FINAL EXAM Flashcards
What does PQRSTU mean?
Pain, Quality, Region/Radiation, Severity, Timing, Understanding
socioeconomic factors contributing to low health literacy
vocabulary use, living arrangements, family influences,
scope of practice for UAP
UAP can assist with positioning the patients in the later recovery position, obtain vitals, assist patients with elimination needs and assist in the transfer of patients to the clinical unit
lab values and ranges Potassium Sodium Magnesium Chloride Calcium
Potassium 3.5-5.0 Sodium 136-145 Magnesium 1.3-2.1 Chloride 98-106 Calcium 9 -10.5
2, 3, 4-point gait and swing through
right foot and left crutch are advanced together
2 point gait
2, 3, 4-point gait and swing through
both crutches and affected leg advance together
3 point gait
Differentiate anuria, dysuria, oliguria
failure to produce urine (less than 100 mL in 24 hours)
anuria
Differentiate anuria, dysuria, oliguria
pain or discomfort when urinating
dysuria
Differentiate anuria, dysuria, oliguria
low urine output (100-400 mL in 24 hours)
oliguria
What are precautions for patients with TB
- airborne precautions
- N95 mask,
- negative airflow
- Private room
How would you teach a patient with COPD how to breathe?
Pursed lip breathing, tripod position and use of accessory muscles
2, 3, 4-point gait and swing through
the left crutch is moved forward, then the right lower extremity, followed by the right crutch, and then the left lower extremity.
4 point gait
Which herbal supplements/foods interact with medications?
Astragalus, ginseng
increase BP
Which herbal supplements/foods interact with medications?
Garlic, vitamin E, gingko, fish oil
increase bleeding
Which herbal supplements/foods interact with medications?
St. John’s wort
increase anesthesia recovery time
Which herbal supplements/foods interact with medications?
Kava, valerian
excess sedation
What respiratory complication is associates with
wheezing, cough, dyspnea, chest tightness, SOB and variable airflow obstruction
asthma
What respiratory complication is associates with
high pitched wheezing sound caused by airway obstruction
stridor
What respiratory complication is associates with
High-pitched, musical squeaking sounds that sound polyphonic (multiple notes as in
a musical chord); predominate in expiration
wheezing
What respiratory complication is associates with
Discontinuous, high-pitched, short crackling, popping sounds heard during inspiration that are not cleared by coughing caused by excess fluid
crackles
Small or Large pneumothorax?
mild tachycardia and dyspnea, absent breath sounds over affected area
small pneumothorax
Small or Large pneumothorax?
respiratory distress, shallow rapid respirations, dyspnea, air hunger, oxygen desaturation
large pneumothorax
What are some s/sx of MI?
Pressure or tightness in chest, shortness of breath, sweating, nausea, vomiting, anxiety, dizziness, tachycardia, pain in chest, back or jaw.
Differentiate heart sounds (s1, s2, s3, s4)
soft lubb sound associated with the closure of the tricuspid and mitral valves.
S1
Differentiate heart sounds (s1, s2, s3, s4)
sharp dupp sound associated with the closure of the aortic and pulmonic valves.
S2
Differentiate heart sounds (s1, s2, s3, s4)
low intensity vibration of ventricular walls usually associated with decreased compliance of ventricles filling but may be normal in young adults.
S3
Differentiate heart sounds (s1, s2, s3, s4)
low frequency vibration caused by atrial contraction, pathologic but may be normal in old adults. Also known as an atrial gallop.
S4
What defines a turbulent blood flow that causes buzzing or humming?
bruit
What are abnormal pulsations that can be felt?
thrill
What position is best to listen for extra heart sounds
left lateral decubitus position.
What release substances that either stimulate or inhibit the formation and release groups of hormones from the pituitary gland.
hypothalamus
What controls metabolism, growth, sexual maturation, reproduction, blood pressure
of the hormone melatonin
pituitary
What gland produces produces thyroxine (T4), triiodothyronine (T3), and calcitonin
thyroid
What gland regulates calcium level
parathyroid
What glands are composed of the adrenal cortex and the adrenal medulla
adrenal glands
What hormone-secreting portion of the pancreas is the islets of Langerhans
What cells make and secrete insulin and amylin?
pancreas
B cells
If the patient is going under CT or MRI and IV contrast is used what should the nurse check for?
check for iodine and shellfish allergy
If the patient is going under a MRI check for what?
magnetic, pacemaker
What deficiency of thyroid hormone that causes a general slowing of the metabolic rate
hypothyroidism
What hyperactivity of the thyroid gland with sustained increase in synthesis and release of thyroid hormone?
What is the most common name for this
hyperthyroidism, most common form is Grave’s disease
What are s/sx of hypothyroidism
fatigue, lethargic, personality and mental changes, impaired memory, slowed speech, decreased initiative, somnolence, depression, weight gain, drowsiness, sluggishness, myxedema
How do you perform a glucose tolerance test
Patient drinks 75 g of glucose, samples for glucose are drawn at baseline and at 30, 60, and 120 min.
Test takes 2 hour to complete
What test indicates the amount of glucose linked to hemoglobin?
Hgb A1C Test
What are some risks involved and effects on calcium when the patient is having thyroid surgery?
- Monitor for Chvostek’s and Trousseau’s sign
- Expect hoarseness for 3 or 4 days because of edema
- Respiration can become difficult b/c of excess welling of neck tissues, hemorrhage and hematoma formation
- Laryngeal stridor (harsh, vibratory sound) occur during inspiration and expiration b/c of edema of the laryngeal nerve
A young adult patient is being seen in the clinic with increased secretion of the anterior pituitary hormones. The nurse would expect the laboratory test results to show
a. increased urinary cortisol.
b. decreased serum thyroxine.
c. elevated serum aldosterone levels.
d. low urinary catecholamines excretion.
ANS: A
Increased secretion of adrenocorticotropic hormone (ACTH) by the anterior pituitary gland will lead to an increase in serum and urinary cortisol levels. An increase, rather than a decrease, in thyroxine level would be expected with increased secretion of thyroid-stimulating hormone (TSH) by the anterior pituitary. Aldosterone and catecholamine levels are not controlled by the anterior pituitary.
Which statement by a 50-yr-old female patient indicates to the nurse that further assessment of thyroid function may be necessary?
a. “I notice my breasts are tender lately.”
b. “I am so thirsty that I drink all day long.”
c. “I get up several times at night to urinate.”
d. “I feel a lump in my throat when I swallow.”
ANS: D
Difficulty in swallowing can occur with a goiter. Nocturia is associated with diseases such as diabetes mellitus, diabetes insipidus, or chronic kidney disease. Breast tenderness would occur with excessive gonadal hormone levels. Thirst is a sign of disease such as diabetes.
A patient seen in the emergency department for severe headache and acute confusion has a serum sodium level of 118 mEq/L. The nurse will anticipate the need for which diagnostic test?
a. Urinary 17-ketosteroids
b. Antidiuretic hormone level
c. Growth hormone stimulation test
d. Adrenocorticotropic hormone level
ANS: B
Elevated levels of antidiuretic hormone will cause water retention and decrease serum sodium levels. The other tests would not be helpful in determining possible causes of the patient’s hyponatremia.
Which question from a nurse during a patient interview will provide focused information about a possible thyroid disorder?
a. “What methods do you use to help cope with stress?”
b. “Have you experienced any blurring or double vision?”
c. “Have you had a recent unplanned weight gain or loss?”
d. “Do you have to get up at night to empty your bladder?”
ANS: C
Because thyroid function affects metabolic rate, changes in weight may indicate hyperfunction or hypofunction of the thyroid gland. Nocturia, visual difficulty, and changes in stress level are associated with other endocrine disorders.
A patient will be scheduled in the outpatient clinic for blood cortisol testing. Which instruction will the nurse provide?
a. “Avoid adding any salt to your foods for 24 hours before the test.”
b. “You will need to lie down for 30 minutes before the blood is drawn.”
c. “Come to the laboratory to have the blood drawn early in the morning.”
d. “Do not have anything to eat or drink before the blood test is obtained.”
ANS: C
Cortisol levels are usually drawn in the morning, when levels are highest. The other instructions would be given to patients who were having other endocrine testing.
A 61-yr-old female patient admitted with pneumonia has a total serum calcium level of 13.3 mg/dL (3.3 mmol/L). The nurse will anticipate the need to teach the patient about testing for _____ levels.
a. calcitonin c.thyroid hormone
b. catecholamine d.parathyroid hormone
ANS: D Parathyroid hormone (PTH) is the major controller of blood calcium levels. Although calcitonin secretion is a counter mechanism to PTH, it does not play a major role in calcium balance. Catecholamine and thyroid hormone levels do not affect serum calcium level.
During the nurse’s physical examination of a young adult, the patient’s thyroid gland cannot be felt. The most appropriate action by the nurse is to
a. palpate the patient’s neck more deeply.
b. document that the thyroid was nonpalpable.
c. notify the health care provider immediately.
d. teach the patient about thyroid hormone testing.
ANS: B
The thyroid is frequently nonpalpable. The nurse should simply document the finding. There is no need to notify the health care provider immediately about a normal finding. There is no indication for thyroid-stimulating hormone (TSH) testing unless there is evidence of thyroid dysfunction. Deep palpation of the neck is not appropriate.
Which laboratory value should the nurse review to determine whether a patient’s hypothyroidism is caused by a problem with the anterior pituitary gland or with the thyroid gland?
a. Thyroxine (T4) level
b. Triiodothyronine (T3) level
c. Thyroid-stimulating hormone (TSH) level
d. Thyrotropin-releasing hormone (TRH) level
ANS: C
A low TSH level indicates that the patient’s hypothyroidism is caused by decreased anterior pituitary secretion of TSH. Low T3and T4 levels are not diagnostic of the primary cause of the hypothyroidism. TRH levels indicate the function of the hypothalamus.
The nurse reviews a patient’s glycosylated hemoglobin (A1C) results to evaluate
a. fasting preprandial glucose levels.
b. glucose levels 2 hours after a meal.
c. glucose control over the past 90 days.
d. hypoglycemic episodes in the past 3 months.
ANS: C
Glycosylated hemoglobin testing measures glucose control over the last 3 months. Glucose testing before/after a meal or random testing may reveal impaired glucose tolerance and indicate prediabetes, but it is not done on patients who already have a diagnosis of diabetes. There is no test to evaluate for hypoglycemic episodes in the past.
A patient is taking spironolactone (Aldactone), a drug that blocks the action of aldosterone on the kidney, for hypertension. The nurse will monitor for
a. increased serum sodium.
b. decreased urinary output.
c. elevated serum potassium.
d. evidence of fluid overload.
ANS: C
Because aldosterone increases the excretion of potassium, a medication that blocks aldosterone will tend to cause hyperkalemia. Aldosterone also promotes the reabsorption of sodium and water in the renal tubules, so spironolactone will tend to cause increased urine output, a decreased or normal serum sodium level, and signs of dehydration.
A patient has been newly diagnosed with type 2 diabetes mellitus. Which information about the patient will be most useful to the nurse who is helping the patient develop strategies for successful adaptation to this disease?
a. Ideal weight c. Activity level
b. Value system d. Visual changes
ANS: B
When dealing with a patient with a chronic condition such as diabetes, identification of the patient’s values and beliefs can assist the interprofessional team in choosing strategies for successful lifestyle change. The other information also will be useful but is not as important in developing an individualized plan for the necessary lifestyle changes.
An 18-yr-old male patient with small stature is scheduled for a growth hormone stimulation test. In preparation for the test, the nurse will obtain
a. ice in a basin. c.a cardiac monitor.
b. glargine insulin. d.50% dextrose solution.
ANS: D
Hypoglycemia is induced during the growth hormone stimulation test, and the nurse should be ready to administer 50% dextrose immediately. Regular insulin is used to induce hypoglycemia (glargine is never given IV). The patient does not require cardiac monitoring during the test. Although blood samples for some tests must be kept on ice, this is not true for the growth hormone stimulation test.
The nurse will plan to teach a patient to minimize physical and emotional stress while the patient is undergoing
a. a water deprivation test.
b. testing for serum T3 and T4 levels.
c. a 24-hour urine test for free cortisol.
d. a radioactive iodine (I-131) uptake test.
ANS: C
Physical and emotional stress can affect the results of the free cortisol test. The other tests are not impacted by stress.
The nurse will teach a patient who is scheduled to complete a 24-hour urine collection for 17-ketosteroids to
a. insert and maintain a retention catheter.
b. keep the specimen refrigerated or on ice.
c. drink at least 3 L of fluid during the 24 hours.
d. void and save that specimen to start the collection.
ANS: B
The specimen must be kept on ice or refrigerated until the collection is finished. Voided or catheterized specimens are acceptable for the test. The initial voided specimen is discarded. There is no fluid intake requirement for the 24-hour collection.
Which additional information will the nurse need to consider when reviewing the laboratory results for a patient’s total calcium level?
a. The blood glucose c.The phosphate level
b. The serum albumin d.The magnesium level
ANS: B
Part of the total calcium is bound to albumin, so hypoalbuminemia can lead to misinterpretation of calcium levels. The other laboratory values will not affect total calcium interpretation.
A patient is admitted with tetany. Which laboratory value should the nurse plan to monitor?
a. Total protein c.Ionized calcium
b. Blood glucose d.Serum phosphate
ANS: C
Tetany is associated with hypocalcemia. The other values would not be useful for this patient.
Which information about a patient who is scheduled for an oral glucose tolerance test should be reported to the health care provider before starting the test?
a. The patient reports having occasional orthostatic dizziness.
b. The patient takes oral corticosteroids for rheumatoid arthritis.
c. The patient has had a 10-lb weight gain in the last month.
d. The patient drank several glasses of water an hour previously.
ANS: B
Corticosteroids can affect blood glucose results. The other information will be provided to the health care provider but will not affect the test results.
A registered nurse (RN) is caring for a patient with a goiter and possible hyperthyroidism. Which action by the RN indicates that the charge nurse needs to provide the RN with additional teaching?
a. The RN checks the blood pressure in both arms.
b. The RN palpates the neck to assess thyroid size.
c. The RN orders saline eye drops to lubricate the patient’s bulging eyes.
d. The RN lowers the thermostat to decrease the temperature in the room.
ANS: B
Palpation can cause the release of thyroid hormones in a patient with an enlarged thyroid and should be avoided. The other actions by the new RN are appropriate when caring for a patient with an enlarged thyroid.
The nurse is caring for a 45-yr-old male patient during a water deprivation test. Which finding is most important for the nurse to communicate to the health care provider?
a. The patient complains of intense thirst.
b. The patient has a 5-lb (2.3-kg) weight loss.
c. The patient’s urine osmolality does not increase.
d. The patient feels dizzy when sitting on the edge of the bed.
ANS: B
A drop in the weight of more than 2 kg indicates severe dehydration, and the test should be discontinued. The other assessment data are not unusual with this test.
A patient with a possible pituitary adenoma is scheduled for a computed tomography (CT) scan with contrast media. Which patient information is important for the nurse to communicate to the health care provider before the test?
a. Bilateral poor peripheral vision
b. Allergies to iodine and shellfish
c. Recent weight loss of 20 lb
d. Complaint of ongoing headaches
ANS: B
Because the usual contrast media is iodine-based, the health care provider will need to know about the allergy before the CT scan. The other findings are common with any mass in the brain such as a pituitary adenoma.
The nurse is caring for a 63-yr-old with a possible pituitary tumor who is scheduled for a computed tomography scan with contrast. Which information about the patient is important to discuss with the health care provider before the test?
a. History of renal insufficiency
b. Complains of chronic headache
c. Recent bilateral visual field loss
d. Blood glucose level of 134 mg/dL
ANS: A
Because contrast media may cause acute kidney injury in patients with poor renal function, the health care provider will need to prescribe therapies such as IV fluids to prevent this complication. The other findings are consistent with the patient’s diagnosis of a pituitary tumor.
Which statements will the nurse include when teaching a patient who is scheduled for oral glucose tolerance testing in the outpatient clinic (select all that apply)?
a. “You will need to avoid smoking before the test.”
b. “Exercise should be avoided until the testing is complete.”
c. “Several blood samples will be obtained during the testing.”
d. “You should follow a low-calorie diet the day before the test.”
e. “The test requires that you fast for at least 8 hours before testing.”
ANS: A, C, E
Smoking may affect the results of oral glucose tolerance tests. Blood samples are obtained at baseline and at 30, 60, and 120 minutes. Accuracy requires that the patient be fasting before the test. The patient should consume at least 1500 calories/day for 3 days before the test. The patient should be ambulatory and active for accurate test results.
List all the cranial nerves
Number, Name and Description
I-Olfactory: smell
II- Optic- vision (retina of eyes)
III- Oculomotor: holding head steady and follow movement of finger, penlight, check for pupillary constriction and accommodation
IV- Trochlear: one eye movement muscle
V-Trigeminal: close eyes and identify light touch, patient clench teeth, blink reflex)
VI- Abducens: one eye movement
VII- Facial: facial expressions and cheek muscles (patient raise eyebrows, close eyes tightly, purse lips)
VIII- Vestibulocochlear: equilibrium sensory (complaint of dizziness, vertigo, unsteadiness or has auditory dysfunction)
IX- Glossopharyngeal: test gag reflex
X- Vagus: test gag reflex (have patient say “ah”)
XI- Accessory: shrug shoulders
XII- Hypoglossal: muscles of tongue (protrude tongue)
Name all four of the cerebral lobes and its location
- frontal: located behind the forehead
- parietal: located behind the frontal lobe, on top of the brain
- temporal: located behind the ear
- occipital: located on the back portion
Differentiate function of cerebrum, cerebellum, brainstem
includes the midbrain, pons, and medulla
brainstem
Differentiate function of cerebrum, cerebellum, brainstem
located in the posterior cranial fossa inferior to the occipital lobe
cerebellum
Differentiate function of cerebrum, cerebellum, brainstem
composed of the right and left cerebral hemispheres and divided into four lobes
cerebrum
Out of the three, where is the reticular formation located?
brainstem
Out of the three, which one coordinates voluntary movement and maintains trunk stability and equilibrium
cerebellum
Which receives information from the cerebral cortex, muscles, joints, and inner ear
cerebellum
When the patient has a left hemispheric stroke, what is the best way to approach the patient?
speak to the patient approaching from the right side
What sign identifies that the big toe bends up and back to the top of the foot and other toes fans out after the sole of the foot has been firmly stroked
Babinski’s sign
Identify all the s/sx of Parkinson’s disease
What medication do you give for Parkinson’s disease?
Bradykinesia, rigidity, tremor at rest, gait disturbance, TRAP (Tremor, Rigidity, Akinesia, Postural instability), slight limp, shuffling, propulsive gait, loss of postural reflexes, speech abnormalities, drooling
Carbidopa-Levodopa
What type of aphasia is loss of speech damage to the frontal lobe
Broca’s area
What type of aphasia is when the language and potential functional deficits, damage to the temporal lobe
Wernicke’s Area
What does the Glasgow Coma Scale divided into? There are three parts.
What is the highest score and lowest for this? What if the score is 8 and lower?
- eye opening
- motor response to stimuli
- verbal response
- Highest GCS score is 15 for a fully alert patient and lowest is 3
- GCS score of 8 or less indicates coma and mechanical ventilation should be considered
What test consist of the ability to perceive the form and nature of objects
having the patient close the eyes and identify the size and shape of easily recognized objects (coins, keys, safety pin) placed in their hands
What test is the ability to feel writing on the skin
Graphesthesia Test
test by having patient identifying numbers traced on the palm of the hands
another name for loss of or impaired language faculty (comprehension, expression, or both)
aphasia
another name for double vision
diplopia
another name for loss of vision in one side of visual field
Homonymous hemianopsia
difficulty in swallowing
dysphagia
lack of coordination of movement
ataxia
impaired of voluntary movement, resulting in fragmentary or incomplete movements
Dyskinesia
paralysis on one side
hemiplegia
jerking or bobbing of eyes as they track moving object
Nystagmus
loss of pain sensation
Analgesia
absence of sensation
anesthesia
alteration in sensation (numbness and tingling often described as “pins and needles” sensation
Paresthesia
paralysis of lower extremities
Paraplegia
paralysis of all extremities
Quadriplegia
What test includes mild weakness of the arm demonstrated by downward drifting of the arm or pronation of the palm
Pronator Drift Test
What test is passively moving the limbs through their range of motion
Test Muscle Tone
Test that includes patient alternatively touch the nose, then touch the examiner’s finger
Finger-to- Nose Test
Test in having the patient stroke the heel of one foot up and down the shin on the opposite leg
Heel-to-Shin Test
When admitting an acutely confused patient with a head injury, which action should the nurse take?
a. Ask family members about the patient’s health history.
b. Ask leading questions to assist in obtaining health data.
c. Wait until the patient is better oriented to ask questions.
d. Obtain only the physiologic neurologic assessment data.
ANS: A
When admitting a patient who is likely to be a poor historian, the nurse should obtain health history information from others who have knowledge about the patient’s health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data, which could adversely affect decision making about treatment. Asking leading questions may result in inaccurate or incomplete information.
Which finding would the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion?
a. Spasticity c.Impaired sensation
b. Flaccidity d.Hyperactive reflexes
ANS: B
Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions.
The nurse performing a focused assessment of left posterior temporal lobe functions will assess the patient for
a. sensation on the left side of the body.
b. reasoning and problem-solving ability.
c. ability to understand written and oral language.
d. voluntary movements on the right side of the body.
ANS: C
The posterior temporal lobe integrates the visual and auditory input for language comprehension. Reasoning and problem solving are functions of the anterior frontal lobe. Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary movement on the right side is controlled in the left precentral gyrus
To assess the functions of the trigeminal and facial nerves (CNs V and VII), the nurse should
a. check for unilateral eyelid droop.
b. shine a light into the patient’s pupil.
c. touch a cotton wisp strand to the cornea.
d. have the patient read a magazine or book.
ANS: C
The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to evaluate function of the oculomotor nerve.
Which action will the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)?
a. Assist to stand and ambulate.
b. Withhold oral fluids and food.
c. Insert an oropharyngeal airway.
d. Apply artificial tears every hour.
ANS: B
The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve. Balance and coordination are cerebellar functions.
A patient with suspected meningitis is scheduled for a lumbar puncture. Before the procedure, the nurse will plan to
a. enforce NPO status for 4 hours.
b. transfer the patient to radiology.
c. administer a sedative medication.
d. help the patient to a lateral position.
ANS: D
For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration.
During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurse’s directions to move his hands and feet. The nurse will suspect
a. cerebellar injury. c. frontal lobe damage.
b. a brainstem lesion. d. a temporal lobe lesion.
ANS: C Expressive speech (ability to express the self in language) is controlled by Broca’s area in the frontal lobe. The temporal lobe contains Wernicke’s area, which is responsible for receptive speech (ability to understand language input). The cerebellum and brainstem do not affect higher cognitive functions such as speech.
A patient has a tumor in the cerebellum. The nurse will plan interventions to
a. prevent falls. c. avoid aspiration.
b. stabilize mood. d. improve memory.
ANS: A
Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability.
Which problem can the nurse expect for a patient who has a positive Romberg test result?
a. Pain c.Aphasia
b. Falls d.Confusion
ANS: B
A positive Romberg test result indicates that the patient has difficulty maintaining balance when standing with the eyes closed. The Romberg does not test for orientation, thermoregulation, or discomfort.
The nurse will anticipate teaching a patient with a possible seizure disorder about which test?
a. Cerebral angiography
c. Electromyography (EMG)
b. Evoked potential studied
d. Electroencephalography (EEG)
ANS: D
Seizure disorders are usually assessed using EEG testing. Evoked potential is used to diagnose problems with the visual or auditory systems. Cerebral angiography is used to diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle.
Which assessments will the nurse make to monitor a patient’s cerebellar function (select all that apply)?
a. Test for graphesthesia.
b. Observe arm swing with gait.
c. Perform the finger-to-nose test.
d. Assess heat and cold sensation.
e. Measure strength against resistance.
ANS: B, C
The cerebellum is responsible for coordination and is assessed by looking at the patient’s gait and the finger-to-nose test. The other assessments will be used for other parts of the neurologic assessment.
The Glasgow Coma Scale (GCS) is divided into three areas. They include:
a. Pupillary response, a reflex test, and assessing pain
b. Eye opening, motor response to stimuli, and verbal response
c. Orientation, rapid alternating movements, and the Romberg test
d. Response to fine touch, stereognosis, and sense of position
b
The medical record indicates that a person has an injury to Broca’s area. When meeting this person, you expect:
a. Receptive aphasia
b. Difficulty speaking
c. Visual disturbances
d. Emotional lability
b
The control of body temperature is located in:
a. Wernicke’s area
b. The hypothalamus
c. The cerebellum
d. The thalamus
b
Cerebellar function is assessed by which of the following?
a. Coordination: hopping on one foot
b. Muscle size and strength assessment
c. Cranial nerve examination
d. Spinothalamic test
a
A 65-year-old man has noticed a change in his personality and his ability to understand. He also cries and becomes angry very easily. The cerebral lobe responsible for these behaviors is the _______ lobe.
a. Occipital
b. Frontal
c. Parietal
d. Temporal
d. temporal
Which part of the brain is able to control temperature?
hypothalamus
fibrous collagen tissue that attaches muscle to bone
tendons
flexible connective tissue that connects bones
cartilage
fibrous connective tissue that connects two bones
ligaments
A full movement potential of a joint.
ROM
the muscle doesn’t noticeably change length and the affected joint doesn’t move
isometric
shorten a muscle to produce movement
isotonic
What are some nursing considerations for below-the-knee amputations
- Make sure below the knee amputation and if they develop gangrene.
- Once patients have amputation, patients may claim they have phantom pain, phantom limb.
- They may misinterpret the pain
How do you assess for bulge?
gently press just the medial of the patella, then move the hand in an ascending motion. Then press firmly on the lateral aspect of the knee
medial aspect that ‘bulges’ out after lateral pressure (positive “bulge sign”) is consistent with a moderate amount of fluid.
How do you assess for ballottement
- Increased fluid in the suprapatellar pouch over the patella at the knee joint.
- To test ballottement the examiner would apply downward pressure towards the foot with one hand, while pushing the patella backwards against the femur with one finger of the opposite hand.
What is crepitation?
frequent, audible crackling sound with palpable grating that accompanies movement
A patient complains of shoulder pain when the nurse moves the patient’s arm behind the back. Which question should the nurse ask?
a. “Are you able to feed yourself without difficulty?”
b. “Do you have difficulty when you are putting on a shirt?”
c. “Are you able to sleep through the night without waking?”
d. “Do you ever have trouble lowering yourself to the toilet?”
ANS: B
The patient’s pain will make it more difficult to accomplish tasks such as putting on a shirt or jacket. This pain should not affect the patient’s ability to feed himself or use the toilet because these tasks do not involve moving the arm behind the patient. The arm will not usually be positioned behind the patient during sleeping.
A patient with left knee pain is diagnosed with bursitis. The nurse will explain that bursitis is an inflammation of
a. a fluid-filled sac found at some joints.
b. a synovial membrane that lines the joint.
c. the connective tissue joining bones within a joint.
d. the fibrocartilage that acts as a shock absorber in the knee.
ANS: A
Bursae are fluid-filled sacs that cushion joints and bony prominences. Fibrocartilage is a solid tissue that cushions some joints. Ligaments are connective tissue joining bones within a joint The synovial membrane lines many joints but is not a bursa.
Which information in a 67-yr-old woman’s health history will alert the nurse to the need for a more focused assessment of the musculoskeletal system?
a. The patient sprained her ankle at age 13.
b. The patient’s mother became shorter with aging.
c. The patient takes ibuprofen for occasional headaches.
d. The patient’s father died of complications of miliary tuberculosis.
ANS: B
A family history of height loss with aging may indicate osteoporosis, and the nurse should perform a more thorough assessment of the patient’s current height and other risk factors for osteoporosis. A sprained ankle during adolescence does not place the patient at increased current risk for musculoskeletal problems. A family history of tuberculosis is not a risk factor. Occasional nonsteroidal antiinflammatory drug (NSAID) use does not indicate any increased musculoskeletal risk.
Which information obtained during the nurse’s assessment of a patient’s nutritional-metabolic pattern may indicates increased risk for musculoskeletal problems?
a. The patient takes a multivitamin daily.
b. The patient dislikes fruits and vegetables.
c. The patient is 5 ft, 2 in tall and weighs 180 lb.
d. The patient prefers whole milk to nonfat milk.
ANS: C
The patient’s height and weight indicate obesity, which places stress on weight-bearing joints and predisposes the patient to osteoarthritis. The use of whole milk, avoidance of fruits and vegetables, and use of a daily multivitamin are not risk factors for musculoskeletal problems.
Which medication information will the nurse identify as a potential risk to a patient’s musculoskeletal system?
a. The patient takes a daily multivitamin and calcium supplement.
b. The patient takes hormone replacement therapy (HRT) to prevent “hot flashes.”
c. The patient has severe asthma requiring frequent therapy with oral corticosteroids.
d. The patient has headaches treated with nonsteroidal antiinflammatory drugs (NSAIDs).
ANS: C
Frequent or chronic corticosteroid use may lead to skeletal problems such as avascular necrosis and osteoporosis. The use of HRT and calcium supplements will help prevent osteoporosis. NSAID use does not increase the risk for musculoskeletal problems.
After completing the health history, the nurse assessing the musculoskeletal system will begin by
a. having the patient move the extremities against resistance.
b. feeling for the presence of crepitus during joint movement.
c. observing the patient’s body build and muscle configuration.
d. checking active and passive range of motion for the extremities.
ANS: C
The usual technique in the physical assessment is to begin with inspection. Abnormalities in muscle mass or configuration will allow the nurse to perform a more focused assessment of affected areas. The other assessments are also included but are usually done after inspection.
A patient has a new order for magnetic resonance imaging (MRI) to evaluate possible left femur osteomyelitis after hip arthroplasty surgery. Which information indicates the nurse should consult with the health care provider before scheduling the MRI?
a. The patient has a pacemaker.
b. The patient is claustrophobic.
c. The patient wears a hearing aid.
d. The patient is allergic to shellfish.
ANS: A
Patients with permanent pacemakers cannot have an MRI because of the force exerted by the magnetic field on metal objects. An open MRI will not cause claustrophobia. The patient will need to be instructed to remove the hearing aid before the MRI, but this does not require consultation with the health care provider. Because contrast medium will not be used, shellfish allergy is not a contraindication to MRI.
The nurse notes crackling sounds and a grating sensation with palpation of an older patient’s elbow. How will this finding be documented?
a. Torticollis c. Subluxation
b. Crepitation d. Epicondylitis
ANS: B
Crackling sounds and a grating sensation that accompany movement are described as crepitus or crepitation. Torticollis is a twisting of the neck to one side, subluxation is a partial dislocation of the joint, and epicondylitis is an inflammation of the elbow causing a dull ache that increases with movement.
Which finding for a 77-yr-old patient seen in the outpatient clinic requires further nursing assessment and intervention?
a. Symmetric joint swelling of fingers
b. Decreased right knee range of motion
c. Report of left hip aching when jogging
d. History of recent loss of balance and fall
ANS: D
A history of falls requires further assessment and development of fall prevention strategies. The other changes are more typical of bone and joint changes associated with normal aging.
The nurse admits a 55-yr-old woman with multiple sclerosis to a long-term care facility. Which finding represents a safety concern? Ataxic gait Radicular pain Severe fatigue Urinary retention
Ataxia gait
An ataxic gait is a staggering, uncoordinated gait. Fall risk is the highest in individuals with gait instability and visual or cognitive impairments. The other signs and symptoms (e.g., fatigue, urinary retention, radicular pain) may also occur in the patient with multiple sclerosis.
The nurse is performing a musculoskeletal assessment on an 81-yr-old patient whose mobility has been progressively declining. How should the nurse safely assess range of motion (ROM) in the affected leg?
a. Observe the patient’s unassisted ROM in the affected leg.
b. Perform passive ROM, asking the patient to report any pain.
c. Ask the patient to lift progressive weights with the affected leg.
d. Move both the patient’s legs from a supine position to full flexion.
Observing the patient’s active ROM is more accurate and safe than lifting weights. Passive ROM should be performed with extreme caution; it may cause harm when performed on older patients.
A 50-yr-old patient reports shoulder discomfort after raking the yard. Which problem should the nurse suspect? Bursitis Fasciitis Sprained ligament Achilles tendonitis
Bursitis
Bursitis is common in adults older than age 40 years and with repetitive motion, such as raking. Plantar fasciitis occurs as a stabbing pain at the heel caused by straining the ligament that supports the arch. Achilles tendonitis is an inflammation of the tendon that attaches the calf muscle to the heel bone and causes pain with walking or running. A sprained ligament occurs when a ligament is stretched or torn from a direct injury or sudden twisting of the joint, not from repetitive motion.
