Exam 1: NR304 (Latest Updates
Health Assessment II | Questions & Answers |
Grade A | 100% Correct (Verified Solutions)
1. **Hypoglossal** ANS The nurse is performing a neuro assessment on a
client. The nurse assesses the tongue for strength. Which cranial nerve is the
nurse assessing?
Trochlear
Glossopharyngeal
Abducens
Hypoglossal
2. **Tinel's sign** ANS Used to detect carpal tunnel syndrome. It is
performed by lightly tapping over the nerve to elicit a sensation of tingling or
"pins and needles" in the distribution of the nerve
3. **Lordosis** ANS A curving inward of the lower back
4. **Morse Fall Scale** ANS A rapid and simple method of assessing a
patient likelihood of falling
5. **Scoliosis** ANS A sideways curvature of the spine
1
,6. **Phalen's test** ANS A provocative test use in the diagnosis of carpal
tunnel syndrome. A positive test occurs with numbness and tingling on the
Palmer aspect of the first, second, third, and real half of the fourth digit within
60 seconds of assuming the position. Dorsal side of the hands touch and bend
90° at the wrist
7. **Ortolani maneuver** ANS checks for congenital hip dislocation;
performed every visit until 1 year old. If it is positive you will hear a click
8. **Bulge sign** ANS A medial aspect that bulges out after lateral pressure
is consistent with a moderate amount of fluid. Positive sign
9. **Ballottement** ANS A medical sign which indicates increased fluid in
the suprapatellar pouch over the patella at the knee joint
10. **Rheumatoid arthritis** ANS a chronic autoimmune disease with
inflammation of the joints and marked deformities
- Swan neck and boutonniere deformities
- rheumatoid nodules ulner deviation
Pain gets better with movement
11. **Swan neck deformity** ANS Joint closest to the fingertip is
permanently bent toward the palm all the nearest joint to the palm is bent
away from it
2
, 12. **Boutonniere deformity** ANS The result of an injury due to the
tendons that straightens the middle joint of your finger
13. **Osteoarthritis** ANS A disease of the joints in which cartilage breaks
down Bouchard nodes - found in proximal joint Heberden nodes - found in
distal joint Pain gets worse with movement
14. **Muscle strength testing** ANS
5 - Full range of motion against gravity with full resistance - normal
4 - Full range of motion against gravity with moderate resistance - good
3 - Full range of motion with gravity - fair
2 - Full range of motion without gravity (passive motion) - Poor
1 - palpable muscle contraction but no movement - trace
0 - no muscle contraction - zero
15. **Hendrich II Fall Risk Model** ANS Provides a determination of risk
for falling based on gender, mental and emotional status, symptoms of
dizziness, and known categories of medications
16. **Get up and go test** ANS get up from chair walk a short distance turn
around and sit; screening test for fall
17. **Tinetti POMA** ANS Screens elderly patients with balance and gait
impairment or fall risks. A common clinical test for assessing a persons static
and dynamic balance abilities
3
Health Assessment II | Questions & Answers |
Grade A | 100% Correct (Verified Solutions)
1. **Hypoglossal** ANS The nurse is performing a neuro assessment on a
client. The nurse assesses the tongue for strength. Which cranial nerve is the
nurse assessing?
Trochlear
Glossopharyngeal
Abducens
Hypoglossal
2. **Tinel's sign** ANS Used to detect carpal tunnel syndrome. It is
performed by lightly tapping over the nerve to elicit a sensation of tingling or
"pins and needles" in the distribution of the nerve
3. **Lordosis** ANS A curving inward of the lower back
4. **Morse Fall Scale** ANS A rapid and simple method of assessing a
patient likelihood of falling
5. **Scoliosis** ANS A sideways curvature of the spine
1
,6. **Phalen's test** ANS A provocative test use in the diagnosis of carpal
tunnel syndrome. A positive test occurs with numbness and tingling on the
Palmer aspect of the first, second, third, and real half of the fourth digit within
60 seconds of assuming the position. Dorsal side of the hands touch and bend
90° at the wrist
7. **Ortolani maneuver** ANS checks for congenital hip dislocation;
performed every visit until 1 year old. If it is positive you will hear a click
8. **Bulge sign** ANS A medial aspect that bulges out after lateral pressure
is consistent with a moderate amount of fluid. Positive sign
9. **Ballottement** ANS A medical sign which indicates increased fluid in
the suprapatellar pouch over the patella at the knee joint
10. **Rheumatoid arthritis** ANS a chronic autoimmune disease with
inflammation of the joints and marked deformities
- Swan neck and boutonniere deformities
- rheumatoid nodules ulner deviation
Pain gets better with movement
11. **Swan neck deformity** ANS Joint closest to the fingertip is
permanently bent toward the palm all the nearest joint to the palm is bent
away from it
2
, 12. **Boutonniere deformity** ANS The result of an injury due to the
tendons that straightens the middle joint of your finger
13. **Osteoarthritis** ANS A disease of the joints in which cartilage breaks
down Bouchard nodes - found in proximal joint Heberden nodes - found in
distal joint Pain gets worse with movement
14. **Muscle strength testing** ANS
5 - Full range of motion against gravity with full resistance - normal
4 - Full range of motion against gravity with moderate resistance - good
3 - Full range of motion with gravity - fair
2 - Full range of motion without gravity (passive motion) - Poor
1 - palpable muscle contraction but no movement - trace
0 - no muscle contraction - zero
15. **Hendrich II Fall Risk Model** ANS Provides a determination of risk
for falling based on gender, mental and emotional status, symptoms of
dizziness, and known categories of medications
16. **Get up and go test** ANS get up from chair walk a short distance turn
around and sit; screening test for fall
17. **Tinetti POMA** ANS Screens elderly patients with balance and gait
impairment or fall risks. A common clinical test for assessing a persons static
and dynamic balance abilities
3
