In a person with an upper motor neuron lesion such as a cerebrovascular accident,
which of these physical assessment findings should the nurse expect?
a. Hyperreflexia
b. Fasciculations
c. Loss of muscle tone and flaccidity
d. Atrophy and wasting of the muscles
Give this one a try later!
, a. Hyperreflexia
The nurse places a key in the hand of a patient and he identifies it as a penny. What
term would the nurse use to describe this finding?
a. Extinction
b. Astereognosis
c. Graphesthesia
d. Tactile discrimination
Give this one a try later!
b. Astereognosis
When performing a musculoskeletal assessment, the nurse knows that the correct
approach for the examination should be:
a. Proximal to distal.
b. Distal to proximal.
c. Posterior to anterior.
d. Anterior to posterior.
Give this one a try later!
a. Proximal to distal.
The nurse is reviewing a patient's medical record and notes that he is in a coma. Using
the Glasgow Coma Scale, which number indicates that the patient is in a coma?
a. 6
b. 12
,c. 15
d. 24
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a. 6
The ability that humans have to perform very skilled movements such as writing is
controlled by the:
a. Basal ganglia.
b. Corticospinal tract.
c. Spinothalamic tract.
d. Extrapyramidal tract.
Give this one a try later!
b. Corticospinal tract.
A 21-year-old patient has a head injury resulting from trauma and is unconscious.
There are no other injuries. During the assessment what would the nurse expect to
find when testing the patient's deep tendon reflexes?
a. Reflexes will be normal.
b. Reflexes cannot be elicited.
c. All reflexes will be diminished but present.
d. Some reflexes will be present, depending on the area of injury.
Give this one a try later!
a. Reflexes will be normal.
, A 14-year-old boy who has been diagnosed with Osgood-Schlatter disease reports
painful swelling just below the knee for the past 5 months. Which response by the
nurse is appropriate?
a. "If these symptoms persist, you may need arthroscopic surgery."
b. "You are experiencing degeneration of your knee, which may not resolve."
c... "Your disease is due to repeated stress on the patellar tendon. It is usually self-
limited, and your symptoms should resolve with rest."
d. "Increasing your activity and performing knee-strengthening exercises will help
decrease the inflammation and maintain mobility in the knee."
Give this one a try later!
c... "Your disease is due to repeated stress on the patellar tendon. It is
usually self-limited, and your symptoms should resolve with rest."
In the assessment of a 1-month-old infant, the nurse notices a lack of response to
noise or stimulation. The mother reports that in the last week he has been sleeping all
of the time, and when he is awake all he does is cry... The nurse hears that the infant's
cries are very high pitched and shrill. What should be the nurse's appropriate
response to these findings?
a. Refer the infant for further testing.
b. Talk with the mother about eating habits.
c. Do nothing; these are expected findings for an infant this age.
d. Tell the mother to bring the baby back in 1 week for a recheck.
Give this one a try later!
a. Refer the infant for further testing.
A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that
when he walks, his left arm is immobile against the body with flexion of the shoulder,
which of these physical assessment findings should the nurse expect?
a. Hyperreflexia
b. Fasciculations
c. Loss of muscle tone and flaccidity
d. Atrophy and wasting of the muscles
Give this one a try later!
, a. Hyperreflexia
The nurse places a key in the hand of a patient and he identifies it as a penny. What
term would the nurse use to describe this finding?
a. Extinction
b. Astereognosis
c. Graphesthesia
d. Tactile discrimination
Give this one a try later!
b. Astereognosis
When performing a musculoskeletal assessment, the nurse knows that the correct
approach for the examination should be:
a. Proximal to distal.
b. Distal to proximal.
c. Posterior to anterior.
d. Anterior to posterior.
Give this one a try later!
a. Proximal to distal.
The nurse is reviewing a patient's medical record and notes that he is in a coma. Using
the Glasgow Coma Scale, which number indicates that the patient is in a coma?
a. 6
b. 12
,c. 15
d. 24
Give this one a try later!
a. 6
The ability that humans have to perform very skilled movements such as writing is
controlled by the:
a. Basal ganglia.
b. Corticospinal tract.
c. Spinothalamic tract.
d. Extrapyramidal tract.
Give this one a try later!
b. Corticospinal tract.
A 21-year-old patient has a head injury resulting from trauma and is unconscious.
There are no other injuries. During the assessment what would the nurse expect to
find when testing the patient's deep tendon reflexes?
a. Reflexes will be normal.
b. Reflexes cannot be elicited.
c. All reflexes will be diminished but present.
d. Some reflexes will be present, depending on the area of injury.
Give this one a try later!
a. Reflexes will be normal.
, A 14-year-old boy who has been diagnosed with Osgood-Schlatter disease reports
painful swelling just below the knee for the past 5 months. Which response by the
nurse is appropriate?
a. "If these symptoms persist, you may need arthroscopic surgery."
b. "You are experiencing degeneration of your knee, which may not resolve."
c... "Your disease is due to repeated stress on the patellar tendon. It is usually self-
limited, and your symptoms should resolve with rest."
d. "Increasing your activity and performing knee-strengthening exercises will help
decrease the inflammation and maintain mobility in the knee."
Give this one a try later!
c... "Your disease is due to repeated stress on the patellar tendon. It is
usually self-limited, and your symptoms should resolve with rest."
In the assessment of a 1-month-old infant, the nurse notices a lack of response to
noise or stimulation. The mother reports that in the last week he has been sleeping all
of the time, and when he is awake all he does is cry... The nurse hears that the infant's
cries are very high pitched and shrill. What should be the nurse's appropriate
response to these findings?
a. Refer the infant for further testing.
b. Talk with the mother about eating habits.
c. Do nothing; these are expected findings for an infant this age.
d. Tell the mother to bring the baby back in 1 week for a recheck.
Give this one a try later!
a. Refer the infant for further testing.
A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that
when he walks, his left arm is immobile against the body with flexion of the shoulder,
