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Exam VI studyguide
Health Assessment
| Question | Answer |
|---|---|
| A patient is being assessed for range of joint movement. You ask him to move his arm in towards the center of his body. This movement is called: | adduction |
| During your assessment of the cranial nerves, you find the following: lack of blink in right eye with corneal reflex; inability to sense light touch on face; asymmetry in jaw movement. This would indicate dysfunction of which of following cranial nerves? | Cranial nerve V |
| The RN is assessing a patient's reflexes. The RN supports the patient's upper arm and strikes the tendon just above the elbow. This is done to assess which of the following reflexes? | The triceps reflex. |
| A patient has just arrived in the surgical recovery room following bronchoscopy. The RN will be assessing for return of the gag reflex. This is checking the status of: | cranial nerves IX/X |
| When doing the history on a patient with a seizure disorder, you are assessing whether she has an aura. Which of the following would be the best question for obtaining this information? | "Do you have any warning sign before your seizure starts?" |
| A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform the following movement: | Flexion |
| Which of the following scores would indicate that a patient is in a coma, based on the criteria of the Glasgow Coma Scale? | 6 |
| The temporomandibular joint can be palpated by placing the fingers in the depression: | anterior to the tragus of the ear. |
| You are assessing the neurologic status of a patient following a head injury. You note that the patient's left pupil fails to constrict when a penlight is directed across the eye. This would indicate dysfunction of which of the following cranial nerves? | Cranial nerve III |
| Assessment: 29 yr old; always dropping things; falling down. Ask person pat knees w/both hands, lift up, turn hands over, & pat knees w/backs of hands. Instructed to repeat process several times & as rapidly as possible. Notice un | rapid alternating movements. |
| You suspect that a patient has carpal tunnel syndrome, and so you ask her to perform Phalen's test. To perform this test, she would: | hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. |
| When you ask your 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet further apart. You would document this as a(n): | positive Romberg's sign. |
| Which of the following statements is accurate concerning areas of the brain? | The hypothalamus controls temperature and regulates sleep. |
| To test cranial nerve XII, instruct the patient to: | stick out their tongue and move it side to side. |
| In order to assess cranial nerve VIII, the RN will: | perform a "whisper test" to check for hearing acuity. |
| You are testing the function of cranial nerve XI. Which of the following best describes the response you would expect if the nerve is intact? | Moves the head and shoulders against resistance with equal strength |
| During the history, a patient tells you that "it feels like the room is spinning around me." You would document this as: | vertigo |
| The nurse is explaining to a patient that there are "shock absorbers" in his back to cushion the spine and to help it move. The nurse is referring to his: | Intervertebral discs |
| The RN instructs the patient to hold their forearm in the position of supination. This would include the following movement: | turning the hand so that the palm is facing upward. |
| Mrs. B. comes in for an evaluation and states, "I have noticed a round bump on the back of my wrist." The RN finds a cystic, nontender nodule on the dorsum of the wrist and tells her: | "That is a ganglion cyst." |
| A 30-year-old woman tells you she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain would you be concerned about with these findings? | Cerebellum |
| A patient states that "she can hear a crunching or grating sound" when she kneels. Passive ROM maneuvers of the knee reveals a rough, grating palpable quality. You suspect the sound the patient hears is: | crepitation |
| Hematopoiesis takes place in the: | bone marrow. |
| A 70-year-old female tells you that every time she gets up in the morning or after she's been sitting she gets "dizzy." What would be your response? | "You need to get up slowly when you've been lying or sitting." |
| Shoulder pain should be investigated closely as it may be from local causes or it may be due to a cause such as hiatal hernia or a cardic or a pleural condition, which could be potentially dangerous. This pain from another location is called: | referred pain. |
| A nursing home resident has fallen in the hallway. The RN arrives at the patient's side to assess for possible hip fracture. The RN should check for: | leg length discrepancy. |
| Mrs. A. has had rheumatoid arthritis for years and is starting to notice that her fingers are drifting to the side. This is commonly referred to as: | ulnar deviation. |
| The shoulder joint is enclosed by a group of four powerful muscles and tendons that support and stabilize it called the: | rotator cuff. |
| The RN notes loss of muscle mass and a lack of fullness surrounding the deltoid muscle. This is documented as: | atrophy |
| The two parts of the nervous system are the: Question 30 answers | Central and peripheral |
| Mrs. S complains of pain in her calf muscles which occurs when she walks much of a distance but subsides with rest. The RN suspects: | intermittent claudication. |
| In order to test for strength of the ankle and foot, the nursing student instructs the patient to point their toes towards the floor while the student is applying resistance against the movement. This movement is called: | plantar flexion. |
| A patient complains of wrist pain. In order to assess range of motion, the RN instructs the patient to turn the forearm so that the palm is down. This movement is called: | pronation |
| A patient who has had osteoarthritis for years comes to the clinic to ask about changes in her hands. The nurse knows that changes associated with osteoarthritis include: | Bouchard's nodules |
| Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called: | Ligaments |
| An 85-year-old gentleman comes to you for information on why he seems to be getting shorter as he ages. You would explain that decreased height occurs with aging because: | of the shortening of the vertebral column. |
| Assessment of 80 yr old, you note following: inability to identify vibrations at ankle, identify position of big toe; slower & more deliberate gait; slightly impaired tactile sensation. All other neurologic findings normal. What's assessment of findings? | Normal changes due to aging |
| A patient is complaining of pain in his joints that is worse in the morning, is better after he has moved around for awhile, and then gets worse again if he sits for long periods of time. The nurse suspects that he may have: | rheumatoid arthritis |
| A professional tennis player comes into the clinic complaining of a sore elbow. The nurse suspects that he has tenderness at the: | medial and lateral epicondyle |
| A patient has been diagnosed with osteoporosis and asks the nurse, "What is osteoporosis?" The nurse knows that osteoporosis can be defined as: | Loss of bone density |
| Patient suffered minor head injury. Patient's wife says she is concerned because she has noted a change in his personality and ability to understand. He also cries and becomes angry very easily. Which cerebral lobe is responsible for these behaviors? | Frontal |
| The nurse has completed the musculoskeletal examination of a patient's knee and has found a positive bulge sign. The nurse suspects: | swelling from fluid in the suprapatellar pouch |
| The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of the following movements: | Flexion and extension |
| The knee joint is the articulation of the femur, the tibia, and the: | patella |
| In order to screen for scoliosis, instruct the patient to: | stand with the feet shoulder-width apart and bend forward slowly to touch the toes. |
| You instruct a patient to close their eyes. You place a key in one of the patient's hands and he is able to identify it as a key. This test is called: | Stereognosis |
| A 40-year-old male has come into the clinic with complaints of "severe pain in his left big toe which seems to be a swollen and red and hot." Dinner last night consisted of liver and onions and a glass of red wine. His complaints would suggest: | acute gout. |
| Neurologic assessment; 41 yr old w/history of diabetes. When testing ability to feel vibrations of tuning fork, you note following: can't feel vibrations on great toe or ankle bilaterally; able to feel vibrations on both patellae. What would U suspect? | Peripheral neuropathy |
| Assessing neurologic status of patient who has late-stage brain tumor. W/reflex hammer, nurse draws light stroke up lateral side of sole of foot; inward across ball of foot; patient's toes fan out; big toe shows dorsiflexion. Nurse recognizes this as: | a positive Babinski's sign, which is abnormal for adults |
| An elderly woman has come for a health exam. Which of the following is a common age-related change in the curvature of the spinal column? | Kyphosis |
Created by:
chaptravelman
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