NU160/NU 160 Exam 4 (New 2026/2027 Version) Comprehensive Mental Health Review | Exam Questions with Accurate Solutions | Grade A – Galen

…..DLDD NU160/NU 160 Exam 4 (New 2026/2027 Version) Comprehensive Mental Health Review | Exam Questions with Accurate Solutions | Grade A – Galen Q. 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. ANSWER 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. Q. 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 ANSWER 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 Trendelenberg test is for hip disease. Q. 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 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. Q. 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 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. Q. 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. ANSWER C. Spasticity. Rationale: Atony is the lack of tone or strength, tremors are involuntary contractions of muscles, and fasciculation is involuntary twitching. Q. 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. 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. Q. 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. 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. Q. 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 ANSWER A. Adduction. Rationale: Adduction of the hip may cause the artificial hip to dislocate. The other activities are not restricted. Q. 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 ANSWER C. MRI. Rationale: Systematic reviews demonstrated that MRI has the highest specificity for diagnosing stress fractures and is followed by nuclear scintigraphy. Repeat x-ray imaging is not indicated and has the lowest specificity for detecting stress fractures. A CT scan is not the most appropriate imaging for stress fractures. Q. A man had a motor vehicular accident and fractured his right ankle. He was transferred from the emergency department to the orthopedic nursing unit for further observation and possible surgery in the next 12 hours. What is the priority nursing assessment of the admitting orthopedic nurse? a. Temperature b. Capillary refill proximal to the injury of the right ankle c. Capillary refill distal to the injury of the left ankle d. Capillary refill distal to the injury of the right ankle ANSWER D. Capillary refill distal to the injury of the right ankle. Rationale: Capillary refill is the priority nursing assessment to evaluate tissue perfusion for orthopedic trauma patients. Temperature is not a priority nursing assessment. Assessment of capillary refill should be distal to the injury and not proximal. The patient fractured his right ankle, and assessment of the left ankle is not the priority. Q. A clinical nurse is assessing a patient's knowledge and understanding of bone health and maintenance. Which of the following responses of the patient indicates adequate understanding to maintain musculoskeletal health? a. I will take calcium supplementation as prescribed and eat plenty of citrus fruits. b. I will expose myself to sunlight at least 1 hour daily and eat plenty of green, leafy vegetables. c. I will take calcium supplementation and vitamin D as prescribed. d. I will exercise daily and take vitamin E as prescribed. ANSWER C. I will take calcium supplementation and vitamin D as prescribed. Rationale: Calcium is essential for bone growth and remodeling. Vitamin D is essential for calcium absorption. Eating plenty of citrus fruits or increasing vitamin C intake will not assist in calcium absorption. Exposing to sunlight for at least an hour daily is not needed and is impractical. Weight-bearing exercises help build stronger bones, but vitamin E will not assist in calcium absorption. Which of the following patients is at highest risk for osteoporosis? a. A young man, weight-lifter, who drinks beer three times a week, with a stable job b. A middle-age woman of lower socioeconomic status who is a heavy smoker and drinks alcohol six times a week c. A woman who works as a vice-president, takes a shot of vodka six times a week, and exercises regularly d. A retired man, non-smoker, who drinks alcohol socially B. A middle-age woman of lower socioeconomic status who is a heavy smoker and drinks alcohol six times a week. Rationale: Women of lower socioeconomic status are more likely to report limitations in activity and arthritis, obesity, and osteoporosis. Also, smoking increases the risk of developing fractures for both men and women. Alcohol use is associated with increased risk of osteoporosis because it raises parathyroid hormone levels, which causes calcium loss from bones. Use of the GCS provides relatively objective assessment of LOC. The three functions assessed are: a. pupil reaction, orientation, and sensation b. verbal response, eye opening, and motor response c. eye opening, motor response, and sensation d. verbal response, pupil reaction, and motor response B. Verbal response, eye opening, and motor response. Rationale: The Glasgow Coma Scale (GCS) does not include pupillary response and sensation. Abnormalities of pupil reaction are associated with altered consciousness but may also result from peripheral nerve injury. Sensation cannot be assessed accurately if the patient has any difficulty with communication. The patient with a head injury and increasing ICP is likely to have which assessment findings? a. Decreased LOC and sluggish pupil b. Left-sided weakness and facial droop c. Right ptosis and right-sided loss of vision d. Dilated left pupil and receptive aphasia A. Decreased LOC and sluggish pupil. Rationale: Because increasing intracranial pressure is a global process, the findings are more general and less specific. Findings localized to the left or right side are more commonly associated with specific areas of the brain, as with a stroke. The chart states that a 62-year-old woman has had a stroke in the right parietal area of the brain. The nurse expects to note which of the following? a. Tremors on the left side of the face b. Tremors on the right side of the face c. Weakness in the right arm d. Weakness in the left arm D. Weakness in the left arm. Rationale: Weakness results from loss of motor function in the motor cortex of the brain. Tremors are associated with other diseases (e.g., Parkinson disease and multiple sclerosis). The deficit is on the opposite side of the body because the motor fibers cross, causing leftsided weakness. The nurse performs BP screening at the local community center. As part of the health promotion intervention, the nurse also discusses the following risk factors for stroke: a. Low BP, lack of exercise, and diet high in fat b. High BP, diet high in fat, and smoking c. Diet high in fat, smoking, and walking five times weekly d. Obesity, swimming five times weekly, high BP B. High BP, diet high in fat, and smoking. Rationale: A health history of diabetes mellitus, carotid artery disease, atrial fibrillation, and sickle cell disease places a person at risk for neurovascular disease. Additionally, the lifestyle choices of smoking, high-fat diet, obesity, and physical inactivity increase the person's risk for stroke. If the great toe extends upward and the other toes fan out in response to stroking the lateral aspect of the sole of the foot, this is documented as which of the following? a. Hyporeflexia b. Normal plantar reflex c. Cushing response d. Babinski sign D. Babinski sign. Rationale: The Babinski sign indicates pathological hyperreflexia. A normal plantar reflex would result in toes curling downward to the same stimulus. The Cushing response refers to a pattern of changes in vital signs, not reflexes. A patient in a nursing home was admitted with a diagnosis of dementia. He started a fire because he was cooking at home and forgot that he left a pan on the stove. The nursing diagnosis that is highest priority is: a. ineffective brain tissue perfusion b. risk for injury c. acute confusion d. impaired memory B. Risk for injury. Rationale: Safety assumes priority because of the risk for injury. Impaired memory is also a likely diagnosis because of his forgetfulness. No data exist about confusion, so that is an area that needs further assessment. Ineffective brain perfusion is associated more with a stroke. A 26-year-old man was in a motor vehicle accident and suffered a complete spinal cord injury to L3. The nurse assesses the patient for loss of motor function in the: a. legs b. abdomen c. chest d. arms A. Legs. Rationale: The level of injury in the spinal cord correlates with innervation on the skin according to the level of the dermatome. Innervation of the arm roughly correlates with C5 to T1. Innervation of the chest correlates with T1 to T8. Innervation of the abdomen corresponds to T9 to T12. Innervation of the legs corresponds to L1 to S1. . While the nurse performs formal patient assessment, assistive personnel often observe changes when obtaining vital signs or assisting patients with ADLs. When discussing care for a patient with back pain, the nurse should particularly alert the assistant to watch for: a. dizziness b. bowel/bladder incontinence c. difficulty swallowing d. arm weakness B. Bowel/bladder incontinence. Rationale: Dizziness and difficulty swallowing are potential signs of cerebral rather than spinal cord lesions. Arm weakness from spine problems would indicate cervical injury (with associated neck rather than back pain). Bowel and bladder incontinence can occur with spinal cord injury at any level. A 47-year-old woman states she is having vertigo and some difficulty with balance. The nurse should assess: a. accommodation b. the whisper test c. shoulder strength d. soft touch b. the whisper test Of the following changes, which is the earliest sign of progressing brain herniation that originates in the cerebral hemispheres? a. An enlarging pupil that is sluggishly reactive to light b. Altered mentation c. Widening pulse pressure with bradycardia d. Reflex posturing of extremities B. Altered mentation. Rationale: Mental status changes are the earliest (often initially subtle) indications of generalized hemispheric dysfunction and occur prior to the cranial nerve or brainstem compression required to produce the other listed signs. When teaching the breast self-examination, the nurse should inform the woman that it is best to perform the exam is which of the following times? Select all that apply. a. Just before the menstrual period b. Just after the menstrual period c. On the 4th to 7th days of the menstrual cycle d. On the 10th day of the menstrual cycle C. On the 4th to 7th days of the menstrual cycle. Rationale: the breasts are least congested with the end of the menstrual period. In postmenopausal patients, the time of the month for the SBE is irrelevant, because breast size remains stable. For these patients, a day of the month that they will remember. Gynecomastia may occur in an older male secondary to a. testosterone deficiency. b. lymphatic engorgement. c. trauma. d. decreased activity level. A. Testosterone deficiency. Rationale: Changes in testosterone levels promote breast growth. Lymphatic engorgement does not naturally accompany aging. Trauma may cause inflammation but not gynecomastia. Decreased activity level may occur with aging, but it does not affect the breast tissue. A male patient presents to the clinic with a complaint of a hard, irregular, nontender mass on his chest under the areola. Upon examination, the nurse notes that the mass is immobile and suspects a. gynecomastia. b. benign lesion. c. Paget disease. d. carcinoma. D. Carcinoma. Rationale: Gynecomastia is noninflammatory enlargement of male breast tissue. Paget disease may cause intraductal carcinoma, presenting with clear, yellow discharge and dry, scaling crusts that spread outward from the nipple to the areola. When examining the breast of a 75-year-old woman, the nurse would expect to find which of the following? a. Enlarged axillary lymph nodes b. Multiple large firm lumps c. A granular feel to the breast tissue d. Pale areola C. A granular feel to the breast tissue. Rationale: In older women, secretion of estrogen and progesterone decreases, leading to atrophy of the glandular tissue and its replacement with fibrous connective tissue. This tissue feels granular. Axillary lymph nodes do not enlarge. Multiple large, firm lumps are a sign of benign breast disease (BBD), which occurs in patients aged 30 to 55 years. Areolae do not change in color. A 23-year-old nulliparous woman is concerned that her breasts seem to change in size all month long and they are very tender around the time she has her period. The nurse should explain to her that a. nonpregnant women usually do not have these breast changes and this is cause for concern. b. breasts often change in response to stress, so it is important to assess her life stressors. c. cyclical breast changes are normal. d. breast changes normally occur during pregnancy and she should have a pregnancy test. C. Cyclical breast changes are normal. Rationale: Breasts often change throughout the menstrual cycle, with corresponding variations in hormonal levels. It is important to examine the upper outer quadrant of the breast because it is a. more prone to injury and calcifications. b. where most breast tumors develop. c. where most of the suspensory ligaments attach. d. the largest quadrant of the breast. B. Where most breast tumors develop. Rationale: Most tumors occur in this region called the tail of Spence. A patient with benign breast condition is likely to a. develop breast cancer later in life. b. require hormone replacement therapy. c. be a teenager. d. have it resolve after menopause. D. Have it resolve after menopause. Rationale: BBD occurs most often in patients aged 30 to 55 years and decreases or resolves after menopause. It does not predispose someone to breast cancer and is not treated with hormone replacement therapy. The nurse palpates a fine, round, mobile, nontender nodule and suspects that it is a. a fibroadenoma. b. a cyst. c. a fibrocystic breast change. d. breast cancer. A. A fibroadenoma. Rationale: A cyst is soft to firm, often tender, round, and mobile. Fibrocystic breast changes feel nodular and ropelike. Breast cancer is irregular, firm, and fixed. Peau d'orange appearance is highly suggestive of which of the following? a. Breast cancer b. Gynecomastia c. Papillomas d. Colostrum A. Breast cancer. Rationale: Enlargement of the breasts (B) is common in teenage boys and elderly men. C is small tumors of the subareolar ducts. D is clear, milky white fluid that precedes milk production. Peau d'orange (i.e., orange peel) appearance is caused by breast edema from blocked lymph drainage and indicates advanced cancer. The correct position in which to place the patient to palpate the breasts is a. left lateral position with arm over head. b. sitting forward with hands on hips. c. supine with arm over head. d. supine with arms at side. C. Supine with arm over head. Rationale: A pillow should also be placed under the patient's shoulder on the side being assessed. The patient should be supine for the examination. B indicates the position for inspection. Placing the arm over the head stretches the skin and makes palpation easier. When performing an abdominal assessment, what is the correct sequence? a. Inspection, palpation, percussion, auscultation b. Palpation, percussion, inspection, auscultation c. Inspection, auscultation, percussion, palpation d. Auscultation, inspection, palpation, percussion C. Inspection, auscultation, percussion, palpation. Rationale: For the abdomen, auscultation must be performed before percussion and palpation to prevent minimizing bowel sounds. A patient reports changes in bowel pattern. Which is the best question to determine normal bowel habits? a. How often do you have a bowel movement? b. What was your bowel pattern before you noticed the change? c. Is there a family history of irritable bowel syndrome? d. Have any of your parents or siblings had cancer of the colon? B. What was your bowel pattern before you noticed the change? Rationale: Determining the patient's bowel pattern before symptoms began is most valid in establishing the normal pattern. When percussing the abdomen, the nurse notices a dullness at the anterior right costal margin at the right midclavicular line. Which organ is most likely involved? a. Liver b. Spleen c. Sigmoid colon d. Kidney A. Liver. Rationale: The spleen is normally found in the 9th to 11th left intercostal space (ICS) in the left midaxillary line (MAL). The colon is in the lower quadrants of the abdomen. The kidney is located in the posterior flank, in the lower rib cage. It is percussed for tenderness and is not always palpable. What percussion sound is heard over most of the abdomen? a. Resonance b. Hyperresonance c. Dullness d. Tympany D. Tympany. Rationale: The small intestine and colon, which are hollow organs, are predominant over most of the abdominal cavity. The result is tympany as the percussion sound. A patient with a history of kidney stones presents with complaints of pain, hematuria, and nausea with vomiting. What assessment technique will elicit kidney pain? a. Inspection with indirect lighting b. Iliopsoas muscle sign c. Indirect percussion for CVA tenderness d. Blumberg sign C. Indirect percussion for CVA tenderness. Rationale: Fist percussion over the costovertebral angle (CVA) is the only technique listed that reflects a technique for assessing the kidney. The two specialty techniques are used to assess peritoneal inflammation. When auscultating the abdomen, the nurse hears a bruit to the right of the midline slightly below the umbilicus. The nurse documents this finding as a bruit of which of the following? a. Right renal artery b. Right femoral artery c. Right iliac artery d. Abdominal aorta C. Right iliac artery. Rationale: The iliac arteries are located to the left and right of the midline of the abdomen, below the umbilicus. The aorta is midline, the renal artery is above the umbilicus, and the femoral artery is located in the groin. A patient with a history of cirrhosis tells the nurse that his abdomen seems to be getting larger and that he has gained 9.7 kg (20 lb) in the past 6 months. How will the nurse determine whether the abdominal enlargement is from accumulation of fluid or fat from the weight gain? a. Listen for a fluid wave b. Percuss the abdomen for shifting dullness c. Auscultate for lymph nodes d. Stroke the abdomen to elicit the abdominal reflex B. Percuss the abdomen for shifting dullness. Rationale: Percussing elicits a change from tympany to dullness when the abdomen is in its most dependent position. Fat remains static. Which assessment technique best confirms splenic enlargement? a. Deep palpation under the left costal margin b. Fist percussion of the spleen with the patient in a sitting position c. Deep palpation over the RUQ with the patient lying on the right side d. Percussion along the left MAL spleen and gentle palpation D. Percussion along the left MAL spleen and gentle palpation. Rationale: Percussion is the best technique to estimate the size of the spleen; gentle palpation is necessary to reduce the risk of splenic rupture. B. Balance and equilibrium are associated with cranial nerve VIII. Rational: Performing a whisper test will evaluate hearing, also associated with CN VIII. Testing for accommodation evaluates CN III. Shoulder shrug assesses CN XI and soft touch assesses CN V. A patient with a tympanic abdomen complains of pain in the RUQ. Which sign would the nurse expect to be positive? a. Murphy sign b. Psoas sign c. Rovsing sign d. Obturator sign A. Murphy sign. Rationale: The Murphy sign tests for gallbladder pain. The other signs test for peritoneal irritation in the lower quadrants. When documenting a finding over the stomach, the nurse most accurately identifies the region as a. epigastric. b. hypogastric. c. RUQ. d. LUQ. A. Epigastric. Rationale: The epigastric region is located above the umbilicus and straddles the midline between the right and left upper quadrants. The correct position in which to place a healthy adult male client to examine the rectum and prostate is a. the left lateral Sims position with right knee flexed and left leg extended. b. the supine position with hips and legs flexed and feet positioned on the examining table. c. the modified knee-chest position with the patient prone and knees flexed under hips. d. standing and leaning over the examination table with chest and shoulders resting on the table. D. Standing and leaning over the examination table, chest and shoulders resting on the table. Rationale: Standing is preferred because it allows for visualization of the anus and palpation of the rectum. If the patient cannot stand, the Sims position (A) is used. During a physical assessment, using the handle of the reflex hammer, you gently stroke the inner left thigh of the patient, which causes the ipsilateral testicle to rise. What superficial reflex is demonstrated? a. Abdominal reflex b. Babinski reflex c. Brachioradialis reflex d. Cremasteric reflex D. Cremasteric reflex. Rationale: The superficial cremasteric reflex is created by stroking the upper thigh, which causes the ipsilateral testicle to rise. Absence of this reflex is seen in association with disorders of the pyramidal tract above the level of the first vertebra. A 20-year-old Caucasian man complains of a mass in his left testicle. In addition to his age and race, what else is a risk factor for testicular cancer? a. Colon cancer in his mother b. Personal history of cryptorchidism c. UTI in the previous month d. Congenital hydrocele B. Personal history of cryptorchidism. Rationale: Cryptorchidism (undescended testicle at birth) is a risk factor for testicular cancer. A 20-year-old male patient presents with scrotal pain. A suspected diagnosis that requires immediate referral is a. testicular torsion. b. hydrocele. c. epididymitis. d. inguinal hernia. A. Testicular torsion. Rationale: Testicular torsion requires immediate surgical intervention to prevent strangulation of the testicle. Which of the following would you recognize as an unexpected finding while examining the male genitalia? a. Smegma is present on the uncircumcised patient. b. Testes are palpable and firm within the scrotal sac. c. You note an impulse at the tip of your finger during hernia examination. d. The urethral meatus has a slitlike opening central to the distal tip of the glans. C. You note an impulse at the tip of your finger during hernia examination. Rationale: Indirect inguinal hernia presents with an impulse at the tip of the nurse's finger during hernia examination. All other answers represent normal findings. When examining the scrotum of an adult Hispanic male, a normal finding is a. symmetrical scrotal sac with two movable testes. b. smooth, rubbery, saclike surface that is sensitive to gentle compression. c. asymmetrical sac with left side lower than right side. d. reddish colored skin that is darker than general body skin and has sebaceous cysts. C. Asymmetrical sac with left side lower than right side. Rationale: Elevation of the affected testicle will usually lessen pain in epididymitis. All other choices usually present with testicular torsion. A young male presents for a sports physical examination. In addition to examining for hernias, it would be appropriate for you to do which of the following? a. Teach testicular self-examination. b. Evaluate for urinary retention. c. Examine for prostate cancer. d. Draw blood to measure prostatic surface antigen. A. Teach testicular self-examination. Rationale: This age group is at high risk for testicular cancer; prostate cancer usually occurs later in life. A patient complains of a soft, irregular mass on the left side of the scrotum he noticed while walking. The nurse palpates a mass that feels like "a bag of worms." These findings are consistent with which condition? a. Hydrocele b. Varicocele c. Spermatocele d. Epididymitis B. Varicocele. Rationale: Varicocele is a condition caused by abnormal dilation and tortuosity of the veins along the spermatic cord, often on the left side. Upon palpation, the varicocele feels like a bag of worms. A 70-year-old man presents with the following symptoms: straining to void, nocturia, dribbling, and hesitancy when voiding. These signs are consistent with what condition? a. Benign prostatic hypertrophy (BPH) b. Prostatitis c. Testicular cancer d. Phimosis A. Benign prostatic hypertrophy (BPH). Rationale: As men age, fibromuscular structures of the prostate gland atrophy and are gradually replaced by collagen, which enlarges the gland. Consequences include nocturia, dribbling, and hesitancy when voiding. You are inspecting the groin of an older adult man who lives in a long-term care facility. Which of the following is an expected finding that you will document? a. Pediculosis in hair distribution b. Hypospadias on the glans c. Yellow discharge from the meatus d. Smegma under the foreskin D. Smegma under the foreskin. Rationale: Smegma is a thin, white, cheesy substance that may normally be present under the foreskin. Pediculosis is infestation with lice. Hypospadias occurs when the urethral meatus is on the ventral side of the penis. Yellow discharge indicates an infection. Which sexually transmitted infection presents with painful red superficial vesicles along the penis or on the glans? a. Gonorrhea b. Chlamydia c. Syphilis d. Herpes simplex virus 2 (HSV-2) D. Herpes simplex virus 2 (HSV-2). Rationale: Herpes presents with painful vesicles along the penis or on the glans. A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. Which of the following would the nurse do? Ask a client to identify scents. Loss of bone density that occurs with greatest frequency in postmenopausal women is called Osteoporosis Moving a part of the body away from the midline is called? Abduction Assessment of the musculoskeletal system usually proceeds from general to specific and from Head to toe The nurse walks into a client's room and finds that the client is disoriented to time and place but is awake and responsive. What term best describes this client? Confused Lifestyle can play a big part in developing risk factors for stroke. Which of the following can greatly reduce a client's risk for stroke? Select all that apply. (a)Quitting smoking, (b)Regularly exercising, (c)Maintaining a healthy weight When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk? 68-year-old African American male with hypertension A client comes to the clinic and reports a sore knee. The nurse notes popping and cracking noises when the client attempts to bend the knee. The client exhibits signs of pain by facial expression. The nurse knows that the popping and cracking noises should be charted as what? Crepitus A nursery nurse is assessing the neurologic status of a newborn. What area would the nurse be assessing? Reflexes The nurse is assessing a 51-year-old morbidly obese client who is seeking care for the recent loss of sensation in his feet and toes. The client also complains of intermittent burning and tingling in his feet that radiate up his legs. For which of the following health problems should the nurse first assess? Diabetic peripheral neuropathy Risk factors in which of the following areas are most readily changed to reduce the potential risk for falls? Environmental The nurse is assessing an older adult. Which assessment finding would the nurse recognize as a finding associated with aging? Kyphosis A client has sustained an injury to the cerebellum. Which area should be the nurse's primary focus for assessment? Coordination Which technique should the nurse use to perform scoliosis screening in a school-age child? Have the child bend forward at the waist. The nurse is preparing to perform the Romberg test on an adult male client. The nurse should instruct the client to stand erect with arms at the sides and feet together. A neurologic change associated with normal aging is a decrease in reaction time. When preparing an education session for a group of women who have been identified as postmenopausal, the nurse should include which teaching point? Increase intake of vitamin D and calcium. The nurse is preparing to palpate the breasts of a female client. Which technique would be most appropriate? Use the flat pads of three fingers. A group of students is preparing for their clinical experience, for which they are required to demonstrate the techniques for examining the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order? Inspect, auscultate, percuss, palpate To promote relaxation of the abdominal muscles, which of the following would be most appropriate for the nurse to do? Place a pillow under both of the client's knees. When assessing the rectum, the nurse observes what appear to be engorged areas near the rectal opening. The nurse would most likely document this finding as which of the following? Hemorrhoids A client calls the clinic and asks to speak to the nurse. The client tells the nurse that she has just started taking morphine for advanced cancer, is constipated, and wonders what is causing this. What would be the nurse's best response? "People can become constipated when taking certain medications." What is considered a modifiable risk factor for breast cancer? Obesity While conducting the physical examination, which of the following assessments would require the nurse to auscultate the abdomen? To identify bowel sounds A middle-aged female tells the nurse that she is concerned because her breasts are not as firm as they used to be and asks what might be causing this. What is an appropriate response by the nurse? "Firmness of the breasts decreases with age as estrogen levels decrease." While interviewing a client, a nurse asks the client whether she has ever noticed any lumps or swelling in the breasts. What other area associated with the possible risk for breast cancer should she ask about regarding the presence of lumps or swelling? Underarm A nurse is inspecting a client's nipples. Which of the following findings should the nurse regard as a cause for concern? A recently retracted nipple that was previously everted As part of an abdominal assessment, the nurse must palpate a client's liver. In which quadrant is this organ located? Right upper quadrant On inspecting a newborn's breasts, the nurse notes that they are enlarged and engorged, with a white liquid discharge. The infant's mother is concerned about it. Which of the following should the nurse tell the mother regarding this finding? It is due to the influence of the maternal hormones and should resolve in a few days. . A woman appears restless and is wringing her hands prior to having a clinical breast examination performed. Which statement by the nurse would be most appropriate? "You seem to be anxious. Can you tell me what you are thinking?" An adult male client reports hesitancy when urinating. The nurse would further assess this client for which complication? Prostate enlargement The client tells the nurse "I am so glad I had a mastectomy and I will never have breast cancer again." How should the nurse best respond? "We need to continue to perform examinations. Breast cancer can reoccur." The client tells the nurse that she has benign breast disease and so she is not worried about any lumps or nodules in her breasts. How would the nurse best respond? "It is important to perform self breast examinations as there could be changes or additional lumps in your breasts that would need further examination." The nurse is assessing an older adult client who has lost 2.27 kg (5 lb) since her last visit 1 year ago. The client tells the nurse that her husband died 2 months ago. The nurse should further assess the client for appetite changes. The nurse is preparing to assess the abdomen of a hospitalized client 2 days after abdominal surgery. The nurse should first inspect the abdominal area. A nurse is providing client education to a group of prepubescent girls at a local elementary school. What would the nurse be most likely to include in the presentation? Information about the stages of breast development The nurse is assessing a client's abdomen as shown. Which technique is the nurse using? Two-handed deep palpation How is bone pain described? Deep, dull, and boring What if a patient had muscle pain, would the description of pain be different? If yes, how? Muscle pain is decribed as sore, tender, cramping, pain, movement. Is a fractured bone the same as a broken bone? Yes, it is a medical term for broken bone Open vs. Closed fractures Types of fractures Spiral Greenstick Buckle Growth plate Stress Pathological fracture Describe nerve pain Burning, tingling, pins and needling and may radiate How many cranial nerves are there? Twelve (XII) What sense does the Olfactory nerve control? Smell Which cranial nerve controls eyeball movement? Oculomotor Which cranial nerve controls hearing and equilibrium? Vestibulocochlear/Auditory Which cranial nerve is being assessed when the nurse asks the pt to raise eyebrows, purse lips and smile? Facial Which cranial nerve controls movement of the trapezius and sternocleidomastoid muscles? Spinal accessory What cranial nerve is being assessed when a pt is asked to swallow and the gag reflex is observed to be nocrmal? Glossopharyngeal Which of the following is an assessment of the Trigeminal nerve? Light touch over the anterior scalp and jaw, clench teeth Which is the only cranial nerve that travels out of the cranium area? Vagus X Which cranial nerve can cause syncope? Vagus X Vagus Nerve X is special: "The Wanderer" Only cranil nerve that leaves the cranial area Affects digestion and heart rate Goes to larynx, esophagus, trachea, rectum, and anus Cough, sneeze, gag reflex, and hiccups Vasovagal Syncope - Vagus Nerve overreacts to triggers Extreme heat Fear of bodily harm Sight of blood Straining to have BM Enema- Monitor pts closely Suppository - monitor pts closely Standing for a long time Stimulates certain muscles in the heart that slow the heart rate - when overreacting can cause sudden drop in heart rate and BP - resulting in fainting/syncope (vasovagal syncope) Cranial nerve I Olfactory (smell) Sensory Cranial Nerve II Optic (visual acuity) - Use the snellen chart Sensory Cranial Nerve III Oculomotor - PERRLA Motor Cranial Nerve IV Trochlear (eye movement, 6 cardinal fields of gaze (CFG)) Motor Cranial Nerve V Trigeminal - Swipe cotton tip lightly (anterior scalp, paranasal sinuses, and jaw) or clench teeth & palpate muscle strength Both Sensory and Motor Cranial Nerve VI Abducens (eye movement, 6 CFG) Motor Cranial Nerve VII Facial (Smile symmetry, raise eyebrows, puff out cheeks) Both Sensory and Motor Cranial Nerve VIII Vestibulocochlear/auditory (hearing, normal conversation or whispers test) Sensory Cranial Nerve IX Glossopharyngeal (Gag reflex) Both Sensory and Motor Cranial Nerve X Vagus (say "ah", bilateral raising of a soft palate and uvula) Both sensory and motor Cranial Nerve XI spinal accessory (turn head and shrug shoulders against resistance with hands) Motor Cranial Nerve XII Hypoglossal (tongue should protrude midline, tongue to nose to chin, side to side (symmetry, strength, movement)) Motor Nerves (OOOTTAFAGVSH) On Old Olympus Tower Tops A Fin And German Viewed Some Hops On Old Olympus Tower Tops A Fin And German Viewed Some Hops Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Vestibulocochlear/Auditory Glossopharyngeal Vagus Spinal Accessory Hypoglossal Function (SSMMBMBSBBMM) Some Say Marry Money But My Brother Says Bad Business Marry's Money Some Say Marry Money But My Brother Says Bad Business Marry's Money Sensory Sensory Motor Motor Both Motor Both Sensory Both Both Motor Motor What is the earliest and most sensitive indicator if altered cerebral function? a. unequal pupils b. paralysis of one side of the body c. change in level of consciousness d. loss of deep tendon reflexes Change in level of consciousness When PERRLA is normal, which cranial nerve is responsible? a. optic CN II b. oculomotor CN III c. trochlear CN IV d. abducens CN IV Oculomotor CN III Health related patient reaching in relation to neurological assessment includes what? a. pupillary response b. injury prevention c. stroke protection d. sensory perception Injury Prevention Stroke protection Rational: Risk assessment and health-related patient teaching include stroke prevention and injury prevention. Do women that have had mastectomies need to perform self-breast exams? Yes - the cancer could come back What is one topic pertinent to abdominal health promotion? Food-borne illness (3 areas of focus involving the GI system include: colorectal illness, and hepatitis) Mrs. Jones presents at the emergency department complaining of severe pain in her abdomen. She has a history of a liver transplant. What would the nurse know NOT to do? Palpate the abdomen Glascow Coma Scale (GCS) Only useful to assess patients with altered conciousness 3-15 point scale High score of 15 and low score of 3 What are the three parts of the Glascow coma scale 1. Eye response 2. Verbal response 3. Motor response CVA Risks Age Gender Family History Race Previous CVA or TIA's Diabetes, A fib (atrial fibrillation) HTN Hyperlipidemia Smoking Obesity Alcohol What is CVA cerebrovascular accident (stroke); caused by plaque, clot, bleeding in vessels of brain -stroke in right side of the brain will have motor and sensory deficits on the left side of the body -stroke in the left side of the brain will have right-sided motor and sensory deficit dysphasia generation of speech, and sometimes its comprehension receptive aphasia Wernicke's area, unable. to understand language, spoken or written expressive aphasia Broca's area of brain, loss of the ability to produce language. global aphasia both expressive and receptive aphasia Musculoskeletal system functions 1. Support for the body 2. Mobility 3. Protection for organs 4.Produce blood cells 5. Store Minerals: calcium and phosphorus What age do we start screening for scoliosis and how? 11-12 years old Standing behind the patient to assess symmetry of the hips, scapulae, shoulders, and any skin folds or creases. common musculoskeletal symptoms Pain or discomfort, weakness, stiffness or limited movement (contractures), deformity, lack of balance and coordination (ataxia) GALS locomotor screen Gait Arms Legs Spine What is Anorexia Nervosa? refusal to maintain a minimally normal weight, intense fear of gaining weight, often has a need for control What is Bulimia Nervosa? binge eating followed by purging (vomiting, laxatives, diuretics) What to assess for Anorexia? How long? How much wt pt has lost? intake? What s/s will anorexia pt have? under-nourished sunken eyes yellow skin cold extremities dry brittle hair & nails poor skin turgor amenorrhea bradycardia constipation fine hair all over body to help reg temps What are some interventions for anorexia? Daily morning wt (face away) distract from exercise Stabilize them medically Coping skills underlying anxiety tx Help identify things they do have control over work on self-esteem small freq meals distract from exercise accompany to bathroom after meals limit exercise Tx for anorexia? SSRI zyprexia provac yoga group & family therapy What are signs that eating habits are normalizing? They will start eating more on their own w/ out being told What is a potentially lethal tx complication that can occur when severely malnourished pts are refed? refeeding syndrome need to consult dietician What s/s will bulimia pt have? healthy looking difficulty with impulsivity & compulsivity vomiting (self induced) dehydration electrolyte imbalance bradycardia dental caries/tooth erosion russells sign What is Russell's sign? Calluses on knuckles from self-induced vomiting Which is easier to treat bulimia or anorexia? Bulimia d/t nourishment & shame/want for change What are some interventions for bulimia? coping strategies identify triggers restric bathroom after meals or monitor stabilize first (concerned w/ electrolytes) health teaching and promotion CBT What to educate bulimia pt to watch for? s/s of electrolyte imbalance What is pica? eating non food items What is rumination disorder? Repeated regurgitation, chewing, and re-swallowing of food What is avoidant/restrictive food intake disorder? avoiding/restricting food starting in childhood, no distortion of body image What is the 1st most dangerous to withdraw from? alcohol What is the 2nd most dangerous to withdraw from? benzos Why do we see so much substance abuse? self medication What are some comorbidities from alcohol? cirrhosis fatty liver pancreatitis For substance abuse to be dx'ed they have to have? negative consequences Examples of negative consequences d/t substance abuse? crime health issues loss of job failure in school violence Whose at large risk for alcohol poisoning? college students Alcohol poisoning? A dangerous toxic condition that occurs when a person drinks a large amount of alcohol in a short period of time can result in aspiration or shut down of CNS What are alcohol poisoning s/s? inability to arouse RR10 cool and clammy cyanosis vomiting What are signs of alcohol intoxication? staggering slurred speech repeats self lack of coordination What are signs of alcohol withdrawl? hyper alert anorexia irritable startles easily seizures elevated vs tremors n/v Complications of alcohol withdrawal? Wernickes and Korsakoffs What is the tx for Wernickes and Korsakoffs? Give thiamine Wernickes is? acute/reversible Korsakoffs is? chronic What are s/s of wernickes & korsakoffs? altered gait vestibular dysfunction confusion ocular motility abnormalities sluggish reaction to light unequal pupil size What puts someone at higher risk for DTs? medical dx or experienced them before people who have been using hard & heavy for a long time What are delirium tremens (DTs)? life-threatening alcohol withdrawal syndrome Delusions visual & tactile hallucinations anxious restless tremors n/v sweating When do DTx occur? 24-72 hours after last drink Alcohol Assessment- Questions to ask - open ended - Type of alcohol - how much consumed - for how long - when last consumed -have you ever had DTs or seizures Alcohol nursing process? detox rehab housing/hospitalization What is Al-Anon? a support group for an alcoholic's family and friend. What is Alateen? a support group to help teenagers whose parents are alcoholics What is pharm alcohol tx? antibuse atrexia contrave What are examples of opiates? Heroin Morphine Fentanyl Methadone Meperidine What do opiates do? Depress CNS slow RR What are heroin intoxication s/s? constricted pupils drowsiness slurred speech decreased rr &bp What are heroin withdrawal s/s? yawning pain n/v agitation loss of appetite diaphoresis nasal stuffiness runny eyes What is tx for heroin withdrawal? pain meds antianxiety meds ani-emetics nutrition methadone/buprenorphine/naltrexone/clonadine What are risks associated with opioid overdose? death resp depression What does cocaine do? cns stimulant increase sexual arousal increase violence What are cocaine intoxication s/s? feeling of having heart attack pupil dilation dryness of oral and nasal cavity excessive motor activity What are cocaine withdrawal s/s? depression paranoia lethargy anxiousness insomnia n/v sweating chills What is a risk associated with inhalant use? cardiac arrhythmias What is behavioral theory? learned responses, particularly if the behavior is rewarded What is social learning theory? observe and imitate others (learned response) With anger we should be? proactive vs reactive (intervene early) What is the greatest predictor of violence? previous violence If there is a hx of violence? Make sure to have a PRN med on hand/ordered With anger what can we help identify? the feeling behind the anger What is the best way to approach a pt who is escalating? clamly, give space, back up "It looks like your pretty upset, what happened?" What can we give for anger interventions? benzo halodal Anger tx? model appropriate responses and ways to cope teach methods to appropriately express the anger coping mechanisms last resort restraints What are some contraindications of restraints? seizures pregnancy breathing issues spinal/back issues What needs to be met with restraints? nutrition hydration elimination What needs to be documented when in restraints? skin integrity pulses every 15mins rom order How long can an adult stay in violent restraints? 4hrs How long can an adult stay in non-violent restraints? 24 hours Restraint release procedure? communicate make sure know what behavior happened expectations debrief w/ pt and staff When pt is verbally abusive? say that is not appropriate and leave the room (setting boundaries) What is intimate abuse? 2 capable minded adults Is intimate abuse mandated to report? no b/c of honeymoon phase (change their minds) perp is @ higher risk for violence when someone somws up to check Most common type of abuse in children? neglect What is required for us to do for intimate abuse? provide education on a safety plan What are some examples of vulnerable persons? geriatric low economic status low education women children What is the tension building phase? victim feels tense and afraid abuser is edgy, has minor explosions What is the acute battering stage? tension becomes unbearable, victim may provoke an incidence to get it over with serious battering incident victim may try to cover up the injury or may look for help What is the honeymoon stage? The perpetrator apologizes and makes promises. The victim wants to believe things will change and feels guilty We do not advise victim to leave abuser b/c? it implies judgement and victim is at greatest risk for being killed when they leave Abuse in child reporting? it is mandated to report any suspicions When a child comes in w/ broken bone, what should we ask? What happened? What happens when you act badly? Ask parent how do they discipline and do they have any help? What is important to document with child abuse? picture, verbatim statements, what you are seeing Abuse primary prevention measure taken to preen the occurrence (education) Abuse Secondary prevention early intervention in abusive situations to minimize their disabling or long term effects Abuse tertiary prevention facilitate healing and rehab providing support assisting survivors achieve safety, health & well being Abused victims goal? empowerment develop solid sense of self Sexual distress is more common when? assaulted by intimates Fear/anxiety is more common when? assaulted by strangers acute stress disorder vs PTSD? Acute stress disorder - 3 days to 1 month PTSD - for longer than 1 month PTSD s/s? negative thoughts/feelings dissociative symptoms (depersonalization) intrusive symptoms avoidance arousal symptoms Effects of incest? -negative self-image -depression -eating disorders -personality disorders -self-destructive behaviors -substance abuse psychological effects of sexual assault? Depression Suicide Anxiety Fear Difficulties with daily functioning Low self-esteem Sexual dysfunction Somatic complaints Specialized sexual assault services? -sexual assault nurse examiners (SANEs) RNs with specialized training in caring for sexual assault patients demonstrated competency in conducting medical and legal evaluations ability to be an expert witness in court -sexual assault response team (SART) Sexual assault exam steps 1. head to toe assessment for injury 2. detailed genital exam 3. evidence collection 4. documentation of physical findings 5. tx (STDs), discharge planning, follow up care What are some indicators of improvement post sexual assault? being social doing reg daily routine being able to talk about it sexual assault nursing interventions? counseling promotion of self-care activities case management What is hospice care? pt who physician has certified 6months to live pt care not curing pt What is palliative care? taking care of pt w/ terminal dx (ex. cancer, dementia) goal is to keep comfortable and optimizing quality of life What is voluntary euthanasia? individual does so w/ provider assistance What is Passive euthanasia? individual is unable to consent What is involuntary euthanasia? used in cases such as death penalty What are s/s of dying? modeling of skin death rattle End of life nursing care includes? communication (clear, listening, observing) presence keep comfortable anticipatory grief sustenance What is grief? emotional response to loss What is bereavement? period of grieving following a death, includes process by which a person experience grief including thoughts and feelings What is mourning? the act of showing sorrow or grief What is Physiological loss? loss of mobility, organ, extremity What is loss of security and sense of belonging? the loss of an individual impacts a relationship/changes role What is loss of self-esteem? chang in value r/t work, peers, relationships What is loss r/t self-actualization? loss of hope to fulfill dreams What is Kubler-Ross' stages of dying? denial anger bargaining depression acceptance What are the 3 types of grieving? Complicated disenfranchised grief caused by public tragedy What is complicated grief? outside of norm not moving on, lasting longer than expected affecting daily life What is disenfranchised grief? loss that cannot be acknowledged openly or mourned publicly ex. affair & person affair w/ dies or an abortion What are risk factors for complicated grief? death of spouse or child death of parent if under age 11 sudden death multiple deaths death by suicide or murder missing persons w/ no closure What is persistent complex bereavement disorder? 12 months or more