M a r y v i l l e
N U R S
6 1 2
F i n a l
Which
of
the
Following
disorders
is
known
to
be
heredity?
Peripheral
neuropathy
Meningitis
Huntington
Chorea
Seizure
disorder
-
ANS
Huntington
Chorea
The
Examiner
asks
the
patient
to
close
her
eyes
and
then
place
a
vibrating
tuning
fork
on
the
patients
ankle
and
asks
her
to
indicate
what
is
felt.
What
is
being
assessed?
-
ANS
Primary
sensory
function
Multiple
sclerosis
-
ANS
Fatigue,
bowel
and
bladder
dysfunction,
sexual
dysfunction,
sensory
changes,
muscle
weakness
Myasthenia
gravis
-
ANS
An
autoimmune
disorder
of
neuromuscular
junction
involved
with
muscle
activation.
Whisper
T est
-
ANS
CN
V1 1 1
acoustic
Patient
sticks
out
tongue
and
moves
it
from
side
to
side
-
ANS
CN
X1 1
Hypoglossal
T aste
test
with
sugar ,
salt,
and
lemon
-
ANS
CN
V1 1
and
CN
1X
Facial
and
glossopharyngeal
Patient
puf fs
out
cheeks
and
shows
teeth
-
ANS
CN
V1 1
facial
Patient
shrugs
shoulders
against
examiner's
hands
-
ANS
CN
X1
Spinal
accessary
Smell
test
with
cof fee,
orange
and
cloves
-
ANS
CN
1
Olfactory
Eyes
constrict
and
dilate
in
response
to
light
-
ANS
CN
1 1 1
oculomotor
patient
clinches
teeth
(temporal
muscles
contracted)
-
ANS
CN
V
T rigeminal
positive
Babinski
sign
be
considered
a
normal
finding
in
what
ages?
-
ANS
0-24
months The
nurse
observes
the
gait
of
a
client
as
he
enters
the
room.
He
uses
short
steps,
keeps
his
knees
in
contact,
and
walks
with
considerable
ef fort.
What
term
is
used
to
describe
this
gait?
-
ANS
Scissors
gait
A
nurse
observes
very
fine,
rapid,
continuous
twitching
of
a
patient's
finger
while
at
rest.
How
should
the
nurse
document
this
finding?
-
ANS
Fasciculation
A
fasciculation
is
a
fine,
rapid
twitching
that
may
occur
with
some
lower
motor
neuron
disease.
Paralysis
is
loss
of
motor
function.
Spasticity
is
abnormally
increased
muscle
tone.
An
intention
tremor
is
an
involuntary
contraction
of
a
muscle
group
occurring
with
voluntary
movement
Under
what
conditions
should
a
patient
be
tested
for
clonus?
-
ANS
When
deep
tendon
reflexes
are
hyperactive
Clonus,
repeated
reflex
muscle
movement,
is
tested
when
a
patient
has
hyperactive
reflexes.
It
is
found
with
diseases
of
the
upper
motor
neuron.
Nuchal
rigidity ,
neck
stif fness,
is
a
sign
of
meningeal
irritation.
Absent
reflexes
are
associated
with
lower
motor
neuron
diseases.
Decorticate
positioning,
a
state
of
flexion
with
the
arms
adducted,
occurs
with
hemispheric
lesion
of
the
cerebral
cortex.
The
abdominal
reflexes
are
tested
to
assess
functioning
of
the
nerves
in
which
location
of
the
spine?
-
ANS
Thoracic
Which
change
is
most
commonly
observed
in
aging
patients?
-
ANS
Kyphosis,
advanced
posterior
curvature
of
the
thoracic
spine,
occurs
commonly
with
age.
Lordosis,
scoliosis,
and
ankylosis
are
not
as
commonly
associated
with
age.
While
palpating
the
patient's
knee,
the
nurse
finds
ef fusion
in
the
joint.
What
further
assessment
will
support
this
finding?
-
ANS
T esting
for
ballottement
is
a
test
to
detect
fluid
in
the
joint
Which
assessment
finding
is
associated
with
lumbar
stenosis?
-
ANS
Pain
associated
with
prolonged
standing
Lumbar
stenosis,
narrowing
of
the
spinal
canal,
causes
pain
associated
with
prolonged
standing.
Pain
is
improved
by
bending
forward.
Risk
factors
for
osteoarthritis
-
ANS
Risk
factors
for
osteoarthritis
include
obesity ,
aging,
and
a
family
history
of
osteoarthritis.
overuse
of
joints,
as
with
certain
sport
activities
and
occupations,
is
a
risk
factor .
N U R S
6 1 2
F i n a l
Which
of
the
Following
disorders
is
known
to
be
heredity?
Peripheral
neuropathy
Meningitis
Huntington
Chorea
Seizure
disorder
-
ANS
Huntington
Chorea
The
Examiner
asks
the
patient
to
close
her
eyes
and
then
place
a
vibrating
tuning
fork
on
the
patients
ankle
and
asks
her
to
indicate
what
is
felt.
What
is
being
assessed?
-
ANS
Primary
sensory
function
Multiple
sclerosis
-
ANS
Fatigue,
bowel
and
bladder
dysfunction,
sexual
dysfunction,
sensory
changes,
muscle
weakness
Myasthenia
gravis
-
ANS
An
autoimmune
disorder
of
neuromuscular
junction
involved
with
muscle
activation.
Whisper
T est
-
ANS
CN
V1 1 1
acoustic
Patient
sticks
out
tongue
and
moves
it
from
side
to
side
-
ANS
CN
X1 1
Hypoglossal
T aste
test
with
sugar ,
salt,
and
lemon
-
ANS
CN
V1 1
and
CN
1X
Facial
and
glossopharyngeal
Patient
puf fs
out
cheeks
and
shows
teeth
-
ANS
CN
V1 1
facial
Patient
shrugs
shoulders
against
examiner's
hands
-
ANS
CN
X1
Spinal
accessary
Smell
test
with
cof fee,
orange
and
cloves
-
ANS
CN
1
Olfactory
Eyes
constrict
and
dilate
in
response
to
light
-
ANS
CN
1 1 1
oculomotor
patient
clinches
teeth
(temporal
muscles
contracted)
-
ANS
CN
V
T rigeminal
positive
Babinski
sign
be
considered
a
normal
finding
in
what
ages?
-
ANS
0-24
months The
nurse
observes
the
gait
of
a
client
as
he
enters
the
room.
He
uses
short
steps,
keeps
his
knees
in
contact,
and
walks
with
considerable
ef fort.
What
term
is
used
to
describe
this
gait?
-
ANS
Scissors
gait
A
nurse
observes
very
fine,
rapid,
continuous
twitching
of
a
patient's
finger
while
at
rest.
How
should
the
nurse
document
this
finding?
-
ANS
Fasciculation
A
fasciculation
is
a
fine,
rapid
twitching
that
may
occur
with
some
lower
motor
neuron
disease.
Paralysis
is
loss
of
motor
function.
Spasticity
is
abnormally
increased
muscle
tone.
An
intention
tremor
is
an
involuntary
contraction
of
a
muscle
group
occurring
with
voluntary
movement
Under
what
conditions
should
a
patient
be
tested
for
clonus?
-
ANS
When
deep
tendon
reflexes
are
hyperactive
Clonus,
repeated
reflex
muscle
movement,
is
tested
when
a
patient
has
hyperactive
reflexes.
It
is
found
with
diseases
of
the
upper
motor
neuron.
Nuchal
rigidity ,
neck
stif fness,
is
a
sign
of
meningeal
irritation.
Absent
reflexes
are
associated
with
lower
motor
neuron
diseases.
Decorticate
positioning,
a
state
of
flexion
with
the
arms
adducted,
occurs
with
hemispheric
lesion
of
the
cerebral
cortex.
The
abdominal
reflexes
are
tested
to
assess
functioning
of
the
nerves
in
which
location
of
the
spine?
-
ANS
Thoracic
Which
change
is
most
commonly
observed
in
aging
patients?
-
ANS
Kyphosis,
advanced
posterior
curvature
of
the
thoracic
spine,
occurs
commonly
with
age.
Lordosis,
scoliosis,
and
ankylosis
are
not
as
commonly
associated
with
age.
While
palpating
the
patient's
knee,
the
nurse
finds
ef fusion
in
the
joint.
What
further
assessment
will
support
this
finding?
-
ANS
T esting
for
ballottement
is
a
test
to
detect
fluid
in
the
joint
Which
assessment
finding
is
associated
with
lumbar
stenosis?
-
ANS
Pain
associated
with
prolonged
standing
Lumbar
stenosis,
narrowing
of
the
spinal
canal,
causes
pain
associated
with
prolonged
standing.
Pain
is
improved
by
bending
forward.
Risk
factors
for
osteoarthritis
-
ANS
Risk
factors
for
osteoarthritis
include
obesity ,
aging,
and
a
family
history
of
osteoarthritis.
overuse
of
joints,
as
with
certain
sport
activities
and
occupations,
is
a
risk
factor .
