quizzes for review for exam 3

shifting dullness

ascites

lymph edema

nonpitting unilateral edema

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?

"Try to avoid drinking too much coffee or other caffeinated fluids." To reduce the risk of osteoporosis, the nurse would instruct the client to avoid excessive caffeine or alcohol consumption; increase physical exercise or activity, especially weight-bearing activities; increase calcium intake to approximately 1000 to 1500 mg daily; and get adequate vitamin D to absorb calcium such as with sun exposure.

Inspection of a client's knee reveals swelling, and the nurse suspects that there is significant fluid in the knee. What test would the nurse perform to confirm the suspicion?

Ballottement test The ballottement test is used to detect large amounts of fluid in the knee. Phalen's test and Tinel's test would be used to assess for carpal tunnel syndrome. Lasegue's test is used to detect low back pain.

When explaining how the nurse would test graphesthesia, which of the following would the nurse include?

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. Graphesthesia is the ability to identify what is being drawn on the client's body when the client's eyes are closed. Two-point discrimination is tested by having the client identify the number of points felts when touched with the ends of two applicators at the same time. Extinction is tested by simultaneously touching the client in the same area on both sides of the body at the same points and having the client identify the area touched. Point localization is tested by briefly touching the client and then asking the client to identify the points touched.

When documenting the findings of a neurologic assessment, which of the following would be most important?

Describe the client's response. Although data verification is important, when documenting the neurologic assessment findings, it is important to describe the client's response rather than label the behavior. Subjective and objective data must be documented.

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.

Flexion Extension Pronation When testing the range of motion of the elbow joint, the nurse would test flexion and extension, and supination and pronation of the forearm. Abduction, rotation, and circumduction would be tested in the shoulder or the hip.

The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam?

Hop on one foot Hoping on one foot is often impossible for the older adult because of decreased flexibility and strength and may place the client at risk. The nurse needs to ensure the client's safety by standing close by, especially with tandem walking and Romberg testing, because some older clients may have difficulty with maintaining balance. However, these tests would not be omitted. Older clients may have a slow uncertain gait. This test, however, would not be omitted.

The nurse recognizes that a client who is actively practicing which of the following faiths may be opposed to blood transfusions, even in life threatening situations:

Jehovah's Witness

When examining a client with a rotator cuff tear, which of the following would the nurse expect to find?

Limited abduction Painful and limited abduction accompanied by muscle weakness and atrophy are seen with a rotator cuff tear. Chronic pain and limitation of all shoulder motion is seen with calcified tendonitis. Sharp catches of pain are associated with rotator cuff tendonitis.

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?

Low estrogen levels Modifiable risk factors include low estrogen levels. Small-boned thin frame, personal history of fractures, and age cannot be modified.

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. What would the nurse suspect?

Meningitis impaired range of motion and neck pain associated with fever, chills, and headache could be indicative of a serious infection such as meningitis. Cervical strain is characterized by impaired range of motion and neck pain. Compression fracture is characterized by pain and tenderness of the spinal processes and the paravertebral muscles. Cervical disc degeneration is associated with impaired range of motion and pain that radiates to the back, shoulder, or arms.

When reviewing the neural pathways, a group of students is identifying sensations that travel via the spinothalamic tract. Which sensations are carried by this tract? Select all that apply.

Pain Temperature Light touch Sensations of pain, temperature, and crude and light touch travel by way of the spinothalamic tract, whereas sensations of position, vibration, and fine touch travel by way of the posterior columns.

Which of the following would lead the nurse to suspect meningeal irritation?

Pain and flexion of the hips and knees with neck flexion Pain and flexion of the hips and knees are positive Brudzinski's signs and suggest meningeal irritation. Pain and increased resistance to extending the knee when the client's leg is flexed at both the hip and knee and then straightened is a positive Kernig's sign, suggesting meningeal irritation. Discomfort behind the knee during full extension when testing for Kernig's sign occurs in many normal people.

What would be most appropriate for the nurse to do when assessing motor function of a client's trigeminal nerve?

Palpate temporal and masseter muscles while client clenches the teeth. To test the motor function of the trigeminal nerve (CN V), the nurse asks the client to clench the teeth and palpates the temporal and masseter muscles for contraction. Touching the client's face for dullness or sharp sensations tests the sensory function of the trigeminal nerve. Having the client frown, smile, and wrinkle the forehead tests the motor function of the facial nerve (CN VII). Assessing pupillary dilation tests the oculomotor (CN III) nerve.

Examination of a client's gait reveals that the client is stooped over when walking and that he slowly shuffles. As well, the client maintains a stiff posture when walking. The nurse should document what type of gait?

Parkinsonian gait A parkinsonian gait is characterized by a shuffling gait with turns accomplished in a very stiff manner. The client also has a stooped-over posture with flexed hips and knees. A scissors gait involves thigh overlap. Spastic hemiparesis is characterized by dragging one toe. In foot drop, the client lifts the foot and knee high with each step, then slaps the foot down hard on the ground.

The emergency department nurse's rapid assessment of a young adult client admitted unresponsive reveals fixed, constricted pupils bilaterally. The nurse should consider what possible cause for this assessment finding?

Recent narcotic use Narcotics can cause fixed, constricted pupils. This abnormal finding is not typically associated with stroke, seizures, or cerebellar lesions.

The nurse is performing the Romberg test as part of a client's focused neurological assessment. What finding would constitute a positive Romberg test?

The client moves her feet apart to prevent herself from falling. The Romberg test assesses balance; swaying or repositioning during the test constitutes positive findings. The Romberg test does not address pain during neck flexion or teeth clenching. It does not require the client to touch the nose with a finger.

Which of the following would not be appropriate for the nurse to ask when beginning to assess a client's spirituality?

What religion are you?" "Do you believe in God?" "Would you like to speak to a chaplain?"

The nurse is assessing a client's ability to shrug her shoulders against resistance. The nurse is assessing which cranial nerve?

XI (11) Inability to shrug shoulders against resistance suggests a lesion of cranial nerve XI (spinal accessory nerve). Cranial nerve III is involved with extraocular eye movements. Cranial nerve V is involved with facial sensation. Cranial nerve VII is associated with facial muscles.

chronic obstructive pulmonary disease (COPD)

caused by airflow blockage and breathing-related problems

Fluid volume overload

congestive heart failure

intermittent claudication

cramping in the thighs after walking

fluid volume deficit

dehydration

palpitation

early, rapid, strong, or irregular heart beat due to agitation, exertion, or illness

peritoneal irritation

infection

When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be?

proximal to distal.