Health Assessment: Lung, Thorax, Head & Neck Exam Questions 2024/2025 | Graded A Solutions

Health Assessment: Lung, Thorax, Head & Neck Exam Questions 2024/2025 | Graded A Solutions 1. Which of these statements is true regarding the vertebra prominens? The vertebra prominens is: ANS: A. The spinous process of C7. 2. When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is: ANS: C. A normal finding in a healthy adult. 3. When assessing a patient's lungs, the nurse recalls that the left lung: ANS: A. Consists of two lobes. 4. Which statement about the apices of the lungs is true? The apices of the lungs: ANS: B. Extend 3 to 4 cm above the inner third of the clavicles. 5. During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the: ANS: B. Sternal angle. 6. During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: ANS: C. Muffled voice sounds and symmetric tactile fremitus. 7. The primary muscles of respiration include the: ANS: A. Diaphragm and intercostals. 8. A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate? ANS: C. Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea 9. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? ANS: A. Between the scapulae 10. The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? "Tactile fremitus: ANS: C. "Is caused by sounds generated from the larynx." 11. During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from: ANS: D. Increased density of lung tissue. 12. The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is comparison. ANS: A. Side-to-side 13. When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets that these sounds are: ANS: C. Vesicular breath sounds and normal in that location. 14. The nurse is auscultating the chest in an adult. Which technique is correct? ANS: C. Firmly holding the diaphragm of the stethoscope against the chest 15. The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs will reveal: ANS: A. Dullness. 16. During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation? ANS: A. When the bronchial tree is obstructed 17. The nurse knows that a normal finding when assessing the respiratory system of an older adult is: ANS: B. Decreased mobility of the thorax. 18. When inspecting the anterior chest of an adult, the nurse should include which assessment? ANS: D. Shape and configuration of the chest wall 19. During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? ANS: B. When part of the lung is obstructed or collapsed 20. During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition? ANS: C. Pulmonary consolidation 21. The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds ANS: C. Expected near the major airways. 22. The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? ANS: A. Wheezes 23. A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these? ANS: D. Anteroposterior-to-transverse diameter ratio of 1:1 24. A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with: ANS: B. Pneumothorax. 25. An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with: ANS: A. Asthma. 26. The nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of the older adult? ANS: D. Lungs are less elastic and distensible, which decreases their ability to collapse and recoil. 27. A woman in her 26th week of pregnancy states that she is "not really short of breath" but feels that she is aware of her breathing and the need to breathe. What is the nurse's best reply? ANS: C. "What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong." 28. A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from: ANS: Tuberculosis. 29. A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient? ANS: A. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema 30. A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this cough may indicate: ANS: B. Postnasal drip or sinusitis. 31. During a morning assessment, the nurse notices that the patient's sputum is frothy and pink. Which condition could this finding indicate? ANS: D. Pulmonary edema 32. During auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways? ANS: A. Listening to at least one full respiration in each location 33. A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition? ANS: C. Chest pain that is worse on deep inspiration and dyspnea 34. During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects: ANS: B. Crepitus. 35. The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are: ANS: A. Atelectatic crackles that do not have a pathologic cause. 36. A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 respirations per minute. The nurse interprets this respiration pattern as which of the following? ANS: C. Hypoventilation 37. A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation? ANS: B. Friction rub 38. The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply. ANSWERS: a. Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. c. When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said. d. As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. 39. Normal breath sounds include: ANS: A. Vesicular sounds 40. When auscultating the lungs, it is important to: ANSWERS: A. Compare each side bilaterally. B. Note abnormal sounds. C. Ask the patient to take slow, deep breaths. D. All of the above. 41. When palpating the thorax, which of the following would be an abnormal finding? ANSWERS: A. Tenderness B. Pulsations C. Masses D. All of the above 42. When percussing the thorax, which of the following would be a normal finding? ANSWERS: Both B and C B. Resonance over the lung fields C. Dullness over the ribs, heart, and diaphragm 43. Which of the following indicates normal respiratory function? ANS: A. Symmetrical chest expansion HEAD AND NECK ASSESSMENT(inspect, palpate and auscultate) 1. When assessing the face, which area is best for assessing symmetry of facial features? ANS: A. Nasolabial folds 2. The anterior and posterior triangles are two landmarks used to assess the neck. What two muscles make up these triangles? ANS: C. Trapezius and sternomastoid 3. You are assessing the lymph nodes of the head and neck. Where are the occipital nodes located? ANS: D - At the base of the skull 4. You are assessing the lymph nodes of the head and neck. Where are the submental nodes located? ANS: C - Under the chin 5. You are assessing the lymph nodes of the head and neck. Where are the tonsillar lymph nodes located? ANS: B - At the angle of the jaw 6. You are assessing the lymph nodes of the head and neck. Where are the posterior cervical nodes located? ANS: C - In the posterior triangle 7. When assessing the thyroid gland, you locate the isthmus. Where is the isthmus located? ANS: C - Below the cricoid cartilage 8. To facilitate palpation of the thyroid gland, you instruct your patient to: ANS: C - Swallow 9. If the thyroid gland is enlarged bilaterally, which of the following maneuvers is appropriate? ANS: D - Listen for a bruit over the thyroid lobes 10. It is normal to palpate a lymph node in the neck of a health person. What are the characteristics of these nodes? ANS: A - Mobile, soft, nontender 11. Normal cervical lymph nodes are: ANS: A - Smaller than 1 cm 12. When inspecting the shape of the patient's head, you note an abnormal enlargement of the skull and bony facial structures. The term used to describe this finding is: ANS: D - Acromegaly 13. Palpation of a normal temporal artery reveals: ANS: B - Smooth, readily compressible, and nontender vessel 14. When inspecting your patient's face, you notice asymmetry of the palpebral fissures, nasolabial folds, and facial expression. These findings are characteristic of: ANS: D - Bell's palsy 15. Pain in the mandible during opening and closing of the mouth associated with a clicking sound suggests: ANS: A - Temporomandibular joint dysfunction 16. When describing characteristics of an enlarged lymph node, you would note: ANS: B - Size, shape delimitation, mobility, consistency, tenderness 17. Select the statement that is true regarding migraine headaches? ANS: A - May have prodromal stage 18. The nurse palpates enlarged, tender bilateral submandibular lymph nodes. What action should the nurse perform next? ANS: D - Assess for nasal congestion and sore throat 19. When assessing your patient's head and neck, what would you assess the face for? (Select all that apply) ANSWERS: B - Asymmetry D - Edema/swelling E - Involuntary movements 20. A 43-year-old Asian female presents at the clinic for a routine check-up. The nurse notes that she is dressed in warm clothing even though the temperature outside is 87 F. The nurse also notes that the patient has gained 10 pounds since her last visit 3 months ago. What might the nurse suspect? ANS: D - Hypothyroidism 21. During your physical examination of the patient you note an enlarged tender tonsillar lymph node. What would you do? ANS: C - Look for a source such as infection in the area that it drains 22. What are associated manifestations of a headache cause by a traumatic head injury? (Select all that apply) ANSWERS: A - Attention span deficit C - Gait changes D - Seizures 23. A 72-year-old retired secretary is brought to the clinic by her daughter. The daughter is concerned because her mother seems to be more confused, she has gained more weight, but her appetite has decreased, and she seems to be more "swollen" in general. Blood work is obtained and a diagnosis of profound Hypothyroidism is made. On examination of the skin, one would expect to feel it as: ANS: A - Cool 24. An 18-year-old college student presents to the clinic with complaints that her heart is "racing". A diagnosis of Hyperthyroidism is made. On physical examination of her eyes, what would you expect to find? ANS: B - Protrusion 25. The nurse is caring for a patient who comes to the clinic reporting a lump by her ear. What are the symptoms of a cancerous lymph node? ANS: A - Node is fixed and rubbery 26. What activity is known to aggravate a tension headache? ANS: C - Driving 27. A 16-year-old white female is brought to the clinic by her mother with a chief complaint of a severe headache lasting for more than 24 hours. The mother states, "Just before the headache started my daughter was craving food. I couldn't feed her enough." What is this called? ANS: B - Prodrome 28. A 72-year-old male arrives in the emergency department by ambulance after falling down his front steps. You note two soft lumps, approximately 3 cm in diameter on the right side of his head. What would you identify these as? ANS: D - Edema/swelling from the fall 29. A 55-year-old construction worker presents to the clinic for evaluation of fatigue and weakness. During the course of the interview, the patient reveals that he has noticed both an increase in his ring size and his shoe size; you ask to look at his driver's license and also at any pictures that he has in his wallet of himself from an earlier time. Upon looking at these pictures, you are able to strongly theorize that he has Acromegaly. Which physical finding is most consistent with this diagnosis? ANS: C - Coarsening and enlargement of the facial features 30. The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle? ANS: B - Sternomastoid 31. When examining a client's thyroid gland, the nurse ensures that which equipment is readily available? ANS: D - Cup of water 32. During a health history, a client reports complaints of headaches. Which of the following would lead the nurse to suspect that the client is experiencing cluster headaches? ANS: A - Pain radiating from eye to temporal region 33. A 29-year-old female computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. She denies photophobia and nausea. She spends several hours at a computer monitor/keyboard. She has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis? ANS: A - Tension 34. A nursing instructor is teaching a group of students how to examine the thyroid gland. The instructor would determine that a student needs additional instruction when the student demonstrates which technique? ANS: C - Percussion 35. A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first? ANS: D - Auscultate with the bell over the lateral lobes 36. A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider? ANS: C - Fixed to the underlying tissue 36. When identifying the midline structures of the neck from the mandible to the sterna notch, the nurse notes the structures in what order? ANS: C - Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid 37. A family member of a patient recovering from a traumatic brain injury asks the nurse what can be done to prevent future head injuries. What should the nurse instruct the family member? ANSWERS: A - Wear helmets when playing all contact sports B - Never drive under the influence of alcohol C - Avoid the use of throw rugs 38. During the health interview of the head and neck, a patient tells the nurse about always feeling cold and preferring warm weather. What additional questions can the nurse ask to learn more information about the client's symptoms? (Select all that apply) ANSWERS: A - "Do you dress more warmly than other people? B - "Do you use more blankets than others at home?" D - "Do you perspire less than others?" 39. The nurse should ask about or assess which associated factors when a patient complains of cluster headaches? (Select all that apply) ANSWERS: A - Rhinorrhea B - Ptosis C - Tearing D - Red eye EAR ASSESSMENT(inspect and palpate) 1. A client presents at the clinic complaining of a loss of balance. What test should the nurse expect the physician to carry out on a client with a loss of balance? ANS: d) Romberg test 2. The client is having a Weber test. During a Weber test, where should the tuning fork be placed? ANS: d) In the midline of the client's skull or in the center of the forehead. 3. The nursing student hopefuls are taking a pre-nursing anatomy and physiology class. What will they learn is the anatomical feature that equalizes air pressure in the middle ear? ANS: a) Eustachian tube 4. The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus? ANS: b) A hard nodule composed of uric acid crystals 5. A client admitted to the health care facility is diagnosed with vertigo. Which test is appropriate for the nurse to perform to assess for equilibrium in the client? ANS: b) Romberg 6. A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube? ANS: d) Equalizes the pressure in the middle ear with atmospheric pressure. 7. An increased risk of falls is dangerous for any patient. What patient would be at an increased risk of falls? ANS: c) A patient with vertigo. 8. Which terms refers to the progressive hearing loss associated with aging? ANS: b) Presbycusis 9. The nurse is documenting an objective assessment of the client's ears. Which of the following would be the most appropriate documentation? ANS: a) Hearing intact bilaterally on whisper test 10. Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media? ANS: d) Red, bulging, with an absent light reflex 11. A client visits a community clinic reporting severe allergies causing a "crackling sensation" in the ear. The physician diagnoses serous otitis media. Which of the following is a characteristic of this condition? ANS: a) Fluid collects in the middle ear causing an obstruction of the auditory tube. 12. A mother of a small child calls the clinic and asks to schedule an appointment for ear tube removal. The call is transferred to the nurse. What is the nurse's best action? ANS: a) Ask the mother how long the tubes have been in place. 13. Which action by the nurse is consistent with Weber's test? ANS: d) The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears. 14. A six-month old male infant is brought to the emergency department by his parents for inconsolable crying and pulling at his right ear. When assessing this infant, the nurse is aware that the tympanic membrane should be what color in a healthy ear? ANS: c) Gray 15. Which of the following is a symptom related to vertigo? ANS: d) Spinning sensation 16. The results of a client's Rinne test are as follows: bone conduction > air conduction. How should the nurse explain these findings to the client? ANS: b) "You have a conductive hearing loss." 17. What action should the nurse implement using an otoscope when assessing the ear of an adult client? ANS: c) Pull the auricle out, up, and back 18. When performing a Rinne test, the nurse would perform the steps in what order? ANS: b. place the base of a vibrating tuning fork on the mastoid bone until the patient says she cannot hear the sound a. place the tuning fork in front of the ear and ask the patient if she can hear the sound 19. A nurse performs an inspection and palpation of the auricle when examining the ear of a client. Which documentation by the nurse demonstrates a normal finding? ANS: a) Darwin's tubercle 20. During a pharmacology class the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides? ANS: a) Tinnitus and sensorineural hearing loss 21. Which precaution should a nurse take to ensure the safety of a client when performing the Romberg test? ANS: a) Place arms around the client without touching 22. When inspecting the tympanic membrane, which of the following structures does the nurse expect to identify? ANS: c) Handle of malleus, short process of malleus, cone of light 23. What action should the nurse implement when assessing the ear of an adult client using an otoscope? ANS: c) Pull the auricle out, up, and back. 24. The mother of a small child with tubes in both eardrums asks the nurse if it is okay if the child travels by airplane. What is the nurse's best response? ANS: c) "It's safe to fly because the tubes will equalize pressure." 25. When planning care for a patient with an inner ear infection, the nurse will include interventions to address which potential problem? ANS: b) Vertigo 26. What components of sound does the cochlea interpret? (Select all that apply.) ANSWERS: a) Amplitude d) Frequency ● John Spivey, age 75, is scheduled for a hearing exam. Considering his age, which hearing change might you expect to find? A - Presbycusis ● You are assessing a newborn infant's position of his ears. Which finding would be cause for concern and referral? A - Low-set ears ● Prior to insertion of the otoscope, which areas should be palpated? A - Helix, tragus, mastoid ● You have done the Weber test on your patient, and the patient reports the sound is heard equally in both ears. How would you explain these findings to your patient? A - This is a normal finding ● You have tested your patient's hearing using the Rinne test. The results reveal bone conduction is longer than air conduction. What do these findings suggest? B - Conductive hearing loss ● You are performing an otoscopic exam on a 2-year-old child. To straighten the ear canal, you should: B - Pull helix down ● As you examine the TM, you note the color of the drum. Which TM color would be considered normal? C - Pearly grey ● When performing an otoscopic exam, what type of fluid is considered normal in the external ear canal? B - Cerumen ● In examining the ear of an adult, the canal is straightened by pulling the auricle: C - Up and back ● A common cause of conductive hearing loss is: A - Impacted cerumen ● In the Rinne test, the 2 to 1 ratio refers to: B - The lengths of time until the patient stops hearing the tone by air conduction and by bone conduction ● Upon examination of the tympanic membrane, visualization of which of the following findings indicates the infection of acute purulent otitis media? B - Absent light reflex, reddened drum, bulging drum ● Which statement describes a normal Weber test? C - When a tuning fork is placed in the middle of the forehead, the sound is heard equally in both ears ● Which of these demonstrates proper procedure when performing the Rinne test? C - Strike the tuning fork; hold it to the mastoid process, then the ear ● In doing the otoscope examination of the right ear, the cone of light would be found at On the tympanic membrane: A - 5 o'clock ● When providing patient education on hearing, patients should be reminded to use ear plugs when they are what? (Select all that apply) A - At train stations C - Using lawnmowers E - At concerts ● What structure in the inner ear senses the position and movements of the head and helps maintain balance? B - The labyrinth ● An alternate pathway that bypasses the external and middle ear is called what? A - Bone conduction ● A patient calls the clinic and tells the nurse that the doctor told her that she has "otalgia". The patient cannot remember what the doctor explained this to be. How would the nurse most appropriately respond? B - "Otalgia is pain in the ear." ● The nurse is providing patient teaching to the mother of a 3-month-old with otitis media. What would the nurse explains a risk factor for otitis media? B - Cigarette residue on clothing ● A patient has Darwin's tubercule. What is this? D - A small painless nodule on the helix ● A patient comes to the clinic and reports pain when he touches his ear, specifically the tragus. With what is this finding consistent? B - Otitis externa ● A 52-year-old patient fails the Romberg's test. The nurse explains that this might indicate a dysfunction in what part of the ear? D - The vestibular portion of the inner ear ● While talking with a patient, the nurse suspects that he has hearing loss. Which examination technique is most accurate for assessing hearing loss? D - Audiometry test ● Which data from the health history of a 42-year-old man should be evaluated further as a possible risk for hearing loss? C - "My primary hobby is carpentry." ● The nurse examines a patient's auditory canal and tympanic membrane with an otoscope. Which finding is considered abnormal? B - Yellow or amber color to the tympanic membrane ● When you look at the tympanic membrane with the otoscope, what normal landmark is present? A - Umbo ● A 3-year-old boy is brought to the office by his mother for evaluation of fever, loss of appetite, and emesis. The symptoms have been present for 2 days; the fever is only temporarily relieved with antipyretics. Physical examination reveals Otitis Media. What is the most likely physical finding on otoscopic examination? A - Erythematous, bulging tympanic membrane ● A 15-year-old high school student presents to the clinic complaining of pain in his left ear. He noticed that it occurred shortly after starting swimming lessons at the local YMCA. Upon physical examination the external canal is swollen and tender during insertion of the speculum. What is the most likely diagnosis? D - Otitis Externa ● A 15-year-old member of the high school marching band presents to the clinic for evaluation of hearing loss. He had multiple ear infections as an infant and toddler, and he had to have myringotomy tubes inserted in his ears. Additionally, he suffers from many allergies. His hearing is diminished in the right ear. When you place a vibrating tuning fork on the top of his head, the sound lateralizes to the right ear. The name of this test is: A - Weber's test ● Next, you place vibrating tuning fork on the teenager's right mastoid process, asking him to let you know when the sound is gone, and then you immediately place the same tuning fork near his right ear. He hears the sound equally in air as against his bone. The name of this test is: B - Rinne's test ● The portion of the ear that consists of movable cartilage and skin is called the: ANS: a. auricle. ● The nurse is examining a patient's ears and notices cerumen in the external canal. Which of the following statements about cerumen is correct? ANS: c. The purpose of cerumen is to protect and lubricate the ear. ● When examining the ear with an otoscope, the nurse remembers that the tympanic membrane should appear: ANS: b. pearly gray and slightly concave. ● Which of the following statements concerning the eustachian tube is true? ANS: d. It helps equalize air pressure on both sides of the tympanic membrane. ● A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to: ANS: c. conduct vibrations of sounds to the inner ear. Which of the following cranial nerves is responsible for conducting nerve impulses to the brain from the organ of Corti? ANS: c. CN VIII ● Which of the following statements is true concerning air conduction? ANS: a. It is the most efficient pathway for hearing. ● A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to: ANS: c. ask the patient what medications he is currently taking ● During an interview, the patient states he has the sensation that "everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is: ANS: d. the bony labyrinth ● A patient in her first trimester of pregnancy is diagnosed with rubella. The nurse recognizes that the significance of this in relation to the infant's hearing is which of the following? ANS: b. Rubella can damage the infant's organ of Corti, which will impair hearing. ● The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse? ANS: d. "Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily." ● A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume. The most likely cause of his hearing loss is: ANS: a. otosclerosis. ● A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change? ANS: c. Nerve degeneration in the inner ear ● During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? ANS: c. This is a normal finding and no further follow-up is necessary. ● The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? ANS: d. "Was there any relationship between the ear pain and the discharge you mentioned?" ● A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding: ANS: b. is a characteristic of recruitment. ● While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a great deal of aspirin while she was pregnant. What question would the nurse want to include in the history? ANS: a. "Does your baby seem to startle with loud noise?" ● The nurse is performing an otoscopic examination on an adult. Which of the following is true? ANS: c. Pull the pinna up and back before inserting the speculum. ● The nurse is assessing a 16-year-old patient with head injuries from a recent motor vehicle accident. Which of the following statements indicates the most important reason for assessing for any drainage from the canal? ANS: b. Bloody or clear watery drainage can indicate a basal skull fracture. ● A colleague is assessing an 80-year-old patient who has ear pain and asks him to hold his nose and swallow. The nurse knows that which of the following is true concerning this technique? ANS: a. This should not be used in an 80-year-old patient. ● In performing a voice test to assess hearing, which of the following would the nurse do? ANS: b. Whisper two-syllable words and ask the patient to repeat them. ● In performing an examination of a 3-year-old with a suspected ear infection, the nurse would: ANS: d. perform the otoscopic examination at the end of the assessment. ● Which of the following would be true regarding otoscopic examination of a newborn? ANS: c. The normal membrane may appear thick and opaque. ● The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? ANS: a. The infant turns the head to localize sound. ● During the ear examination of an 80-year-old patient, which of the following would be a normal finding? ANS: a. A high-tone frequency loss ● An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. Additional information the nurse would need to know includes which of the following? ANS: d. Any prolonged exposure to extreme cold ● While performing the otoscopic exam of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and the light reflex is not visible. The most likely cause is: ANS: b. acute otitis media. ● The mother of a 2-year-old is concerned about the upcoming placement of tympanostomy tubes in her son's ears. The nurse would include which of the following in the teaching plan? ANS: d. The purpose of the tubes is to decrease the pressure and allow for drainage. 29. During a hearing assessment the nurse finds that sound lateralizes to the patient's left ear with the Weber test. What can the nurse conclude from this? ANS: c. The patient could have either a sensorineural or a conductive loss. ● A patient states that she is unable to hear well with her left ear. The Weber test shows lateralization to the right ear. Rinne has AC>BC with ratio of 2:1 in both ears, left-AC 10 sec and BC 5 sec, right-AC 30 sec and BC 15 sec. What would be the interpretation of these results? ANS: a. The patient may have sensorineural loss. ● In an individual with otitis externa, which of the following signs would the nurse expect to find on assessment? ANS: d. Enlarged superficial cervical nodes ● When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber- yellow in color and there are air bubbles behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that: ANS: a. this is most likely a serous otitis media. ● The nurse is performing an assessment on a 65-year-old male. He reports a crusty nodule behind the pinna. It bleeds intermittently and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this: ANS: c. could be a potential carcinoma and should be referred. ● The nurse suspects that a patient has otitis media. Early signs of otitis media include which of the following findings of the tympanic membrane? ANS: b. Hypomobility ● The nurse is performing a middle ear assessment on a 15-year-old patient who has a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. The nurse should: ANS: b. know that these are scars caused from frequent ear infections. ● The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which of the following reflects correct procedure? ANS: a. Pull the pinna down. ● Which of the following is a risk factor for ear infections in young children? ANS: d. Secondhand cigarette smoke ● During an otoscopic examination, the nurse notes an area of black and white dots on the tympanic membrane and ear canal wall. What does this finding suggest? ANS: d. Yeast or fungal infection ● A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa so far this season and wants to know what to do to prevent it. The nurse instructs her to: ANS: b. use rubbing alcohol or 2% acetic acid eardrops after every swim. ● During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom is: ANS: c. tinnitus. ● The nurse is testing the hearing of a 78-year-old man and keeps in mind the changes in hearing that occur with aging, such as: (Select all that apply.) b. The progression is slow. e. Sounds may be garbled and difficult to localize. f. Hearing loss reflects nerve degeneration of the middle ear HEART ASSESSMENT(inspect, palpate, percuss and auscultate) ● The nurse performs an admission assessment on an adult client admitted through the ED with a myocardial infarction. The nurse charts "Swooshing sound heard over right carotid artery." How should this documentation be corrected? d) "Right carotid bruit auscultated" ● During an interview with the nurse, a client complains of a fatigue that seems to get worse in the evening. Which of the following causes of fatigue would explain this pattern? a) Decreased cardiac output ● In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers? a) left midclavicular line at the fifth intercostal space ● The client has been diagnosis with severe sepsis. Which finding would indicate the client is experiencing low cardiac output? b) Tachycardia; hypotension ● Where are the heart and great vessels located in the human body? b) The mediastinum, between the lungs above the diaphragm ● A client is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor frequently? b) Blood pressure ● During auscultation of the heart, the nurse notes a swooshing sound. The nurse would document this as what? a) Murmur ● The area known as Erb's point is the third site for auscultation on the precordium. Where is it located? c) 3rd left rib space ● A 58-year-old teacher presents with breathlessness with activity. The client has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems? c) Orthopnea ● While completing the cardiovascular system health history, a patient tells the nurse about using four pillows at night to sleep. The nurse will use this information to further assess which area? d) Shortness of breath ● The nurse understands that when the sympathetic nervous system is stimulated what occurs? Select all that apply. a) Increased cardiac output c) Increased blood pressure e) Increased heart rate ● The nursing instructor is discussing assessment of the heart with students. A student states that he has a client with a rushing vibration in the precordium that the student could feel and that it was in the area of the pulmonic valve. What should the instructor explain that the student is feeling? a) A thrill ● How does the nurse differentiate a pleural friction rub from a pericardial friction rub? d) Have the client hold his or her breath; if the rub persists, it is pericardial Question: Understanding pressures in the left atrium, left ventricle, and aorta is fundamental to understanding heart sounds. Place the following in order of pressures and sounds through one cardiac cycle. Correct response: E. aortic pressure is greater than ventricular pressure B. mitral valve closes producing S1 F. the atrium is empty and pressures in the ventricles increase slightly C. S3 and S4 may be heard if pathologic ventricular compliance D. ventricular pressure increases and forces the opening of the aortic valve A. aortic valve closes producing S2 ● A nurse auscultates a client's carotid arteries, finding the strength of the pulse to be bounding. Which score should the nurse record? c) 4+ ● A client complains of difficulty sleeping, stating he has to sit up with the help of several pillows and cannot breathe when lying flat. This client has a condition known as what? b) Orthopnea ● What finding upon assessment would indicate the client is experiencing shock? d) Systolic blood pressure 50 ● Which characteristic of the apical pulse should a nurse expect to find in the client diagnosed with left ventricular hypertrophy? a) Displaced ● The nurse manager on a cardiac unit should immediately intervenen when observing which staff nurse's assessment technique? c) Palpating carotid pulses simultaneously. ● What nursing diagnosis would be most appropriate for a client admitted with heart failure? d) Ineffective tissue perfusion ● Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known as what? d) Angina ● The nurse is caring for a client who has an elevated cholesterol level. To reduce the mean total blood cholesterol and LDL cholesterol levels, what would be important to teach this client? d) Eat low-fat, low-cholesterol meals ● While performing an admission assessment, the nurse auscultates a high-pitched, scratching, and grating sound at the left lower sternal border. The nurse should know that this would be documented as what type of sound? d) Pericardial friction rub ● The client is experiencing severe sepsis. What assessment finding would the nurse expect? a) 1+ pulses ● The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of? c) Bruits ● A nurse auscultates a client's heart sounds and obtains a rate of 56 beats per minute. How should this rate be documented by the nurse? a) Bradycardia ● A nurse is assessing a client for the presence of asynchronous contraction in the heart. Which of the following should the nurse do? c) Auscultate for split S1 at the base and apex ● A nurse is unable to palpate the apical impulse on an older client. Which assessment data in the client's history should the nurse recognize as the reason for this finding? b) Client has an increased chest diameter ● A client is admitted to the health care facility with reports of chest pain, elevated blood pressure, and shortness of breath with activity. The nurse palpates the carotid arteries as 1+ bilaterally and a weak radial pulse. A Grade 3 systolic murmur is auscultated. Which nursing diagnosis can the nurse confirm based on this data? d) Ineffective Tissue Perfusion ● How should a nurse assess a client for pulse rate deficit? d) Assess for a difference between the apical and radial pulse ● A nurse performs an initial health history on a client admitted for new onset of chest pain. Which data is considered subjective for the cardiovascular system? d) No current medications or treatments A nurse cares for a client who suffered a myocardial infarction two (2) days ago. A high pitched, scratchy, scraping sound is heard that increase with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium? c) Inflammation of the pericardial sac ASSESSMENT OF THE MUSCULOSKELETAL(inspect and palpate) ● What are the functions of the musculoskeletal system? Providing shape to the body and permitting movement ● Why is the identification of musculoskeletal risk factors important? For focused patient teaching aimed toward decreasing deformity or injury ● What guides the performance of the physical assessment of the musculoskeletal system? Subjective data from the history and current condition ● What is important for the nurse to do to assess whether symmetry is present? Comparing one side of the body with the other ● What does the nurse assess each joint for? ROM and muscle strength ● What involves both the musculoskeletal and neurological systems? Gait, coordination, and balance ● What do nurses use to assess the musculoskeletal system? Inspection and palpation ● What do advance practice nurses use to assess the musculoskeletal system? percussion to assess injured joints ● What do patients with fragile bones require to prevent fractures? Gentle handling ● What do nurses consider when developing nursing diagnoses and planning interventions? Abnormal findings in ROM and muscle strength ● How do nurses individualize assessment of the musculoskeletal system? According to the patient's condition, age, gender, and ethnicity ● Mr. Brown was playing soccer and hurt his right knee. It appears swollen. What is the first assessment you should make? B. Compare the swollen knee with the other knee ● Mrs. Johnson, a transcriptionist, reports pain and burning in her right hand. What assessment procedures should you perform next? D. Phalen and Tinel tests ● Which of the following assessment tasks can you appropriately delegate to an unlicensed care provider? A. Height, weight, and vital signs ● When doing an assessment of the spine of an older adult, you can expect to see which variation? C. Kyphosis ● The patient's muscle tone is hypertonic so the muscles are stiff and the movements are awkward. The nurse documents these findings as C. Spasticity ● The correctly document that ROM in the fingers is full and active, you would write that the patient can B. Make a fist, spread and close fingers, and do finger-thumb opposition ● When assessing a newborn, you note that one knee is lower than the other when the legs are flexed and the heels are together on the bed. You should correctly document this finding as positive C. Allis sign ● You are assessing a patient who has been diagnosed with a neuromuscular disorder. You note the patient cannot lift the right left off the bed when you are applying resistance. You would document the muscle strength in the right leg as B. 2.5 ● You note that an adolescent has uneven shoulder height. To differentiate functional from structural scoliosis, you ask the patient to D. Bend forward at the waist while you palpate the spine ● A patient reports that a previous right hip replacement is suddenly painful. Which hip assessment technique should you omit? A. Adduction ● A women reports that her moth has osteoporosis and wants to know what she can do to prevent developing the disease herself. Which of the following responses is best? C. Consume three servings of dairy products per day ● A 42-year-old male patient complains of shoulder pain when the nurse moves his arm behind the back. Which question should the nurse ask? b. "Do you have difficulty when you are putting on a shirt?" ● A patient with left knee pain is diagnosed with bursitis. The nurse will explain that bursitis is an inflammation of b. a small, fluid-filled sac found at some joints. ● The nurse who notes that a 59-year-old female patient has lost 1 inch in height over the past 2 years will plan to teach the patient about d. dual-energy x-ray absorptiometry (DXA). ● Which information in a 67-year-old woman's health history will alert the nurse to the need for a more focused assessment of the musculoskeletal system? b. The patient's mother became shorter with aging. ● Which information obtained during the nurse's assessment of a 30-year-old patient's nutritional-metabolic pattern may indicate the risk for musculoskeletal problems? c. The patient is 5 ft 2 in and weighs 180 lb. ● Which nursing action is correct when performing the straight-leg raising test for an ambulatory patient with back pain? a. Raise the patient's legs to a 60-degree angle from the bed. ● Which medication information will the nurse identify as a concern for a patient's musculoskeletal status? c. The patient has severe asthma and requires frequent therapy with oral corticosteroids. ● A 72-year-old patient with kyphosis is scheduled for dual-energy x-ray absorptiometry (DXA) testing. The nurse will plan to a. explain the procedure. d. 3. ● The nurse finds that a patient can flex the arms when no resistance is applied but is unable to flex when the nurse applies light resistance. The nurse should document the patient's muscle strength as level ● A patient has a new order for magnetic resonance imaging (MRI) to evaluate for left femur osteomyelitis after a hip replacement surgery. Which information indicates that the nurse should consult with the health care provider before scheduling the MRI? a. The patient has a pacemaker. ● After completing the health history, the nurse assessing the musculoskeletal system will begin by c. observing the patient's body build and muscle configuration. ● The nurse notes crackling sounds and a grating sensation with palpation of an older patient's elbow. How will this finding be documented? b. Crepitation ● Which finding is of highest priority when the nurse is planning care for a 77-year-old patient seen in the outpatient clinic? d. History of recent loss of balance and fall ● Which finding from a patient's right knee arthrocentesis will be of concern to the nurse? a. Cloudy fluid ● Which action can the nurse delegate to unlicensed assistive personnel (UAP) who are working in the orthopedic clinic? b. Obtain blood sample for uric acid from a patient with gout. ● A 63-year-old woman has been taking prednisone (Deltasone) daily for several years after a kidney transplant to prevent organ rejection. What is most important for the nurse to assess? C. Back or neck pain ● The home care nurse visits an 84-year-old woman with pneumonia after her discharge from the hospital. Which assessment finding would the nurse expect because of age-related changes in the musculoskeletal system? B. Muscle strength is scale grade 3/5 ● The nurse admits a 55-year-old female with multiple sclerosis to a long-term care facility. Which finding is of most immediate concern to the nurse? A. Ataxic gait ● A 57-year-old postmenopausal woman is scheduled for dual-energy x-ray absorptiometry (DXA). Which statement, if made by the patient to the nurse, indicates understanding of the procedure? B. "This procedure will not cause any pain or discomfort." ● A 42-year-old man who is scheduled for an arthrocentesis arrives at the outpatient surgery unit and states, "I do not want this procedure done today." Which response by the nurse is most appropriate? B. "Tell me what your concerns are about this procedure." ● The bone cells that function in the resorption of bone tissue are called clasts ● While performing passive range of motion for a patient, the nurse puts the ankle joint through the movements of (select all that apply) b. inversion and eversion. ● To prevent muscle atrophy, the nurse teaches the patient with a leg immobilized in traction to perform (select all that apply) tric contractions ● A patient with tendonitis asks what the tendon does. The nurse's response is based on the knowledge that tendons ct bone to muscle ● The increased risk for falls in the older adult is most likely due to es in balance ● While obtaining subjective assessment data related to the musculoskeletal system, it is particularly important to ask a patient about other medical problems such as tes mellitus ● When grading muscle strength, the nurse records a score of 3, which indicates d. active movement against gravity but not against resistance ● A normal assessment finding of the musculoskeletal system is deformity or crepitation. ● A patient is scheduled for an electromyogram (EMG). The nurse explains that this diagnostic test involves tion of small needles into certain muscles ● A 54-year-old patient admitted with cellulitis and probable osteomyelitis received an injection of radioisotope at 9:00 AM before a bone scan. The nurse should plan to send the patient for the bone scan at what time? C. 11:00 AM ● A 54-year-old patient is about to have a bone scan. In teaching the patient about this procedure, the nurse should include what information? D. The patient will be asked to drink increased fluids after the procedure. ● Musculoskeletal assessment is an important component of care for patients on what type of long-term therapy? A. Corticosteroids ● A female patient with a long-standing history of rheumatoid arthritis has sought care because of increasing stiffness in her right knee that has culminated in complete fixation of the joint. The nurse would document the presence of which problem? B. Ankylosis ● The nurse is performing a musculoskeletal assessment of an 81-year-old female patient whose mobility has been progressively decreasing in recent months. How should the nurse best assess the patient's range of motion (ROM) in the affected leg? A. Observe the patient's unassisted ROM in the affected leg. ● In reviewing bone remodeling, what should the nurse know about the involvement of bone cells? B. Osteoblasts deposit new bone. ● When working with patients, the nurse knows that patients have the most difficulties with diarthrodial joints. Which joints are included in this group of joints? (Select all that apply.) A. Hinge joint of the knee D. Ball and socket joint of the shoulder or hip ● An 82-year-old patient is frustrated by her flabby belly and rigid hips. What should the nurse tell the patient about these frustrations? D. "Decreased muscle mass and strength and increased hip rigidity are normal changes of aging." ● A 50-year-old patient is reporting a sore shoulder after raking the yard. The nurse should suspect which problem? A. Bursitis 1. 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: c. Adduction. 2. 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? a. Flexion 3. The functional units of the musculoskeletal system are the: a. Joints. 4. When reviewing the musculoskeletal system, the nurse recalls that hematopoiesis takes place in the: d. Bone marrow. 5. Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called: d. Ligaments. 6. The nurse notices that a woman in an exercise class is unable to jump rope. The nurse is aware that to jump rope, ones shoulder has to be capable of: d. Circumduction. 7. The articulation of the mandible and the temporal bone is known as the: c. Temporomandibular joint. 8. To palpate the temporomandibular joint, the nurses fingers should be placed in the depression of the ear. c. Anterior to the tragus 9. Of the 33 vertebrae in the spinal column, there are: a. 5 lumbar. 10. An imaginary line connecting the highest point on each iliac crest would cross the vertebra. b. Fourth lumbar 11. 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: d. Intervertebral disks. 12. The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. The nurse knows that a rotator cuff injury involves the: d. Glenohumeral joint. 13. During an interview the patient states, I can feel this bump on the top of both of my shoulders it doesn’t hurt but I am curious about what it might be. The nurse should tell the patient that it is his: b. Acromion process. 14. The nurse is checking the range of motion in a patients knee and knows that the knee is capable of which movement(s)? a. Flexion and extension 15. A patient is visiting the clinic for an evaluation of a swollen, painful knuckle. The nurse notices that the knuckle above his ring on the left hand is swollen and that he is unable to remove his wedding ring. This joint is called the? c. Metacarpophalangeal 16. The nurse is assessing a patients ischial tuberosity. To palpate the ischial tuberosity, the nurse knows that it is best to have the patient: b. Flexing the hip. 17. The nurse is examining the hip area of a patient and palpates a flat depression on the upper, lateral side of the thigh when the patient is standing. The nurse interprets this finding as the: b. Greater trochanter. 18. The ankle joint is the articulation of the tibia, fibula, and: a. Talus. 19. The nurse is explaining the mechanism of the growth of long bones to a mother of a toddler. Where does lengthening of the bones occur? c. Epiphyses 20. A woman who is 8 months pregnant comments that she has noticed a change in her posture and is having lower back pain. The nurse tells her that during pregnancy, women have a posture shift to compensate for the enlarging fetus. This shift in posture is known as: a. Lordosis. 21. An 85-year-old patient comments during his annual physical examination that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because: b. The vertebral column shortens. 22. A patient has been diagnosed with osteoporosis and asks the nurse, What is osteoporosis? The nurse explains that osteoporosis is defined as: b. Loss of bone density. 23. The nurse is teaching a class on preventing osteoporosis to a group of perimenopausal women. Which of these actions is the best way to prevent or delay bone loss in this group? c. Performing physical activity, such as fast walking 24. A teenage girl has arrived complaining of pain in her left wrist. She was playing basketball when she fell and landed on her left hand. The nurse examines her hand and would expect a fracture if the girl complains of a: c. Sharp pain that increases with movement. 25. A patient is complaining of pain in his joints that is worse in the morning, better after he moves around for a while, and then gets worse again if he sits for long periods. The nurse should assess for other signs of what problem? c. Rheumatoid arthritis 26. 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? a. Crepitation 27. A patient is able to flex his right arm forward without difficulty or pain but is unable to abduct his arm because of pain and muscle spasms. The nurse should suspect: b. Rotator cuff lesions. 28. A professional tennis player comes into the clinic complaining of a sore elbow. The nurse will assess for tenderness at the: d. Medial and lateral epicondyle. 29. The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen test. To perform this test, the nurse should instruct the patient to: c. Hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. 30. An 80-year-old woman is visiting the clinic for a checkup. She states, I cant walk as much as I used to. The nurse is observing for motor dysfunction in her hip and should ask her to: b. Abduct her hip while she is lying on her back. 31. The nurse has completed the musculoskeletal examination of a patients knee and has found a positive bulge sign. The nurse interprets this finding to indicate: d. Swelling from fluid in the suprapatellar pouch. 32. 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, the patient complains of a pain going down his buttock into his leg. The nurse suspects: c. Herniated nucleus pulposus. 33. The nurse is examining a 3-month-old infant. While the nurse holds his or her thumbs on the infants inner mid thighs and the fingers on the outside of the infants hips, touching the greater trochanter, the nurse adducts the legs until the his or her thumbs touch and then abducts the legs until the infants knees touch the table. The nurse does not notice any clunking sounds and is confident to record a: d. Negative Ortolani sign. 34. During a neonatal examination, the nurse notices that the newborn infant has six toes. This finding is documented as: c. Polydactyly. 35. A mother brings her newborn baby boy in for a checkup; she tells the nurse that he does not seem to be moving his right arm as much as his left and that he seems to have pain when she lifts him up under the arms. The nurse suspects a fractured clavicle and would observe for: c. Limited range of motion during the Moro reflex. 36. A 40-year-old man has come into the clinic with complaints of extreme pain in his toes. The nurse notices that his toes are slightly swollen, reddened, and warm to the touch. His complaints would suggest: b. Acute gout. 37. A young swimmer comes to the sports clinic complaining of a very sore shoulder. He was running at the pool, slipped on some wet concrete, and tried to catch himself with his outstretched hand. He landed on his outstretched hand and has not been able to move his shoulder since. The nurse suspects: d. Dislocated shoulder. 38. A 68-year-old woman has come in for an assessment of her rheumatoid arthritis, and the nurse notices raised, firm, nontender nodules at the olecranon bursa and along the ulna. These nodules are most commonly diagnosed as: d. Subcutaneous nodules. 39. 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: b. Ulnar deviation. 40. A patient who has had rheumatoid arthritis for years comes to the clinic to ask about changes in her fingers. The nurse will assess for signs of what problems? c. Swan-neck deformities 41. A patients annual physical examination reveals a lateral curvature of the thoracic and lumbar segments of his spine; however, this curvature disappears with forward bending. The nurse knows that this abnormality of the spine is called: b. Functional scoliosis. 42. A 14-year-old boy who has been diagnosed with Osgood-Schlatter disease reports painful swelling just below the knee for the past 5 months. Which response by the nurse is appropriate? c. Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest. 43. When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What grade of muscle strength should the nurse record using a 0- to 5-point scale? d. 5 44. The nurse is examining a 6-month-old infant and places the infants feet flat on the table and flexes his knees up. The nurse notes that the right knee is significantly lower than the left. Which of these statements is true of this finding? a. This finding is a positive Allis sign and suggests hip dislocation. 45. The nurse is assessing a 1-week-old infant and is testing his muscle strength. The nurse lifts the infant with hands under the axillae and notices that the infant starts to slip between the hands. The nurse should: c. Suspect that the infant may have weakness of the shoulder muscles. 46. The nurse is examining a 2-month-old infant and notices asymmetry of the infants gluteal folds. The nurse should assess for other signs of what disorder