A 21-year-old engineering student comes to your office complaining of leg and back
pain and of tripping when he walks. He states this started 3 months ago with back and
buttock pain but has since progressed to feeling weak in his left leg. He denies any
bowel or bladder symptoms. He can think of no specific traumatic incidences, but he
was a defensive lineman in high school and junior college. His past medical history is
unremarkable. He denies tobacco use or alcohol or drug abuse. His parents are both
healthy. On examination he is tender over the lumbar spine and he has a positive
straight leg raise on the left. His Achilles tendon deep reflex is decreased on the left.
While watching his gait the nurse notices that the client has to pick his left foot up
high in order not to trip. What abnormality of gait does he most likely have?
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Steppage gait
A nurse is reviewing a client's health record while interviewing her. The nurse sees in
the patient's record a score of 3+ on the biceps reflex test from her previous visit. The
nurse understands that this finding indicates which of the following?
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Increased or brisk, but not pathologic
When testing sensory function of the trigeminal nerve (CN V), which of the following
sensations would the nurse assess?
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Pain and light touch
An 85-year-old retired housewife comes with her daughter to establish care. Her
daughter is concerned because the client has experienced frequent falls in recent
months. As part of the physical examination, the nurse asks the client to walk across
the examination room. Which of the following is not part of the stance phase of gait?
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Foot arched
, A nurse in the emergency department is utilizing the SAD PERSONAS assessment
guide during the mental status assessment of a client. What is the most likely rationale
for the nurse's choice of this assessment tool?
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The client may have a high risk for suicide.
A nurse inspects a client's abdomen and notices that a bulge is present in the right
lower quadrant. How should the nurse further assess this finding using inspection?
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Ask the client to raise the head off the bed
dyspepsia
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ronic or recurrent discomfort or pain centered in the upper abdomen.
The nurse understands that the best plans for referral or intervention will develop
from what part of the nurse-patient interaction?
Give this one a try later!
pain and of tripping when he walks. He states this started 3 months ago with back and
buttock pain but has since progressed to feeling weak in his left leg. He denies any
bowel or bladder symptoms. He can think of no specific traumatic incidences, but he
was a defensive lineman in high school and junior college. His past medical history is
unremarkable. He denies tobacco use or alcohol or drug abuse. His parents are both
healthy. On examination he is tender over the lumbar spine and he has a positive
straight leg raise on the left. His Achilles tendon deep reflex is decreased on the left.
While watching his gait the nurse notices that the client has to pick his left foot up
high in order not to trip. What abnormality of gait does he most likely have?
,Give this one a try later!
Steppage gait
A nurse is reviewing a client's health record while interviewing her. The nurse sees in
the patient's record a score of 3+ on the biceps reflex test from her previous visit. The
nurse understands that this finding indicates which of the following?
Give this one a try later!
Increased or brisk, but not pathologic
When testing sensory function of the trigeminal nerve (CN V), which of the following
sensations would the nurse assess?
Give this one a try later!
Pain and light touch
An 85-year-old retired housewife comes with her daughter to establish care. Her
daughter is concerned because the client has experienced frequent falls in recent
months. As part of the physical examination, the nurse asks the client to walk across
the examination room. Which of the following is not part of the stance phase of gait?
Give this one a try later!
Foot arched
, A nurse in the emergency department is utilizing the SAD PERSONAS assessment
guide during the mental status assessment of a client. What is the most likely rationale
for the nurse's choice of this assessment tool?
Give this one a try later!
The client may have a high risk for suicide.
A nurse inspects a client's abdomen and notices that a bulge is present in the right
lower quadrant. How should the nurse further assess this finding using inspection?
Give this one a try later!
Ask the client to raise the head off the bed
dyspepsia
Give this one a try later!
ronic or recurrent discomfort or pain centered in the upper abdomen.
The nurse understands that the best plans for referral or intervention will develop
from what part of the nurse-patient interaction?
Give this one a try later!
