NURS-160 EXAM 4 STUDY GUIDE 142 QUESTIONS
WITH VERIFIED ANSWERS 2025/2026
B. 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. - CORRECT ANSWER 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.
D. 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
Trendelenburg test is for hip disease. - CORRECT ANSWER 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
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. - CORRECT ANSWER 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
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. -
CORRECT ANSWER 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
C. Spasticity.
Rationale: Atony is the lack of tone or strength, tremors are involuntary
contractions of muscles, and fasciculation is involuntary twitching. - CORRECT
ANSWER 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.
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. - CORRECT ANSWER .
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.
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. - CORRECT ANSWER 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.
A. Adduction.
Rationale: Adduction of the hip may cause the artificial hip to dislocate. The other
activities are not restricted. - CORRECT ANSWER A patient reports that a previous
right hip replacement is suddenly painful. Which hip assessment technique should
you omit?
WITH VERIFIED ANSWERS 2025/2026
B. 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. - CORRECT ANSWER 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.
D. 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
Trendelenburg test is for hip disease. - CORRECT ANSWER 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
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. - CORRECT ANSWER 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
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. -
CORRECT ANSWER 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
C. Spasticity.
Rationale: Atony is the lack of tone or strength, tremors are involuntary
contractions of muscles, and fasciculation is involuntary twitching. - CORRECT
ANSWER 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.
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. - CORRECT ANSWER .
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.
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. - CORRECT ANSWER 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.
A. Adduction.
Rationale: Adduction of the hip may cause the artificial hip to dislocate. The other
activities are not restricted. - CORRECT ANSWER A patient reports that a previous
right hip replacement is suddenly painful. Which hip assessment technique should
you omit?
