FHA EXAM 4

The nurse is assess a young woman who has sprained her left ankle. What is the definition of a sprain?

A stretched or torn liganment

A client who hit his head after falling from his roof has a Glasgow Coma Scale score of 15. Based on this information, the nurse expects the client to be

Alert and oriented

The nurse is assessing a patient's gait. Which factors should the nurse observe as the patient ambulates in the room? Select all that apply.

Arm swing Stride Posture Base of support

The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding?

Astereognosis

While the nurse performs formal patient patients with ADLS. When discussing care for a patient with low back pain. the nurse should particularly alert the assistant to watch fr assessment. assistive personnel often observe changes when obtaining vital signs or assisting

Bowel or bladder incontinence

A nurse is assessing an adult who is comatose after a head injury. In response to stimulus he has spastic muscle tone with flexion of the upper limbs and extension of the lower body. How would this be described?

Decorticate posturing

The nurse is educating a patient on the effects of prolonged immobility. What physiologic changels) would the nurse describe to Mr. Russell? (Select all that apply)

Decreased muscle mass Increased muscle catabolism Development of deep vein thrombosis Decreased muscle protein synthesis Bone demineralization

Which of the following describes Parkinson's Discase?

Deficit of dopamine and degeneration of the basal ganglia

The nurse is completing a health history on a patient reporting musculoskeletal pain. Which questions would be appropriate for the nurse to include in the interview? Select all that apply.

Do you exercise regularly? What type of job do you have? Have you had any recent weight gain? Have you experienced any previous injuries to your joints? What medications are you currently taking?

A client is admitted completely immabilized by an acute exacerbation of multiple sclerasis. Two days after admission. the client cries frequently and refuses to see family members. For this client, the nurse identifies a nursing diagnosis of Hopelessness. To address this diagnosis, which intervention should the nurse include in the client's care plan?

Encourage the client to verbalize his feelings

The nurse is completing passive range-of-motion on a stroke victim. What movements would the nurse expect to complete at the elbow joint?

Flexion, extension, supination, pronation

Which of the following assessment tasks can you appropriately delegate to an unlicensed care provider?

Height. weight, and vital signs

The nurse performs BP screening at the local community center. As part of the health promotion intervention, the nurse also discuss the following risk factors for stroke:

High BP, diet high in fat, and smoking

The nurse is educating a patient on how to prevent falls. Which statement. if made by the patient, indicates that he understood the teaching?

I should press my call light when I want to get out of bed

A patient who suffers from Amyotrophic lateral sclerosis (ALS) is learning information about it. What statement by the patient would indicate he needs more teaching?

Neuromuscular junctions are destroyed

What is the expected response when testing the Achilles Tendon reflex?

Plantar flexion of the ankle joint

A patient has had a spinal cord injury that resulted in permanent paralysis of his lower body (paraplegial. This condition causes immobility and places him at risk for which of the following complications? Select all that apply

Pressure ulcers Contractures Bowel and bladder incontinence

What is the purpose of the blood brain barrier?

Prevents potential toxins from entering the brain

The nurse is educating Ms. Johnson's mother on how to effectively provide passive range-of-motion (ROM) exercises. Which instruction will have the greatest impact on the patient's potential risk for injury?

Provide the affect joint with support during exercise

The nurse is caring for a patient newly admitted with a spinal cord injury. What is the primary goal the nurse will focus on after the patient has been physically stabilized?

Reduce the amount of cellular injury and death

Which topics will the nurse include when preparing education for a patient who has experienced a complete spinal cord separation injury at the T8 level? (Select all that apply)

Respiratory distress Risk of pressure ulcers Risk of deep vein thromnboses

For a client with a compound fracture, which nursing diagnosis should the nurse give the highest priority?

Risk for infection

A patient in a nursing home was admitted with a diagnosis of dementia. He started a fire because he was cooking at home and forgot that he left a pan on the stove. The nursing diagnosis that is highest priority is:

Risk for injury

The nurse is using the Morse Fall Scale to determine a patient's fall risk. What variable(s) will the nurse assess by using this tool? (Select all that apply)

Secondary diagnosis Presence of IV History of falls-

A 47-year-old woman states she is having vertigo and some difficulty with balance. The nurse should assess

The whisper test

The nurse is assessing a patient for fall risk. Which factors would place the patient at a higher risk for falls? Select all that apply.

Use of more than four prescription medicines Depression Gait or balance impairment

A 26-year old man was in a motor vehicle accident and sutfered a complete spinal cord injury to L3. The nurse asses the patient for loss of motor function in the

legs

The nurse will identify both active range of motion (ROM) and physical exercise as an important part of the continuous treatment for a paraplegic patient. What is the primary goal for these interventions?

Maintaining as much movement and upper body strength as possible

The nurse is assessing the muscle strength in the patient's left hand and notes active motion against some resistance. How would the nurse document this finding?

4

What type of ROM is used to assess muscle strength?

Active-resisted

Although a full mental status examination may not be required during a neuro assessment, you must be aware of the four main categories of the assessment while performing the health history interview and general survey. Which of the following contains the names of the four categories?

Appearance. behavior. cognition, and thought processes

You note that an adolescent has uneven shoulder height. To differentiate functional from structural scoliosis, you would ask the patient

Bend forward at the waist while you palpate the spine.

The nurse is assessing flexion in Mr. Russell's hip. What instructions would the nurse give to Mr. Russell to complete this assessment?

Bend your knee to your chest, and then putt it against your abdomen.

Tje nurse is assessing an early-adult aged man who complains of instability in his right knee. what structure is the most likely cause of knee instabilityif it becomes injured or diseased.

Cruciate ligaments within the knee

The nurse is completing passive range-of-motion (ROM) exercises and bends the patient's foot so that the toes point upward. Which joint movement has the nurse performed?

Dorsiflexion

The nurse is assessing a patient's range of motion and notes a limitation in the movement of the elbow joint. Which tool would the nurse use to measure the degree of movement in the joint?

Goinometer

A patient diagnosed with a cerebrovascular accident has CAT scan results that showed a burst aneurysm present in the middle cerebral artery. What type of CVA did this patient have?

Hemorchagic

When performing an assessment, a nurse identifies the following signs and symptoms: impaired coordination, decreased muscle strength, limited range of motion, and the client's reluctance to more. Which nursing diagnosis do these signs and symptoms indicate?

Impaired physical mobility

A patient who has had a stroke causing right side hemiplegia asks the nurse. "What is the purpose of these passive range-of-motion (ROM) exercises? I can move my own arms and legs? What is the best response by the nurse?

Passive range-of-motion exercises will help you to maintain mobility in your joints

During an assessment of muscle strength, the patient is unable to effectively move the legs individually against the resistance provided by the nurse. Which instruction will the nurse provide to continue to evaluate the patient's muscle strength?

Please lift your leg up off of the exam table

If the great toe extends upward and the other toes fan out in response to stroking the lateral aspect of the sole of the foot, this is documented as which of the following?

Positive Babinski sign

When the nurse asks a 58-year-old patient to stand with féet together, arms at his side. and his eyes closed, he starts to sway a moves his feet farther apart. How is this finding documented?

Positive Romberg sign

A nurse is caring for a client with a recent diagnosis of amyotrophic lateral sclerosis. Which of the following psychosocial issues should the nurse encourage the client to discuss when appropriate? Select all that apply.

Possibility about losing mobility Anger about his diagnosis Fears about losing mobility

Which term describes the loss of motor function from a transection injury to the cervical region of the spinal cord?

Quadriplegia

A patient with a spinal cord injury and paraplegia requires intermittent bladder catheterization every 4 hours. Which nursing intervention is needed for the management of a commonly associated complication?

Record the amount and color of urine emptied from the bladder at each catheterization

A client, gravida 1. para 0, is 9 weeks pregnant. She states,"I can't believe l'm pregnant. I just started a new job!" What is the most accurate evaluation of the statement?

She is expressing ambivalence

A nurse is assessing a patient's muscle tone. The patient was asked to relax his muscles as much as possible. The nurse palpates the bodies of the muscles being tested, following with passive range of motion. Which result would the nurse expect to find?

Soft muscles, with mild, even resistance to movement

The patient's muscle tone is hypertonic so the muscles are stiff and the movements are awkward. The nurse documents these findings as

Spasticity

Use of the Glasgow Coma Scale (GCS) provides relatively objective of the Level of Consciousness (LOCI. The three functions assessed are:

Verbal response. eyeopening, and motor response

The chart states that a 62-year-old woman has had a stroke in the right parietal area of the brain. The nurse expects to note which of the following?

Weakness in the left arm