nurse 360 exam 4 Questions With Complete Solutions
aging adult considerations Correct Answers progressive loss of
neurons in the brain and spinal cord. Decreased muscle
bulk/tone (face, neck, spine), strength, decreased fine
coordination. Decreased vibratory sense at ankle, decreased or
absent achilles reflex. Decreased nerve conduction (can affect
reaction time, impulse takes longer to travel. Possible
diminished sense of pain and/or touch. Dimished sense of smell
and taste, motor system slows, dec muscle strength and agility,
possible muscle tremors and or dyskinesias, dec (progressively)
of cerebral blood blow
allis test Correct Answers (compares leg length) infant supine
on table, flex knees and keep feet flat on table (should see knees
at same elevation
Alzheimer's disease Correct Answers incurable, degenerative
neurologic disorder. Most common cause of dementia in western
countries. Cause unknown: theories suggest genetic tendency,
environmental toxins, altered neurotransmitter function,
autoimmune reaction or slow virus. Clients with history of small
strokes have tendency to develop Alzheimer disease. Clinical
findings: three stages have been described. Early stage lasts 2 to
4 years when clients memory begins to fail. Second stage lasts
from 2 to 12 years when client experiences progressive memory
loss and has difficulty with ADLs (language skills deteriorate
and client becomes disoriented and confused). Final stage, client
requires total care and is unable to communicate
,ankle/feet exam Correct Answers observe ankles and feet for
ROM (20 degree dorsiflexion, 45 degree plantar flexion from
midline. 20* eversion, 30* inversion from midline. 10*
abduction, 20* adduction. Equal bilateral flexion and extension
of toes). Test ankles and feet muscles for strength
assess peripheral nerves Correct Answers assess for
sensations. Flex muscles then resist against opposite force,
monofilament for peripheral sensation for peripheral
neuropathy, light touch with cotton tipped swab, vibration using
tuning fork on bony prominence, discrimination testing
(stereognosis, astereognosis (cannot identify object that is in
hand), summation (tap body around same area twice quick so
feels like one big touch, tactile discrimination (sense fine touch),
extinction (both arms touched at same time but only feel one
side <abnormal)
nerve pathway moves muscles involuntarily w/out input from
the brain. Afferent fiber carry message, travel in dorsal root into
the spinal cord, synapse in the cord, send message back through
efferent fibers. Response below the LOC
assessing muscle strength Correct Answers assess against
resistance and gravity. 0/5 is no contraction 1/5 is muscle
flicker, but no movement 2/5 is movement possible but not
against gravity 3/5 is movement possible against gravity, but not
against resistance by examiner 4/5 is movement possible against
some resistance by the examiner 5/5 is normal strength
babinskis response Correct Answers found in infants up to 2
years. Myelination isn't fully complete. So pathologic response
with people older than 2. Draw along lateral aspect of foot and
, over towards great toe. Normal response would be curling of the
toes and plantar flexion < plantar reflex intact and abnormal is
dorsiflexion of toes and fanning of toes <positive Babinski sign
ball-and-socket joints Correct Answers ball-shaped bone fits
into concave area of articulating bone (hip)
bells palsy Correct Answers acute unilateral paralysis of facial
nerve (VII). 7-80% of clients recover fully after a few weeks or
months. Etiology unknown but maybe from a virus. Clinical
findings: history of pain behind ear or face few hours or days
before paralysis, affected side: eye doesn't close, forehand
doesn't wrinkle, unable to whistle or smile, increased
lacrimation. Happens a lot with pregnant women in their 3rd
stage of pregnancy. Sloping of one side of face basically
biceps reflex Correct Answers contraction of biceps muscle,
flexion of elbow
brachioradial reflex Correct Answers supination of forearm,
flexion of elbow
brainstem Correct Answers moves the eyes./mouth, sensory
(hot cold loud), hunger, respirations, consciousness, cardiac
function, temp, involuntary muscle movements, sneezing,
coughing, swallow/vomit. Includes midbrain, pons, medulla.
cranial nerves III-XII originate off of here. Connects lower brain
to spinal cord and is the "life center".
brudzinskis sign Correct Answers patient lies supine; flex
patients neck chin to chest and hold about 10 seconds. If
aging adult considerations Correct Answers progressive loss of
neurons in the brain and spinal cord. Decreased muscle
bulk/tone (face, neck, spine), strength, decreased fine
coordination. Decreased vibratory sense at ankle, decreased or
absent achilles reflex. Decreased nerve conduction (can affect
reaction time, impulse takes longer to travel. Possible
diminished sense of pain and/or touch. Dimished sense of smell
and taste, motor system slows, dec muscle strength and agility,
possible muscle tremors and or dyskinesias, dec (progressively)
of cerebral blood blow
allis test Correct Answers (compares leg length) infant supine
on table, flex knees and keep feet flat on table (should see knees
at same elevation
Alzheimer's disease Correct Answers incurable, degenerative
neurologic disorder. Most common cause of dementia in western
countries. Cause unknown: theories suggest genetic tendency,
environmental toxins, altered neurotransmitter function,
autoimmune reaction or slow virus. Clients with history of small
strokes have tendency to develop Alzheimer disease. Clinical
findings: three stages have been described. Early stage lasts 2 to
4 years when clients memory begins to fail. Second stage lasts
from 2 to 12 years when client experiences progressive memory
loss and has difficulty with ADLs (language skills deteriorate
and client becomes disoriented and confused). Final stage, client
requires total care and is unable to communicate
,ankle/feet exam Correct Answers observe ankles and feet for
ROM (20 degree dorsiflexion, 45 degree plantar flexion from
midline. 20* eversion, 30* inversion from midline. 10*
abduction, 20* adduction. Equal bilateral flexion and extension
of toes). Test ankles and feet muscles for strength
assess peripheral nerves Correct Answers assess for
sensations. Flex muscles then resist against opposite force,
monofilament for peripheral sensation for peripheral
neuropathy, light touch with cotton tipped swab, vibration using
tuning fork on bony prominence, discrimination testing
(stereognosis, astereognosis (cannot identify object that is in
hand), summation (tap body around same area twice quick so
feels like one big touch, tactile discrimination (sense fine touch),
extinction (both arms touched at same time but only feel one
side <abnormal)
nerve pathway moves muscles involuntarily w/out input from
the brain. Afferent fiber carry message, travel in dorsal root into
the spinal cord, synapse in the cord, send message back through
efferent fibers. Response below the LOC
assessing muscle strength Correct Answers assess against
resistance and gravity. 0/5 is no contraction 1/5 is muscle
flicker, but no movement 2/5 is movement possible but not
against gravity 3/5 is movement possible against gravity, but not
against resistance by examiner 4/5 is movement possible against
some resistance by the examiner 5/5 is normal strength
babinskis response Correct Answers found in infants up to 2
years. Myelination isn't fully complete. So pathologic response
with people older than 2. Draw along lateral aspect of foot and
, over towards great toe. Normal response would be curling of the
toes and plantar flexion < plantar reflex intact and abnormal is
dorsiflexion of toes and fanning of toes <positive Babinski sign
ball-and-socket joints Correct Answers ball-shaped bone fits
into concave area of articulating bone (hip)
bells palsy Correct Answers acute unilateral paralysis of facial
nerve (VII). 7-80% of clients recover fully after a few weeks or
months. Etiology unknown but maybe from a virus. Clinical
findings: history of pain behind ear or face few hours or days
before paralysis, affected side: eye doesn't close, forehand
doesn't wrinkle, unable to whistle or smile, increased
lacrimation. Happens a lot with pregnant women in their 3rd
stage of pregnancy. Sloping of one side of face basically
biceps reflex Correct Answers contraction of biceps muscle,
flexion of elbow
brachioradial reflex Correct Answers supination of forearm,
flexion of elbow
brainstem Correct Answers moves the eyes./mouth, sensory
(hot cold loud), hunger, respirations, consciousness, cardiac
function, temp, involuntary muscle movements, sneezing,
coughing, swallow/vomit. Includes midbrain, pons, medulla.
cranial nerves III-XII originate off of here. Connects lower brain
to spinal cord and is the "life center".
brudzinskis sign Correct Answers patient lies supine; flex
patients neck chin to chest and hold about 10 seconds. If
