Exam 3 Flashcards
What is a full ROM against gravity with some resistance graded as?
4
What is the graded muscle strength for a client who cannot resist gravity?
2
What are the parameters of the muscle strength scale?
0-5
-contracture-full ROM
Muscle strength grade 5?
ROM full
Between what grades of muscle strength is considered active?
3-5
What is a contracture?
fixed joint, which is graded as a 0 for ROM
What is clonus?
Very strong deep tendon reflex, +4
What is the grading scale for deep tendon reflexes?
0-4
What is the grade for no deep tendon reflex?
0
What is the grade for a weak deep tendon reflex?
1
What is the grade for an expected deep tendon reflex?
2
What grade indicates a strong deep tendon reflex?
3
What grade is associated with a very strong/hyperactive deep tendon reflex?
4
What type of assessment interprets how pain and loss of function will impact ADLs?
functional assessment
What ROM is performed when rotating the arms internally?
internal rotation
What is scoliosis?
abnormal lateral curvature of the spine
What is the exaggerated curvature of the thoracic spine called?
kyphosis
What is known as a tingling/numbness sensation?
paresthesia
What is paresis?
partial paralysis
What cranial nerve assesses for wrinkling of the forehead, eyes closing, and smiling?
VII (7) -facial
What does a positive Romberg test indicate?
loss of balance
What is pronation?
turning the forearms so that the palm is down
What is eversion?
turning inside out
The nurse is assessing range of motion in a client who is able to actively achieve full range of motion against full resistance. How will the nurse grade this client’s muscle strength?
grade 5
A 75- year old female client is being assessed by the nurse. Which of the following is a common age-related change in the curvature of the spinal column?
kyphosis
The nurse asks the client to smile. Which cranial nerve is the nurse assessing?
Facial VII
The nurse is testing a client’s deep tendon reflexes and notes clonus. How will the nurse grade this client’s deep tendon reflexes?
+4
Which test will the nurse perform to test a client’s cerebellar function?
finger to nose test
The nurse asks the client to close their eyes and touch the tip of their nose with their index finger. What is the nurse assessing?
coordination
What position is best for dysphagia?
high-fowler (90 degrees)
What is known as the shortening of the connective tissue and/or joint fixation?
contracture
How will the nurse fit crutches to prevent nerve damage?
2-3 finger widths from axilla; 15-30 degree elbow angle
How should the nurse manage the effects of immobility on the respiratory system?
teach the client to use an IS (incentive spirometer)
Why apply SCDs? (Sequential compression device)
promote venous return
What intervention should the nurse take to reduce symptoms of orthostatic hypotension?
dangle legs while sitting for 1-2 min
How should the nurse manage the effects of immobility on blood flow to the skin?
turn the client every 2 hours
What is a HIGH fall risk intervention:
-apply a bed alarm to the client’s bed
-move client closer to nurses station/getting a sitter
What is true for restraints?
assess for discontinuation at least every 2 hours
What kind of client might be the most motivated to learn?
the client who believes treatment will make them feel better
How may immobility impact the cardiac system? How will the patient present?
-activity intolerance
-light headed, dizzy, increased HR, decreased BP
How should the nurse manage the effect of immobility on the respiratory system?
coughing and deep breathing
Why use SCDs?
prevent DVTs
The nurse shines a pen light across a client’s right field of vision and the client’s right pupil constricts. How will the nurse document this finding?
positive direct light reflex
The nurse moves a client’s limb away from the mid-line. Which range of motion will the nurse document this as?
abduction
A movement allowed by certain joints of the skeleton that decreases the angle between two adjoining bones, such as bending the elbow, which decreases the angle between the humerus and the ulna is known as which of the following?
flexion
The act of turning to a face down position, or of rotating the horizontal forearm so that the palm of the hand faces the ground is known as which of the following?
pronation
How far should a client move a cane in front of them?
For maximum support when walking, the patient places the cane forward 6-10 inches
Which leg should step first when using a cane?
The client moves the weaker leg forward to the cane so the body weight is divided between the cane and the stronger leg
Which movements should a client with a total hip replacement avoid?
90 Degree flexion, adduction, and internal rotation
Which statement will the nurse include when teaching a client to use a walker?
” Your walker should be as tall as your wrist.”
How should a client move with a walker?
When walking the client should move the walker, affected side, then step with the stronger side.
The nurse is caring for a client who can not bear weight and is uncooperative. The nurse should use __________________ when transferring this client from the bed to the chair.
a full body swing
The nurse will place the client with dysphagia in the _________________ position to reduce their risk for aspiration during meals.
high-fowler
What technique of body mechanics should the nurse use when caring for clients?
evenly distribute the weight,
do not lift over 35 lbs alone, keep an wide stance, and hold weight close to the body
How will the nurse determine the correct measurement of a pair of crutches for their client?
The crutch pads are 3 fingers from the axilla with elbow flexion at 20 degrees
What statement made by the client about crutch safety requires further teaching by the nurse?
“Lean on the crutches to support my body weight”
Which interventions will the nurse implement to reduce the impact of immobility on a client’s integumentary system?
Turn the client every 1-2 hours, maintain a positive fluid balance, and teach the client to shift every 15 minutes
The nurse will apply which device for a client who is at risk for thrombus formation?
compression stockings
The nurse is caring got four clients with immobility from different conditions. Which client should the nurse place in the side-lying position?
client with pressure ulcers
dysmetria
incoordination
dyskinesia
involuntary movement
paresthesia
numbness or tingling
dysphagia
difficulty swallowing
aphasia/dysphasia
difficulty speaking
dementia
chronic confusion
delirium
acute confusion
alert
client is responsive and able to open their eyes and answer questions spontaneously + appropriately
lethargic
client can open their eyes + respond but is drowsy and falls asleep readily
There is no response to repeated painful stimuli?
comatose
client responds to light shaking but can be confused and slow to respond
obtunded
client requires painful stimuli (pinching a tendon or rubbing the sternum) to achieve a brief response. Client may not be able to respond verbally
stuporous
CN 1 I
olfactory smell
CN 2 II
optic
vision
CN 3 III
oculomotor
opening eyelids, pupil constriction, lens shape
CN 4 IV
trochlear
Extraocular movement down/inward
CN 5 V
trigeminal
clenching teeth
CN 6 VI
abducens
lateral eye movement
CN 7 VII
facial
Wrinkle forehead, smile, taste
CN 8 VII
acoustic
hearing
CN 9 IX
glossopharyngeal
gag reflex
CN 10 X
vagus
swallowing; say “ahh”
CN 11 XI
spinal accessory
turn head; shrug shoulders
CN 12 XII
hypoglossal
protrude and wiggle tongue
Turning a body part away from midline
eversion
Turning a body part towards midline
inversion
ROM where you do the movement + not move past pain or resistance?
passive ROM
ROM where the patient is able to perform the movements that you demonstrate?
active ROM
When do you use high-fowlers?
90 degrees
Respiratory distress, swallowing
problems
When do you use semi fowlers?
45-60 degrees
-Decreases pooling of
respiratory secretions and
urinary stasis
- Promotes lung expansion
-Used for feeding, respiratory
therapy, NG tube insertion,
nasotracheal suctioning
When do you use semi-fowlers?
30 degrees
-mechanically
ventilated client to
prevent gastroesophageal
reflux and aspiration
How should the nurse manage the effects of limited mobility on blood flow to the skin?
30 degree lateral side turning every 1-2 hours
How often must you release restraints?
every 2 hours
