NURS 612 FINAL EXAM MARYVILLE UNIVERSITY
ADVANCED HEALTH ASSESSMENT NEWEST 2024
ACTUAL EXAM 150 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) ALREADY GRADED A+
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.
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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
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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
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Trendlenburg sign - ANSWER-Weak hip abductor
Herberden nodes and bouchard nodes noted on the hands - ANSWER-
Osteoarthritis
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
Subcutaneous nodules on the forearm near the elbow - ANSWER-Rheumatoid
arthritis
tenderness, swelling, and boggy sensation with palpation along the grooves of the
olecranon process; increased pain with pronation and supination - ANSWER-
Epicondylitis (tennis elbow) or tendonitis
A child with muscle atrophy and symptoms of progressive muscle weakness -
ANSWER-Muscular dystrophy
A child complaining of pain in the elbow and wrist; will not move his or her arm;
maintains arm in a flexed and pronated position - ANSWER-Radial head
subluxation
Chronic inflammatory disease involving the spine and sacroiliac joints - ANSWER-
Ankylosing spondylitis
Numbness, burning, and tingling in the hands - ANSWER-Carpal tunnel syndrome
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