCS is used to determine the functional state of the brain, not of any particular site in the brain. A patient who is able to obey commands would receive a GCS score of more than 6.
A patient reports a sudden and severe throbbing headache and right arm weakness. The nurse notices that the patient has facial drooping and stuttered speech. The MRI reports reveal the development of an atherosclerotic plaque formation in the middle cerebral artery. What condition in the patient could be associated with these findings?
A sudden and severe throbbing headache, arm weakness, and facial drooping indicate a cerebrovascular accident (CVA). The patient who is experiencing a CVA may also have difficulty in speaking. Atherosclerosis involves the formation of plaque on the inner walls of the arteries. This plaque may rupture and form a thrombus, which blocks the blood vessels of the brain, resulting in a thrombotic stroke. The patient with a silent stroke may not experience any symptoms of the stroke. Embolic stroke occurs due to the presence of an embolus or a movable clot in the blood vessels. This is common in the patients with atrial flutter or fibrillation. Hemorrhagic stroke may occur when there is bleeding from a weakened artery of the brain.
Which test helps to screen the gross and fine motor coordination skills of an infant?
The Denver II test helps to screen the gross and fine motor coordination skills in an infant. This test enables the nurse to assess whether the infant has achieved age-specific developmental motor skills. The nurse performs the Weber test to assess hearing ability of a patient. The Romberg test helps to assess the upright postural control in the patient. The nurse uses the heel-to-shin test to check the lower extremity coordination. These tests are performed in older children and adults.
How would an adult patient normally respond to the plantar reflex?
The normal response to plantar reflex is flexion of the toes and inversion and flexion of the forefoot. Extension of the big toe and fanning of all toes is an abnormal response; however, it is normal in infants. This positive Babinski sign occurs with upper motor neuron disease of the corticospinal or pyramidal tract. If the stretched tendons of the flexed knee are struck just below the patella, extension of the lower leg will be the expected response. This is the quadriceps reflex. In the brachioradialis reflex, the relaxed forearm is stroked directly, about 2 to 3 cm above the radial styloid process. The normal response will be flexion and supination of the forearm.
While assessing the deep tendon reflexes in a patient, the nurse finds that the responses are very brisk and hyperactive, with clonus. Which grade should the nurse enter in the patient's medical record?
The nurse assesses the deep tendon reflexes to determine the intactness of the reflex arcs at the specific spinal levels. The nurse measures the reflex response on a 4-point scale. The nurse documents very brisk and hyperactive responses with clonus as grade 4+. This indicates that the patient has an upper motor neuron lesion. Grade 3+ responses are brisker than the average response. The nurse records average and normal responses as grade 2+. The nurse documents a diminished reflex that occurs only with reinforcement as a grade 1+ reflex.
Which condition may cause decorticate posture in a patient?
The patient with lesions in the hemispheres of the cerebral cortex may show decorticate posture. Decorticate posture involves flexion of the arms, extension of the lower extremities, and plantar flexion. The patient with cerebral damage may have difficulties associated with memory and thinking. Due to differential functions of the midbrain and pons, a lesion in the midbrain and upper pons may result in decerebrate posture, but not decorticate posture.
While performing a head-to-toe assessment on a patient, the nurse instructs the patient to rest in a supine position. The nurse tells the patient, "Raise each leg and extend your knees." What is the nurse focusing on in this part of the assessment?
This portion of the assessment is focusing mainly on the hips. To check the flexion of hips, the patient first needs to rest in a supine position and then raise each leg and extend the knees. To test the functional mobility of the shoulders, the patient first moves both the arms forward and up in a wide vertical arc, and then moves the arms back at the sides with the elbows extended. Touching chin to chest and lifting the chin toward the ceiling tests the functionality of the cervical spine. The expected result of this test is to observe hip flexion of 90 degrees. This position cannot detect the viability of the knee joints, because the knees need to dangle to be assessed correctly.
The nurse is caring for a patient with swelling and tenderness at the anterior portion of the knee. The nurse observes that the affected skin is red and shiny. During examination, the nurse finds that the patient's range of motion is normal. What does the nurse infer from these findings?
Localized swelling on the anterior knee between the patella and the skin indicates prepatellar bursitis. The cause of prepatellar bursitis is trauma. Erythema occurs at the site due to capillary congestion. It does not affect the range of motion of the knee but will cause discomfort while moving the knee joint. Range of motion is restricted in cases of rheumatoid arthritis. Synovial thickening is a sign of synovitis, or inflammation of the synovial membrane, and it causes difficulty moving the joint. Osgood-Schlatter disease refers to inflammation of the patellar ligament. A painful lump below the knee is the characteristic sign of Osgood-Schlatter disea
What are the different functions of cartilage?
Cartilage is connective tissue that covers the surface of opposing bones in synovial joints. It cushions the bone, aiding in movement and providing stability to the musculoskeletal structure. Cartilage also smooths the surface of the bone, facilitating movement. Cartilage receives nourishment from the synovial fluid during joint movement and does not provide nourishment for the synovial fluid.
"Pigeon toes" is a condition in which the toes point inward while walking. Therefore, the child with "pigeon toes" tends to walk on the lateral side of the foot, and the longitudinal arch appears higher than normal. The child with genu varum tends to walk with a waddling gait. The child with "flatfeet" takes a broad-based stance. The child with genu valgum tends to stand with ankles apart and the knees touching.
Cranial nerve X is also known as the vagus nerve, and it innervates the heart and the digestive tract. The patient with bilateral lesions on the vagus nerve may have difficulty swallowing, and the fluids may be regurgitated through the nose. Cranial nerve XII, which is also known as the hypolossal nerve, innervates the tongue and controls the movement of the tongue. Therefore, the patient with a cranial nerve XII lesion may have a slow rate of movement of the tongue. Cranial nerve V, which is also referred to as the trigeminal nerve, innervates the muscles of the jaw. Therefore, the patient with a unilateral cranial nerve V lesion may have weakness of the jaw muscles. Cranial nerve III, which is also referred to as the oculomotor nerve, innervates the muscles of the eyeball. Therefore, the patient with cranial nerve III paralysis may have dilated pupils and ptosis, or drooping eyelids.
During the assessment of a patient, the nurse finds that the distal part of the great toe is directed away from the body's midline. Which complication is present in the patient?
Generally, the toes point straight forward and lie flat. Hallux valgus is a deformity in which the great toe deviates away from the medial prominence of the head of the first metatarsal. The patient with polydactyly has extra fingers or toes. Crepitation refers to the audible and palpable crunching sound that occurs while moving the joints. The patient with carpal tunnel syndrome may have a burning and tingling sensation in the joint.
What does the nurse tell a patient with carpal tunnel syndrome when performing the Phalen test?
In carpal tunnel syndrome, atrophy occurs in the median nerve of the wrist and the hand that causes pain, burning, and numbness. During the Phalen test, which is used to assess if a patient has carpal tunnel syndrome, the nurse asks the patient to hold the wrist in acute flexion for 60 seconds. The nurse should ask the patient to bend forward and touch his or her toes while checking the range of motion of the spine. The nurse should ask the patient to flex the knee and hip to 90 degrees while checking the range of motion of the hip. The nurse asks the patient to rotate the arms behind the back while checking the range of motion of the shoulders.
Which statement describes decerebrate rigidity?
In decerebrate rigidity, the upper extremities of the patient are stiffly extended and adducted. The palms are pronated, the teeth are clenched, and the back is hyperextended. It indicates a lesion in the brainstem at the midbrain or upper pons. In decorticate rigidity, the arms are flexed and adducted (i.e., tight against the thorax), and the legs are extended with plantar flexion. This indicates a hemispheric lesion of the cerebral cortex. In flaccid quadriplegia, complete loss of muscle tone and paralysis of all four extremities occur. It indicates a completely nonfunctional brainstem. Prolonged arching of the back, with the head and heels bent backward, is a symptom of opisthotonos. This indicates meningeal irritation.
The nurse is caring for a 5-month-old baby who has a hip dislocation. Which physical assessments does the nurse perform to confirm the diagnosis of hip dislocation?
In hip dislocation, the head of the femur is displaced out of the cup-shaped acetabulum. In the Allis test, the nurse compares the lengths of both legs. If the nurse finds that one leg is significantly shorter than the other, it is a positive indication of the Allis sign, and this suggests hip dislocation. The nurse flexes the knees and the hip joint of the patient while performing the Ortolani test. If the nurse hears a clunk sound as the head of the femur pops back into place, it is a positive Ortolani sign, which suggests hip dislocation. The nurse performs the Tinel test and Phalen test to confirm carpal tunnel syndrome. The nurse performs the Lasegue test to confirm herniated nucleus pulposus.
An elderly patient complains of stiffness in the knee joints and severe pain with motion. On further assessment, the nurse learns that the patient has joints with a hard bony protuberance on the joint. What can the nurse suspect from the findings?
In osteoarthritis, joints show stiffness and swelling. Osteoarthritis manifests as hard, bony protuberances along with pain and limitation of motion. Osteoarthritis is a noninflammatory, localized, progressive disorder involving deterioration of articular cartilage and subchondral bone. Ankylosing spondylitis is a chronic, progressive inflammation of the spine and sacroiliac joints. Subcutaneous nodules are raised, firm, nontender nodules that occur with rheumatoid arthritis. Gouty arthritis manifests as a bulge or fullness in grooves on either side of the olecranon process. The bulge caused by gouty arthritis is manifested differently than that of osteoarthritis.
Which complication may occur due to a decrease in the blood supply to the femoral epiphysis?
Inadequate blood supply to the femoral epiphysis may cause necrosis of the femoral head, resulting in Legg-Calve-Perthes syndrome, or coxa plana. Spina bifida occurs due to incomplete closure of the posterior vertebrae. Talipes equinovarus, or clubfoot, occurs due to genetic or environmental factors, such as exposure to cigarette smoke. Congenital hip dislocation refers to the displacement of the femoral head out of the acetabulum. Decreased blood supply to the femoral head will not cause hip dislocation.
What are the characteristics of lower motor neuron lesions?
Marked muscular atrophy occurs mostly due to lower motor neuron lesions, whereas upper motor neuron lesions may cause little or no atrophy. Fasciculation refers to rapid and continuous twitching of the muscles. This occurs due to muscular atrophy and muscle weakness in a patient with lower motor neuron lesions. Spasticity refers to hypertonicity of the muscles. Lower motor neuron lesions may lead to hypotonia of the muscles, resulting in flaccidity. Lower motor neuron lesions may result in hyporeflexia or areflexia, but not hyperreflexia. Lower motor neurons do not control superficial reflexes such as the abdominal reflex. Loss of superficial abdominal reflexes may occur in the patient with upper motor neuron lesions.
While assessing the muscles around the wrist joint of a patient, the nurse finds full range of motion against gravity and some resistance. Which grade should the nurse document in the patient's medical record?
Muscle testing helps in assessing the strength of the muscles around the joints. The nurse documents the grade as 4 when there is full range of motion against gravity and some resistance. The nurse documents the grade as 1 when there is a very slight contraction. The nurse documents the full range of motion and passive motion as grade 2. Grade 3 indicates full range of motion with gravity and without resistance.
The nurse is caring for a patient who has numbness on one side of the spine and decreased function of the left leg. During the physical examination, the nurse observes that the patient has lateral tilting and forward bending of the spine. Which test helps the nurse assess the patient's condition?
Numbness on one side of the spine and decreased function of the leg indicate sciatic pain in the patient. The patient with a herniated nucleus pulposus or sciatic pain may have lateral tilting and forward bending of the spine. The Lasegue test helps determine the presence of a herniated nucleus pulposus in the patient; the patient with this condition will have pain while lifting the leg. The Phalen test helps confirm carpal tunnel syndrome. The Thomas test helps detect flexion deformity. The forward bending test helps assess scoliosis in the patient.
The nurse is caring for a patient who has resting tremors and abnormally slow movement. The nurse also observes flat expression, reduced eye blinking, and slouched posture in the patient. What reason does the nurse expect for these findings in the patient?
Resting tremors, slow movement, or bradykinesia, flat expression, reduced eye blinking, and slouched posture indicate parkinsonism in the patient. It is a neurodegenerative disease of the central nervous system. It occurs due to the degeneration of the dopaminergic neurons in the substantia nigra of the brain. Damage to the cerebral cortex may cause cerebral palsy, but not parkinsonism. The patient with cerebral palsy may have seizures, but not resting tremors. Damage to the corticospinal tract and degeneration of the upper motor neurons may result in hemiplegia, which refers to the contralateral paralysis of the upper and lower limbs. The patient with hemiplegia will not necessarily have slouched posture. The patient with hemiplegia may have a posture characterized by an adducted shoulder, flexed elbow, pronated wrist, and extended leg.
The nurse is caring for a patient who reports redness, swelling, and painful motion of the knee and ankle joints. While palpating, the nurse observes crepitation. What does the nurse infer from these findings?
Rheumatoid arthritis is characterized by redness, swelling, and painful motion of the affected joints. An audible and palpable crunching during the movement is called crepitation; this occurs due to the roughening of articular surfaces of the joints. Inflammation and swollen joints do not characterize osteoporosis. Osteoporosis refers to the increased loss of bone matrix, leading to an increased risk for fractures. Osteoarthritis is a noninflammatory disease. Ankylosing spondylitis manifests as the inflammation of spine and sacroiliac joints, but not the knee and ankle joints.
A patient who had a stroke is experiencing a severe throbbing headache, vomiting, and focal seizures. After reviewing the medical reports of the patient, the nurse confirms that the patient had a hemorrhagic stroke. Which condition could have caused the stroke?
Severe throbbing headache, vomiting, and focal seizures indicate a stroke in the patient. The patient with hemophilia will have a defect in the coagulation cascade. Therefore, any hemorrhage in the brain may lead to hemorrhagic stroke due to the defect in the clotting mechanism. Endocarditis and atrial fibrillation may lead to the formation of a moving clot or embolus in the blood vessels. Atherosclerosis may lead to the formation of a thrombus in the blood vessels. Therefore, endocarditis, atrial fibrillation, and atherosclerosis are associated with ischemic stroke, but not hemorrhagic stroke.
While assessing an adult patient, the nurse observes stiff extension of the upper and the lower extremities, clenching of the teeth, and hyperextension of the back. What could be the cause of these findings in the patient?
Stiff extension of the upper and lower extremities, clenching of the teeth, and hyperextension of the back indicate decerebrate rigidity in the patient. A lesion in the upper pons of the midbrain may lead to the loss of certain motor reflexes, resulting in decerebrate rigidity. The patient with meningeal irritation may have an opisthotonos posture, but not decerebrate rigidity. Opisthotonos posture refers to the prolonged arching of the back with the head and heels bent backwards. Lesions in the cerebral cortex may cause decorticate rigidity, but not decerebrate posture. Decorticate rigidity is characterized by flexion of the arm, wrist, and fingers; adduction of the arm; and extension of the lower extremities, along with plantar flexion.
The nursing instructor is teaching a class on the types of joints. Which statement by the student nurse about synovial joints indicates effective learning?
Synovial joints are freely movable joints. The bones in a synovial joint are separated from each other and are enclosed in the synovial cavity with synovial fluid inside. The bones in nonsynovial joints are united by fibrous tissue or cartilage. The bones comprising nonsynovial joints are immovable. Some nonsynovial joints can move very slightly, and the bones are joined with cartilage.
After assessing a 3-year-old child, the nurse suspects pyramidal tract disease. Which finding is consistant with this condition?
The Babinski reflex is present at birth and disappears by the age of 24 months. The presence of a Babinski reflex after 2 or 2.5 years of age indicates that the child has impaired function of the pyramidal tract. The child with pyramidal tract disease may have decreased functioning of the spinal cord. Extension of the limbs is a sign of intracranial hemorrhage. The presence of a Moro reflex after 5 months of age indicates severe central nervous system injury. However, central nervous system injury may not lead to pyramidal tract disease in the child. Asymmetry of the upper limb movements indicates brachial plexus palsy, not pyramidal tract disease.
Which areas of consciousness would a nurse rate while assessing a patient with the Glasgow Coma Scale?
The Glasgow Coma Scale is an accurate and reliable quantitative tool that defines the level of consciousness by giving it a numeric value. The scale is divided into three areas: eye opening, verbal response, and motor response. Each area is scored separately. The total score reflects the functional level of the brain. A fully alert healthy person has a score of 15, whereas a score of 7 or less reflects coma. Although assessments of the vital signs are important for a critically ill person, pulse rate and blood pressure are unreliable parameters of central nervous system deficit. Any changes are late consequences of rising intracranial pressure.
How would a patient respond normally to the brachioradialis reflex test?
The brachioradialis reflex originates at cervical vertebrae 5 and 6. The nurse holds the patient's thumbs to suspend the forearms in relaxation. The forearm is stroked directly, about 2 to 3 cm above the radial styloid process. The normal response is flexion and supination of the forearm. When the stretched tendons of the flexed knee are stroked below the patella, extension of the lower leg is the expected response. This is the quadriceps reflex. Wrist drop, also known as radial nerve palsy, is a condition in which a patient cannot extend the wrist, and it hangs flaccidly. Dyskinesia is repetitive stereotyped movements in the jaw, lips, or tongue. It is generally accompanied by senile tremors.
What should the patient's response be when the nurse tests the cremasteric reflex?
The cremasteric reflex is a male reflex. If the nurse lightly strokes the inner aspect of the patient's thigh with a reflex hammer or tongue blade, elevation of the scrotum should occur. Contraction of the quadriceps muscle occurs when the quadriceps reflex is tested. The anal wink or the anal reflex is the reflexive contraction of the external anal sphincter that is caused by stroking the skin around the anus. Stroking the lateral part of the sole of the foot with a sharp object produces plantar flexion of the big toe. This normal response is called the flexor plantar reflex.
A patient has a lateral curve of the thoracic and lumbar segments while standing, and the nurse observes that the curve disappears when the patient is bending. What cause does the nurse expect for this condition in the patient?
The forward bend test helps screen for scoliosis. There are two types of scoliosis: functional, which is flexible and structural, which is fixed. In functional scoliosis, the curve appears while standing and disappears when bending. The difference in length of the legs may cause functional scoliosis in the patient. Hip dislocation will not cause scoliosis in the patient. A forward bend in the spine will not cause scoliosis in the patient; this may be due to a herniated nucleus pulposus. Rotation of the vertebral bodies is characteristic of structural scoliosis.
What is the major function of the glossopharyngeal nerve?
The glossopharyngeal nerve is cranial nerve IX. Its major motor function is to help in swallowing. The gag reflex, also known as a laryngeal spasm, is a reflex contraction of the back of the throat, evoked by touching the roof of the mouth, the back of the tongue, the area around the tonsils, and the back of the throat; the sensory limb of cranial nerve IX predominantly mediates this reflex. Lateral movement of the eye is controlled by the abducens nerve, or cranial nerve VI. The sensory part of the vagus nerve (cranial nerve X) contributes to the ability to taste. The hypoglossal nerve (cranial nerve XII) controls the muscular movement of the tongue.
The nurse is assessing a patient who is on long-term therapy for seizures. An assessment shows that the patient has a staggering gait and a positive Romberg sign. Which medication could cause these complications?
The health care provider may prescribe sedative medications such as barbiturates for the patient who is on long-term therapy for seizures. The cerebellum controls the balance and motor functions. Barbiturates such as phenobarbital (Luminal) directly act on the cerebellum and decrease its activity. Therefore, the patient who is on long-term barbiturate therapy may have a staggering gait and impaired balance, or positive Romberg sign. Anticonvulsant drugs such as phenytoin (Dilantin) are antiseizure medications that help to treat epilepsy or seizure disorder. Inability to sleep, weight loss, and decreased appetite are side effects of these drugs. Chlorpromazine is an antipsychotic medication; it may not be present in the prescription of a patient who has seizures. Dopaminergic drugs such as levodopa (Sinemet) increase the dopamine levels in the brain; they do not depress the cerebellum. Therefore, they do not cause staggering gait and impaired balance in the patient.
The nurse is caring for a patient with a seizure disorder. The nurse observes that the patient is in the tonic phase of a generalized seizure. Which findings enabled the nurse to reach such a conclusion?
The nurse is caring for a patient with a seizure disorder. The nurse observes that the patient is in the tonic phase of a generalized seizure. Which findings enabled the nurse to reach such a conclusion?
A patient with a history of a knee injury reports local pain in the knee. What action should the nurse take?
The nurse performs the McMurray test if the patient with a knee injury history reports local knee pain, because the patient will be at risk for a torn meniscus. The Phalen test helps determine carpal tunnel syndrome. The Thomas test helps diagnose flexion deformity. The bulge sign and ballottement of the patella help detect the accumulation of fluid in the joint space.
The nurse asks the patient to close the eyes and then places a paper clip on the patient's palm. The patient is asked to recognize the object. Which test is the nurse performing?
The stereognosis test determines the patient's ability to recognize familiar objects by feeling their forms, sizes, and weights without seeing them. In graphesthesia, a number is traced on the skin to test the patient's ability to "read" it. Graphesthesia is a good measure of sensory loss if the patient cannot make the hand movements that are needed for stereognosis. Such a problem may occur with arthritis. The nurse simultaneously touches both sides of the patient's body at the same point to perform the extinction test. Normally, both sensations are felt. The ability to recognize only one of the stimuli occurs with a sensory cortex lesion. The stimulus is extinguished on the side opposite to the cortex lesion. The discrimination test measures the discrimination ability of the sensory cortex.
While assessing a patient, the nurse firmly strokes the medial aspect of the knee two to three times and taps the lateral aspect of the knee. What does the nurse learn from this assessment technique?
To assess swelling in the suprapatellar pouch, the nurse will check for the bulge sign that confirms the presence of small amounts of fluid as the nurse tries to move the fluid from one side of the joint to the other. To detect large amounts of fluid in the patellar region, ballottement of the patella is a reliable test. The left hand helps compress the suprapatellar pouch to move any fluid into the knee joint. The right hand helps push the patella sharply against the femur. The Phalen test reproduces numbness and burning in a person with carpal tunnel syndrome and is a disorder of the wrist. The patient needs to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of a normal wrist for 60 seconds produces no symptoms in a normal hand. In carpal tunnel syndrome, percussion of the median nerve produces burning and tingling along its distribution, which is a positive Tinel sign.
