Chapters 22, 23, 29

Question 1

You should perform a “head-to-toe” exam from head to toe and _______ to _______?

Answer 1

Proximal to distal (from midline outward)

Question 2

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

Answer 2

Adduction

Question 3

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?

Answer 3

Flexion

Question 4

The functional units of the musculoskeletal system are the:

Answer 4

Joints

Question 5

When reviewing the musculoskeletal system, the nurse recalls that hematopoiesis takes place in the:

Answer 5

Bone Marrow

Question 6

Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called

Answer 6

Ligaments

Question 7

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:

Answer 7

swelling from fluid in the suprapatellar pouch.

Question 8

What 3 bones make up the knee joint?

Answer 8

femur, tibia and patella

Question 9

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:

Answer 9

loss of bone density.

Question 10

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?

Answer 10

Performing physical activity, such as walking

Question 11

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:

Answer 11

start swimming to increase my weight-bearing exercise.”

Question 12

How many years after menopause after menopause, does the lack of estrogen leads to accelerated bone loss

Answer 12

5 years

Question 13

This is a test for carpal tunnel syndrome?

Answer 13

Phalen’s Test

Question 14

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:

Answer 14

hold both hands back to back while flexing the wrists 90 degrees for 60 seconds.

Question 15

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.

Answer 15

Asymmetric joint involvement
Pain with motion of affected joints
Affected joints are swollen with hard, bony protuberances

Question 16

direct percussion of the location of the median nerve at the wrist produces no symptoms in the normal hand

Answer 16

Tinel Sign

Question 17

These are located between the vertebrae

Answer 17

Intervertebral disc

Question 18

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:

Answer 18

Intervertebral disc

Question 19

An imaginary line connecting the highest point on each iliac crest would cross the _____ vertebra.

Answer 19

4th lumbar

Question 20

Of the 33 vertebrae in the spinal column, there are:

Answer 20

5 lumbar

Question 21

The production of RBC’s, WBC’s and platelets is called?

Answer 21

Hematopoiesis

Question 22

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:

Answer 22

Circumduction (moving arm in circle around shoulder)

Question 23

The nurse is checking the range of motion in a patient’s knee and knows that the knee is capable of which movement(s)?

Answer 23

flexion and extension

Question 24

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:

Answer 24

abduct her hip while she is lying on her back.

Question 25

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?

Answer 25

Crepitation

Question 26

The articulation of the mandible and the temporal bone is known as the:

Answer 26

temporomandibular joint. (TMJ)

Question 27

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:

Answer 27

genu valgum.

Question 28

People with osteoarthritis often have hard, non-tender nodules called

Answer 28

Heberden and Bouchard nodules

Question 29

bony overgrowths of the distal interphalangeal joints

Answer 29

Heberden

Question 30

Bony growths of the proximal interphalangeal joints

Answer 30

Bouchard

Question 31

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:

Answer 31

tophi

Question 32

painful swelling of the tibial tubercle just below the knee. It is most likely due to repeated stress on the patellar tendon.

Answer 32

Osgood-Schlatter disease

Question 33

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:

Answer 33

ulnar deviation

Question 34

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:

Answer 34

acute gout

Question 35

During a neonatal examination, the nurse notices that the newborn infant has six toes. This finding is documented as:

Answer 35

polydactyly.

Question 36

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.

Answer 36

syndactyly

Question 37

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:

Answer 37

herniated nucleus pulposus.

Question 38

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.

Answer 38

Frontal

Question 39

controls body temperature and regulates sleep.

Answer 39

hypothalamus

Question 40

The area of the nervous system that is responsible for mediating reflexes is the

Answer 40

spinal cord

Question 41

The ability that humans have to perform very skilled movements such as writing is controlled by the:

Answer 41

Corticospinal tract

Question 42

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?

Answer 42

Cerebellum

Question 43

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)?

Answer 43

Cerebrum

Question 44

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:

Answer 44

Positive Babinski sign, which is abnormal for adults.

Question 45

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?

Answer 45

plantar reflex present

Question 46

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:

Answer 46

Ask the patient to lock her fingers and pull.

Question 47

How would you document a reflex that is brisker than average

Answer 47

3+

Question 48

The ability to perceive passive movements of the extremities is called

Answer 48

Kinesthesia

Question 49

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?

Answer 49

Astereognosis

Question 50

When the nurse is testing the triceps reflex, what is the expected response?

Answer 50

extension of the forearm

Question 51

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:

Answer 51

Chorea

Question 52

A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability

Answer 52

Presence of dysdiadochokinesia.

Question 53

The nurse knows that testing kinesthesia is a test of a person's:

Answer 53

position sense

Question 54

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? ____+

Answer 54

2+

Question 55

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?

Answer 55

6 or 7

Question 56

a standardized, objective assessment that defines the level of consciousness by giving a numeric value.

Answer 56

Glasgow Coma Scale

Question 57

3 areas GCS is divided into:

Answer 57

eye opening, verbal response, & motor response

Question 58

with their eyes closed, place a familiar object (paper clip, key, coin etc.) in the person's hand and ask them to identify it

Answer 58

stereognosis

Question 59

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?

Answer 59

CN VII

Question 60

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:

Answer 60

Moves the head and shoulders against resistance with equal strength.

Question 61

Having the patient stick out the tongue checks the function of

Answer 61

CN XII

Question 62

Testing the eyes for nystagmus or strabismus is performed to check

Answer 62

CN III, IV, VI

Question 63

What cranial nerve is responsible for the “rooting reflex”?

Answer 63

CN V

Question 64

In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect?

Answer 64

Hyperreflexia

Question 65

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?

Answer 65

Hyporeflexia

Question 66

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?

Answer 66

Hyperactive reflexes

Question 67

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?

Answer 67

Level of consciousness, motor function, pupillary response, and vital signs

Question 68

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?

Answer 68

Fasciculation

Question 69

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:

Answer 69

Vertigo

Question 70

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:

Answer 70

Positive Romberg sign.

Question 71

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:

Answer 71

Parkinsonism

Question 72

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:

Answer 72

Is a very ominous sign and may indicate brainstem injury.

Question 73

What is a prolonged arching of the back, with head and heels bent backward?

Answer 73

Opisthotonos

Question 74

complete loss of muscle tone and paralysis of all four extremities, indicating completely nonfunctional brainstem

Answer 74

Flaccid Quadriplegia

Question 75

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

Answer 75

Decerebrate Rigidity

Question 76

The brachioradialis reflex is controlled by which spinal region of the body?

Answer 76

C5-C6

Question 77

constant state of resistance (lead-pipe rigidity); resists passive movements in any direction; dystonia

Answer 77

Rigidity

Question 78

What is a set of rapid, rhythmic contractions of the same muscle?

Answer 78

Clonus

Question 79

assessment for verbal communication

Answer 79

SBAR

Question 80

Decreased muscle tone or hypotonia; muscle feels limp, soft, and flabby; muscle is weak and easily fatigued; limb feels like a rag doll

Answer 80

Flaccidity

Question 81

Increased tone or hypertonia; increased resistance to passive lengthening; then may suddenly give way (clasp-knife phenomenon) like a pocket knife sprung open

Answer 81

Spasticity

Question 82

Localized swelling on anterior knee between patella and skin.

Answer 82

Prepatellar Bursitis

Question 83

Wrist in extreme flexion with ruptures of wrist and finger extensors, caused by severe rheumatoid arthritis

Answer 83

Ankylosis

Question 84

Swelling from excess flid in the joint capsule here from rheumatoid arthrisi.

Answer 84

Joint effusion

Question 85

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?

Answer 85

Dysfunction of the cerebellum