NURS-160 EXAM 4 STUDY GUIDE 100%
SOLVED
Mr. Brown was playing soccer and hurt his right knee. It appears swollen. What is the
first assessment you should make?
a. Palpate for crepitus in the knee.
b. Compare the swollen knee with the other knee.
c. Assess active ROM in the knee.
d. Feel the knee for warmth. - ANSWERB. Compare the swollen knee with the other
knee.
Rationale: The first step is inspection. The first thing to do is to compare one knee with
the other for symmetry. All the other answers are procedures for assessing joints, which
may be indicated but do not represent the first step that the nurse should take.
Mrs. Johnson, a transcriptionist, reports pain and burning in her right hand. What
assessment procedures should you perform next?
a. Trendelenburg and drawer signs
b. McMurray and Thomas tests
c. Bulge test and ballottement
d. Phalen and Tinel tests - ANSWERD. Phalen and Tinel tests.
Rationale: Both Phalen and Tinel signs are specific findings with carpal tunnel
syndrome. Based on Mrs. Johnson's occupation, she is at risk for this problem. Bulge
and ballottement tests look for effusion in the knee joint. The McMurray test assesses
for meniscus tears in the knee. The Thomas test is used to identify flexion contracture of
the hip. The Drawer test is for knee injury and the Trendelenberg test is for hip disease.
Which of the following assessment tasks can you appropriately delegate to an
unlicensed care provider?
a. Height, weight, and vital signs
b. Active and passive ROM
c. History of current complaint
d. Muscle strength - ANSWERA. Height, weight, and vital signs.
Rationale: Nurses frequently delegate the taking of height, weight, and vital signs to
unlicensed care providers. The other items are parts of assessment that cannot be
delegated to unlicensed personnel.
,When doing an assessment of the spine of an older adult, you can expect to see which
variation?
a. Lordosis
b. Torticollis
c. Kyphosis
d. Scoliosis - ANSWERC. Kyphosis.
Rationale: Many older adults normally have an exaggerated forward curve of the
thoracic spine, which may appear even more curved because of fat pad deposits.
The patient's muscle tone is hypertonic so the muscles are stiff and the movements are
awkward. The nurse documents these findings as
a. atony.
b. tremors.
c. spasticity.
d. fasciculation. - ANSWERC. Spasticity.
Rationale: Atony is the lack of tone or strength, tremors are involuntary contractions of
muscles, and fasciculation is involuntary twitching.
. To correctly document that ROM in the fingers is full and active, you would write that
the patient can
a. perform rotation, lateral flexion, and hyperextension.
b. make a fist, spread and close fingers, and do finger-thumb opposition.
c. touch finger to own nose and to examiner's finger back and forth.
d. perform supination, pronation, and lateral deviation. - ANSWERB. Make a fist, spread
and close fingers, and do finger-thumb opposition.
Rationale: Finger movements are flexion, extension, abduction, and adduction. The
fingers do not perform rotation or lateral flexion. Touching the finger to the nose is part
of neurological assessment, not range-of-motion (ROM) testing. The wrist performs
supination, pronation, and lateral deviation.
You note that an adolescent has uneven shoulder height. To differentiate functional
from structural scoliosis, you ask the patient to
a. stand up straight while you check the height of the iliac crest.
b. flex the elbow and pull against your resistance.
c. shrug both shoulders while you provide resistance.
d. bend forward at the waist while you palpate the spine. - ANSWERD. Bend forward at
the waist while you palpate the spine.
, Rationale: Checking the height of the iliac crest will provide information about scoliosis
but will not differentiate functional from structural. With functional scoliosis, the spine
straightens with bending. This problem usually is associated with uneven leg length.
A patient reports that a previous right hip replacement is suddenly painful. Which hip
assessment technique should you omit?
a. Adduction
b. Hyperextension
c. Extension
d. Circumduction - ANSWERA. Adduction.
Rationale: Adduction of the hip may cause the artificial hip to dislocate. The other
activities are not restricted.
A young adult marathoner reports of right foot third metatarsal pain (6/10) and swelling
for more than 4 weeks. An x-ray was ordered, and it did not show abnormal findings.
Which of the following imaging might the nurse expect the physician to order?
a. Repeat x-ray
b. CT scan
c. MRI
d. Nuclear scintigraphy - ANSWERC. MRI.
Rationale: Systematic reviews demonstrated that MRI has the highest specificity for
diagnosing stress fractures and is followed by nuclear scintigraphy. Repeat x-ray
imaging is not indicated and has the lowest specificity for detecting stress fractures. A
CT scan is not the most appropriate imaging for stress fractures.
A man had a motor vehicular accident and fractured his right ankle. He was transferred
from the emergency department to the orthopedic nursing unit for further observation
and possible surgery in the next 12 hours. What is the priority nursing assessment of
the admitting orthopedic nurse?
a. Temperature
b. Capillary refill proximal to the injury of the right ankle
c. Capillary refill distal to the injury of the left ankle
d. Capillary refill distal to the injury of the right ankle - ANSWERD. Capillary refill distal
to the injury of the right ankle.
Rationale: Capillary refill is the priority nursing assessment to evaluate tissue perfusion
for orthopedic trauma patients. Temperature is not a priority nursing assessment.
Assessment of capillary refill should be distal to the injury and not proximal. The patient
fractured his right ankle, and assessment of the left ankle is not the priority.
SOLVED
Mr. Brown was playing soccer and hurt his right knee. It appears swollen. What is the
first assessment you should make?
a. Palpate for crepitus in the knee.
b. Compare the swollen knee with the other knee.
c. Assess active ROM in the knee.
d. Feel the knee for warmth. - ANSWERB. Compare the swollen knee with the other
knee.
Rationale: The first step is inspection. The first thing to do is to compare one knee with
the other for symmetry. All the other answers are procedures for assessing joints, which
may be indicated but do not represent the first step that the nurse should take.
Mrs. Johnson, a transcriptionist, reports pain and burning in her right hand. What
assessment procedures should you perform next?
a. Trendelenburg and drawer signs
b. McMurray and Thomas tests
c. Bulge test and ballottement
d. Phalen and Tinel tests - ANSWERD. Phalen and Tinel tests.
Rationale: Both Phalen and Tinel signs are specific findings with carpal tunnel
syndrome. Based on Mrs. Johnson's occupation, she is at risk for this problem. Bulge
and ballottement tests look for effusion in the knee joint. The McMurray test assesses
for meniscus tears in the knee. The Thomas test is used to identify flexion contracture of
the hip. The Drawer test is for knee injury and the Trendelenberg test is for hip disease.
Which of the following assessment tasks can you appropriately delegate to an
unlicensed care provider?
a. Height, weight, and vital signs
b. Active and passive ROM
c. History of current complaint
d. Muscle strength - ANSWERA. Height, weight, and vital signs.
Rationale: Nurses frequently delegate the taking of height, weight, and vital signs to
unlicensed care providers. The other items are parts of assessment that cannot be
delegated to unlicensed personnel.
,When doing an assessment of the spine of an older adult, you can expect to see which
variation?
a. Lordosis
b. Torticollis
c. Kyphosis
d. Scoliosis - ANSWERC. Kyphosis.
Rationale: Many older adults normally have an exaggerated forward curve of the
thoracic spine, which may appear even more curved because of fat pad deposits.
The patient's muscle tone is hypertonic so the muscles are stiff and the movements are
awkward. The nurse documents these findings as
a. atony.
b. tremors.
c. spasticity.
d. fasciculation. - ANSWERC. Spasticity.
Rationale: Atony is the lack of tone or strength, tremors are involuntary contractions of
muscles, and fasciculation is involuntary twitching.
. To correctly document that ROM in the fingers is full and active, you would write that
the patient can
a. perform rotation, lateral flexion, and hyperextension.
b. make a fist, spread and close fingers, and do finger-thumb opposition.
c. touch finger to own nose and to examiner's finger back and forth.
d. perform supination, pronation, and lateral deviation. - ANSWERB. Make a fist, spread
and close fingers, and do finger-thumb opposition.
Rationale: Finger movements are flexion, extension, abduction, and adduction. The
fingers do not perform rotation or lateral flexion. Touching the finger to the nose is part
of neurological assessment, not range-of-motion (ROM) testing. The wrist performs
supination, pronation, and lateral deviation.
You note that an adolescent has uneven shoulder height. To differentiate functional
from structural scoliosis, you ask the patient to
a. stand up straight while you check the height of the iliac crest.
b. flex the elbow and pull against your resistance.
c. shrug both shoulders while you provide resistance.
d. bend forward at the waist while you palpate the spine. - ANSWERD. Bend forward at
the waist while you palpate the spine.
, Rationale: Checking the height of the iliac crest will provide information about scoliosis
but will not differentiate functional from structural. With functional scoliosis, the spine
straightens with bending. This problem usually is associated with uneven leg length.
A patient reports that a previous right hip replacement is suddenly painful. Which hip
assessment technique should you omit?
a. Adduction
b. Hyperextension
c. Extension
d. Circumduction - ANSWERA. Adduction.
Rationale: Adduction of the hip may cause the artificial hip to dislocate. The other
activities are not restricted.
A young adult marathoner reports of right foot third metatarsal pain (6/10) and swelling
for more than 4 weeks. An x-ray was ordered, and it did not show abnormal findings.
Which of the following imaging might the nurse expect the physician to order?
a. Repeat x-ray
b. CT scan
c. MRI
d. Nuclear scintigraphy - ANSWERC. MRI.
Rationale: Systematic reviews demonstrated that MRI has the highest specificity for
diagnosing stress fractures and is followed by nuclear scintigraphy. Repeat x-ray
imaging is not indicated and has the lowest specificity for detecting stress fractures. A
CT scan is not the most appropriate imaging for stress fractures.
A man had a motor vehicular accident and fractured his right ankle. He was transferred
from the emergency department to the orthopedic nursing unit for further observation
and possible surgery in the next 12 hours. What is the priority nursing assessment of
the admitting orthopedic nurse?
a. Temperature
b. Capillary refill proximal to the injury of the right ankle
c. Capillary refill distal to the injury of the left ankle
d. Capillary refill distal to the injury of the right ankle - ANSWERD. Capillary refill distal
to the injury of the right ankle.
Rationale: Capillary refill is the priority nursing assessment to evaluate tissue perfusion
for orthopedic trauma patients. Temperature is not a priority nursing assessment.
Assessment of capillary refill should be distal to the injury and not proximal. The patient
fractured his right ankle, and assessment of the left ankle is not the priority.
