NURS 612 FINAL EXAM MARYVILLE UNIVERSITY
ADVANCED HEALTH ASSESSMENT NEWEST 2024
ACTUAL EXAM
The nurse observes the gait of a client as he enters the room. He uses
short steps, keeps his knees in contact, and walks with considerable
effort. What term is used to describe this gait? – ANSWER- Scissors gait
A nurse observes very fine, rapid, continuous twitching of a patient’s
finger while at rest. How should the nurse document this finding? –
ANSWER- Fasciculation
A fasciculation is a fine, rapid twitching that may occur with some lower
motor neuron disease. Paralysis is loss of motor function. Spasticity is
abnormally increased muscle tone. An intention tremor is an involuntary
contraction of a muscle group occurring with voluntary movement
Under what conditions should a patient be tested for clonus? –
ANSWER- When deep tendon reflexes are hyperactive
Clonus, repeated reflex muscle movement, is tested when a patient has
hyperactive reflexes. It is found with diseases of the upper motor neuron.
Nuchal rigidity, neck stiffness, is a sign of meningeal irritation. Absent
reflexes are associated with lower motor neuron diseases. Decorticate
positioning, a state of flexion with the arms adducted, occurs with
hemispheric lesion of the cerebral cortex.
The abdominal reflexes are tested to assess functioning of the nerves in
which location of the spine? – ANSWER- Thoracic
Which change is most commonly observed in aging patients? –
ANSWER- Kyphosis, advanced posterior curvature of the thoracic
spine, occurs commonly with age. Lordosis, scoliosis, and ankylosis are
not as commonly associated with age.
While palpating the patient’s knee, the nurse finds effusion in the joint.
What further assessment will support this finding? – ANSWER- Testing
for ballottement is a test to detect fluid in the joint
Which assessment finding is associated with lumbar stenosis? –
ANSWER- Pain associated with prolonged standing
Lumbar stenosis, narrowing of the spinal canal, causes pain associated
with prolonged standing. Pain is improved by bending forward.
Risk factors for osteoarthritis – ANSWER- Risk factors for osteoarthritis
include obesity, aging, and a family history of osteoarthritis. overuse of
joints, as with certain sport activities and occupations, is a risk factor.
A patient states he injured his right ankle while walking the previous
day. How should the nurse assess the ankle initially? – ANSWER- Initial
assessment is inspection of the ankle and comparison with the other
ankle. Palpation, performing passive range of motion, and asking the
patient to walk are done after the initial inspection.
Which assessment finding is consistent with carpal tunnel syndrome? –
ANSWER- Carpal tunnel syndrome, compression of the median nerve,
causes weakness in the thumb and episodes of numbness and burning
that awaken the patient from sleep.
McMurray sign test for? – ANSWER- Anterior cruciate ligament injury
(ACL)
Neer Test – ANSWER- Shoulder rotator cuff impingement or tear
Hawkins test – ANSWER- Shoulder rotator cuff impingement or tear
Katz hand diagram – ANSWER- Median nerve integrity (carpel tunnel)
Thumb abduction test – ANSWER- Median nerve integrity (carpel
tunnel)
Tinal sign – ANSWER- Median nerve integrity (carpal tunnel)
Phalen test – ANSWER- Median nerve integrity (carpal tunnel)
Straight leg raising – ANSWER- L4, L5, S1 nerve root irritation
Femoral stretch test – ANSWER- L1, L2, L3, L4 nerve root irritation
Bulge sign – ANSWER- Effusion of the knee
Anterior and posterior drawer test – ANSWER- Anterior and posterior
cruciate ligament integrity (ACL and PCL)
Varus-valgus stress test – ANSWER- Medial or lateral collateral
ligament instability of the knee (MCL)
Lachman test – ANSWER- Anterior cruciate ligament integrity (ACL)
Thomas test – ANSWER- Flexion contracture of hip
Trendlenburg sign – ANSWER- Weak hip abductor
Herberden nodes and bouchard nodes noted on the hands – ANSWEROsteoarthritis
Low back pain that radiates to the buttocks and posterior thigh with
tenderness over the spine – ANSWER- Lumbar disk herniation
(lumbaosacral radiculopathy)
Heat redness, swelling, and tenderness to the metatarsophalangeal joint –
ANSWER- Gouty arthritis of the great toe
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