Saunders - Assessment Techniques, Musculoskeletal, Neurological

The nurse is performing a neurological assessment on a client with a head injury. The nurse should use which technique to assess the plantar reflex?

Stroking the foot from the heel to the toe

The clinic nurse is preparing to assess the client's apical pulse. The nurse correctly palpates over which area? Click on the image to indicate your answer.

1. left center of your chest, just below the nipple

The nurse is performing a physical assessment of a client's musculoskeletal system and notes that the client is right-handed. The nurse would document which assessment findings as normal? Select all that apply.

2.Muscle strength graded 5/5 3.Symmetrical movements bilaterally 4.Increased muscle size on the dominant arm 5.A 1-cm hypertrophy of the right upper arm

The nurse performs a physical assessment on a client and gathers both subjective and objective data. Which would the nurse document as subjective data?

Client reports difficulty sleeping at night.

The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation?

A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed

The nurse is preparing to test the sensory function of cranial nerve V in a client. The nurse should obtain which item to test the sensory function of this nerve?

A wisp of cotton

The nurse is planning to test the sensory function of the olfactory nerve (cranial nerve 1). The nurse would gather which items to perform the test?

Cloves, peppermint, and soap

The emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion?

Difficulty walking

The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique?

Holding the sides of the client's great toe and, while moving it, asking what position it is in

The nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets this to mean that the client has which condition?

Pronator drift

The nurse is testing the coordinated functioning of cranial nerves III, IV, and VI. To do this correctly, what should the nurse test?

The 6 cardinal fields of gaze

The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?

The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?

The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

The nurse prepares to take the blood pressure of a school-age child. To obtain an accurate measurement, how should the nurse position the blood pressure cuff?

Two thirds of the distance between the antecubital fossa and the shoulder

The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II?

Snellen chart

The registered nurse (RN) is educating a new RN on conducting a problem-based or focused assessment on a client. Which statement by the new RN indicates that the teaching has been effective?

"This is mostly used in a walk-in clinic or emergency department."

A 52-year-old male client is seen in the primary health care provider's (PHCP's) office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 ft, 8 in (173 cm) and his weight is 220 lb (99.8 kg). Vital signs are as follows: temperature, 98.6º F (37º C) orally; pulse, 86 beats/min; and respirations, 18 breaths/min. The blood pressure reading is 184/100 mm Hg. A random blood glucose level is 122 mg/dL (6.8 mmol/L). Which question should the nurse ask the client first?

"When was the last time you had your blood pressure checked?"

The nurse is caring for a pediatric client who just arrived at the emergency department with an extremity fracture. The nurse uses the 5 "Ps" to assess the extent of the client's injury. What are some of the 5 "Ps"? Select all that apply.

1.Pallor 2.Pain and point of tenderness 3.Paralysis distal to the fracture site 5.Sensation distal to the fracture site

The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data?

Ask the client to follow the flashlight through the 6 cardinal positions of gaze.

The nurse is conducting a neurological assessment, including a health history, on a client with a neurological disorder. The nurse observes that the client is having difficulty answering the questions and should perform which action?

Ask the client to give permission for a family member to stay during the interview.

Which action would the nurse take to test cranial nerve XI, the spinal accessory nerve?

Ask the client to shrug the shoulders against the nurse's resistance.

The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/min. On the basis of this finding, which action is most appropriate?

Document the findings

The nurse should ask a client to take which action when testing the function of the spinal accessory nerve (CN XI)?

Elevate the shoulders.

A home care nurse is assessing a client's activities of daily living (ADLs) after a stroke. What should the nurse include in the client's focused assessment?

Self-care needs such as toileting, feeding, and ambulating

The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve?

Separate the client's jaw by pushing down on the chin.