Chapters 22, 23, 29 Flashcards
You should perform a “head-to-toe” exam from head to toe and _______ to _______?
Proximal to distal (from midline outward)
A patient is being assessed for range-of-joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called
Adduction
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 which movement?
Flexion
The functional units of the musculoskeletal system are the:
Joints
When reviewing the musculoskeletal system, the nurse recalls that hematopoiesis takes place in the:
Bone Marrow
Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called
Ligaments
The nurse has completed the musculoskeletal examination of a patient’s knee and has found a positive bulge sign. The nurse interprets this finding to indicate:
swelling from fluid in the suprapatellar pouch.
What 3 bones make up the knee joint?
femur, tibia and patella
A patient has been diagnosed with osteoporosis and asks the nurse, “What is osteoporosis?” The nurse explains to the patient that osteoporosis is defined as:
loss of bone density.
The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal women. Which of these actions is the best way to prevent or delay bone loss in this group?
Performing physical activity, such as walking
The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal woman. A participant shows that she needs more instruction when she states, “I will:
start swimming to increase my weight-bearing exercise.”
How many years after menopause after menopause, does the lack of estrogen leads to accelerated bone loss
5 years
This is a test for carpal tunnel syndrome?
Phalen’s Test
The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen’s test. To perform this test, the nurse should instruct the patient to:
hold both hands back to back while flexing the wrists 90 degrees for 60 seconds.
The nurse is assessing the joints of a woman who has stated, “I have a long family history of arthritis, and my joints hurt.” The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? Select all that apply.
Asymmetric joint involvement
Pain with motion of affected joints
Affected joints are swollen with hard, bony protuberances
direct percussion of the location of the median nerve at the wrist produces no symptoms in the normal hand
Tinel Sign
These are located between the vertebrae
Intervertebral disc
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 disc
An imaginary line connecting the highest point on each iliac crest would cross the _____ vertebra.
4th lumbar
Of the 33 vertebrae in the spinal column, there are:
5 lumbar
The production of RBC’s, WBC’s and platelets is called?
Hematopoiesis
The nurse notices that a woman in an exercise class is unable to jump rope. The nurse knows that to jump rope, one’s shoulder has to be capable of:
Circumduction (moving arm in circle around shoulder)
The nurse is checking the range of motion in a patient’s knee and knows that the knee is capable of which movement(s)?
flexion and extension
An 80-year-old woman is visiting the clinic for a checkup. She states, “I can’t walk as much as I used to.” The nurse is observing for motor dysfunction in her hip and should have her:
abduct her hip while she is lying on her back.
A patient states, “I can hear a crunching or grating sound when I kneel.” She also states that “it is very difficult to get out of bed in the morning because of stiffness and pain in my joints.” The nurse should assess for signs of what problem?
Crepitation
The articulation of the mandible and the temporal bone is known as the:
temporomandibular joint. (TMJ)
A patient tells the nurse that “all my life I’ve been called ‘knock knees.’” The nurse knows that another term for “knock knees” is:
genu valgum.
People with osteoarthritis often have hard, non-tender nodules called
Heberden and Bouchard nodules
bony overgrowths of the distal interphalangeal joints
Heberden
Bony growths of the proximal interphalangeal joints
Bouchard
A man who has had gout for several years comes to the clinic with a problem with his toe. On examination, the nurse notices the presence of hard, painless nodules over the great toe; one has burst open with a chalky discharge. This finding is known as:
tophi
painful swelling of the tibial tubercle just below the knee. It is most likely due to repeated stress on the patellar tendon.
Osgood-Schlatter disease
A woman who has had rheumatoid arthritis for years is starting to notice that her fingers are drifting to the side. The nurse knows that this condition is commonly referred to as:
ulnar deviation
A 40-year-old man has come into the clinic with complaints of “extreme tenderness in my toes.” The nurse notices that his toes are slightly swollen, reddened, and warm to the touch. His complaints would suggest:
acute gout
During a neonatal examination, the nurse notices that the newborn infant has six toes. This finding is documented as:
polydactyly.
webbed fingers are a congenital deformity, usually requiring surgical separation. The metacarpals and phalanges of the webbed fingers are different lengths, and the joints do not line up. TO leave the fingers fused would thus limit their flexion and extension.
syndactyly
During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, he complains of a pain going down his buttock into his leg. The nurse suspects:
herniated nucleus pulposus.
The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband’s personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe.
Frontal
controls body temperature and regulates sleep.
hypothalamus
The area of the nervous system that is responsible for mediating reflexes is the
spinal cord
The ability that humans have to perform very skilled movements such as writing is controlled by the:
Corticospinal tract
A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse?
Cerebellum
The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)?
Cerebrum
The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient’s toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as:
Positive Babinski sign, which is abnormal for adults.
The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding?
plantar reflex present
The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. The nurse’s next response should be to:
Ask the patient to lock her fingers and pull.
How would you document a reflex that is brisker than average
3+
The ability to perceive passive movements of the extremities is called
Kinesthesia
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
When the nurse is testing the triceps reflex, what is the expected response?
extension of the forearm
A 32-year-old woman tells the nurse that she has noticed “very sudden, jerky movements” mainly in her hands and arms. She says, “They seem to come and go, primarily when I am trying to do something. I haven’t noticed them when I’m sleeping.” This description suggests:
Chorea
A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability
Presence of dysdiadochokinesia.
The nurse knows that testing kinesthesia is a test of a person’s:
position sense
During the assessment of deep tendon reflexes, the nurse finds that a patient’s responses are bilaterally normal. What number is used to indicate normal deep tendon reflexes when the documenting this finding? ____+
2+
The nurse is reviewing a patient’s medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?
6 or 7
a standardized, objective assessment that defines the level of consciousness by giving a numeric value.
Glasgow Coma Scale
3 areas GCS is divided into:
eye opening, verbal response, & motor response
with their eyes closed, place a familiar object (paper clip, key, coin etc.) in the person’s hand and ask them to identify it
stereognosis
During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs?
CN VII
The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient:
Moves the head and shoulders against resistance with equal strength.
Having the patient stick out the tongue checks the function of
CN XII
Testing the eyes for nystagmus or strabismus is performed to check
CN III, IV, VI
What cranial nerve is responsible for the “rooting reflex”?
CN V
In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect?
Hyperreflexia
A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual?
Hyporeflexia
In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side?
Hyperactive reflexes
The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment?
Level of consciousness, motor function, pupillary response, and vital signs
Rapid, continuous twitching of resting muscle or a part of muscle without movement of limb, which can be seen by clinicians or felt by patients is called?
Fasciculation
During the taking of the health history, a patient tells the nurse that “it feels like the room is spinning around me.” The nurse would document this finding as:
Vertigo
When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:
Positive Romberg sign.
During an assessment of a 62-year-old man, the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be consistent with:
Parkinsonism
During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? This patient’s response:
Is a very ominous sign and may indicate brainstem injury.
What is a prolonged arching of the back, with head and heels bent backward?
Opisthotonos
complete loss of muscle tone and paralysis of all four extremities, indicating completely nonfunctional brainstem
Flaccid Quadriplegia
upper extremities– flexion of the arm, wrist, and fingers; adduction of arm (tight against core). Lower extremities– extension, internal rotation, plantar flexion. This indicates hemispheric lesion of cerebral cortex
Decerebrate Rigidity
The brachioradialis reflex is controlled by which spinal region of the body?
C5-C6
constant state of resistance (lead-pipe rigidity); resists passive movements in any direction; dystonia
Rigidity
What is a set of rapid, rhythmic contractions of the same muscle?
Clonus
assessment for verbal communication
SBAR
Decreased muscle tone or hypotonia; muscle feels limp, soft, and flabby; muscle is weak and easily fatigued; limb feels like a rag doll
Flaccidity
Increased tone or hypertonia; increased resistance to passive lengthening; then may suddenly give way (clasp-knife phenomenon) like a pocket knife sprung open
Spasticity
Localized swelling on anterior knee between patella and skin.
Prepatellar Bursitis
Wrist in extreme flexion with ruptures of wrist and finger extensors, caused by severe rheumatoid arthritis
Ankylosis
Swelling from excess flid in the joint capsule here from rheumatoid arthrisi.
Joint effusion
The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of always dropping things and falling down. While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect?
Dysfunction of the cerebellum
