Answers With Latest Study Solutions
Which of the Following disorders is known to be heredity?
Peripheral neuropathy
Meningitis
Huntington Chorea
Seizure disorder ANS Huntington Chorea
The Examiner asks the patient to close her eyes and then place a vibrating tuning fork on the patients ankle and
asks her to indicate what is felt. What is being assessed? ANS Primary sensory function
Multiple sclerosis ANS Fatigue, bowel and bladder dysfunction, sexual dysfunction, sensory changes,
muscle weakness
Myasthenia gravis ANS An autoimmune disorder of neuromuscular junction involved with muscle
activation.
Whisper Test ANS CN V111 acoustic
Patient sticks out tongue and moves it from side to side ANS CN X11 Hypoglossal
Taste test with sugar, salt, and lemon ANS CN V11 and CN 1X Facial and glossopharyngeal
Patient puffs out cheeks and shows teeth ANS CN V11 facial
Patient shrugs shoulders against examiner's hands ANS CN X1 Spinal accessary
Smell test with coffee, orange and cloves ANS CN 1 Olfactory
Eyes constrict and dilate in response to light ANS CN 111 oculomotor
, patient clinches teeth (temporal muscles contracted) ANS CN V Trigeminal
positive Babinski sign be considered a normal finding in what ages? ANS 0-24 months
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? ANS 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? ANS 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? ANS 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? ANS
Thoracic
Which change is most commonly observed in aging patients? ANS 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? ANS Testing for ballottement is a test to detect fluid in the joint
Which assessment finding is associated with lumbar stenosis? ANS Pain associated with prolonged
standing
Lumbar stenosis, narrowing of the spinal canal, causes pain associated with prolonged standing. Pain is
improved by bending forward.