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NURS-160 Exam 4 Study Guide exam with correct answers.

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NURS-160 Exam 4 Study Guide exam with correct answers.

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Nursing 160
Course
Nursing 160











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Institution
Nursing 160
Course
Nursing 160

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Uploaded on
September 13, 2025
Number of pages
39
Written in
2025/2026
Type
Exam (elaborations)
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NURS-160 Exam 4 Study Guide exam with |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\




correct answers |||\\\




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.
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c. Assess active ROM in the knee.
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d. Feel the knee for warmth. - correct answer✔✔B. Compare the swollen knee with the other
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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.
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Mrs. Johnson, a transcriptionist, reports pain and burning in her right hand. What assessment
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\




procedures should you perform next? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\




a. Trendelenburg and drawer signs
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b. McMurray and Thomas tests
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c. Bulge test and ballottement
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d. Phalen and Tinel tests - correct answer✔✔D. Phalen and Tinel tests.
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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.
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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 - correct answer✔✔A. 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 - correct answer✔✔C. 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. - correct answer✔✔C. 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. - correct answer✔✔B. 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. - correct answer✔✔D. 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 - correct answer✔✔A. 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 - correct answer✔✔C. MRI.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
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