NUR235 Exam 2: Questions With Easy-to-Understand
Solutions
Assessing the Musculoskeletal System, Assessing the Neurological System,
Assessing Mental Status, Assessing Skin, Hair & Nails
Order used to assess musculoskeletal system Right Ans - interview, inspect,
palpate
What is the nurse inspecting for in the musculoskeletal system? Right Ans -
symmetry, size, contour, color, alignment, AROM, swelling, deformity, atrophy,
masses, tissue condition, abnormalities
What is the nurse palpating for in the musculoskeletal system? Right Ans -
temperature, tenderness, strength, tone, edema, crepitus, nodules,
abnormalities
Muscle tone Right Ans - tension in the muscle at rest
Expected muscle tone Right Ans - slight tension and resistance to passive
movement
Unexpected muscle tone Right Ans - hypertonia, hypotonia, flaccid tone
Hypertonia Right Ans - increased muscle tone (rigid or stiff)
Hypotonia Right Ans - decreased muscle tone (floppy or weak)
Flaccid tone Right Ans - complete absence of tone (no firmness)
How to assess muscle tone Right Ans - through passive ROM
Expected assessment of muscle tone Right Ans - mild, even resistance to
movement
Unexpected assessment of muscle tone Right Ans - flaccidity, spasticity,
rigidity
,How to assess for musculature strength Right Ans - symmetry, squeeze
hands, push feet against hands
Muscle testing scale level 5 Right Ans - full ROM against gravity, full
resistance
Muscle testing scale level 4 Right Ans - full ROM against gravity, some
resistance
Muscle testing scale level 3 Right Ans - full ROM with gravity
Muscle testing scale level 2 Right Ans - full ROM with gravity eliminated
(passive motion)
Muscle testing scale level 1 Right Ans - slight contraction
Muscle testing scale level 0 Right Ans - no contraction
Patient position for assessing posture Right Ans - standing w feet together
and sitting upright
How to assess posture Right Ans - inspect alignment of head, trunk, pelvis,
and extremeties
Posture expected findings Right Ans - upright, erect, comfortable
Posture unexpected findings Right Ans - slumped, abnormal curves
How to assess gait Right Ans - have client walk
What to assess for gait Right Ans - base of support, weight bearing stability,
stride length and cadence, arm swing, posture
Gait expected findings Right Ans - evenly distributed, straight, equal, erect,
coordinated, arms swing opposite, appropriate stride length
Gait unexpected findings Right Ans - uneven, toes point in or out, limps,
shuffles, propels forward, wide based gait, off balance
, Active ROM Right Ans - patient moves through full ROM with verbal or
nonverbal direction
Passive ROM Right Ans - nurse moves each joint through full ROM as
tolerated with verbal or visual direction
Abduction Right Ans - moving away
Adduction Right Ans - toward body
Flexion Right Ans - pulling down
Extension Right Ans - extending out
Medial rotation Right Ans - turning in
Lateral rotation Right Ans - turning out
Jaw open Right Ans - open mouth as wide as possible
Jaw lateral Right Ans - move jaw from side to side
Jaw protrude Right Ans - stick lower jaw out
Jaw retract Right Ans - pull lower jaw back
Cervical spine flexion Right Ans - touch chin to chest
Cervical spine hyperextension Right Ans - look up
Cervical spine lateral Right Ans - touch left and right ear to shoulders
Cervical spine rotation Right Ans - look over left and right shoulder
Lumbar spine flexion Right Ans - bend forward touch toes
Lumbar spine hyperextension Right Ans - arch back
Lumbar spine lateral Right Ans - bend at waist side to side
Solutions
Assessing the Musculoskeletal System, Assessing the Neurological System,
Assessing Mental Status, Assessing Skin, Hair & Nails
Order used to assess musculoskeletal system Right Ans - interview, inspect,
palpate
What is the nurse inspecting for in the musculoskeletal system? Right Ans -
symmetry, size, contour, color, alignment, AROM, swelling, deformity, atrophy,
masses, tissue condition, abnormalities
What is the nurse palpating for in the musculoskeletal system? Right Ans -
temperature, tenderness, strength, tone, edema, crepitus, nodules,
abnormalities
Muscle tone Right Ans - tension in the muscle at rest
Expected muscle tone Right Ans - slight tension and resistance to passive
movement
Unexpected muscle tone Right Ans - hypertonia, hypotonia, flaccid tone
Hypertonia Right Ans - increased muscle tone (rigid or stiff)
Hypotonia Right Ans - decreased muscle tone (floppy or weak)
Flaccid tone Right Ans - complete absence of tone (no firmness)
How to assess muscle tone Right Ans - through passive ROM
Expected assessment of muscle tone Right Ans - mild, even resistance to
movement
Unexpected assessment of muscle tone Right Ans - flaccidity, spasticity,
rigidity
,How to assess for musculature strength Right Ans - symmetry, squeeze
hands, push feet against hands
Muscle testing scale level 5 Right Ans - full ROM against gravity, full
resistance
Muscle testing scale level 4 Right Ans - full ROM against gravity, some
resistance
Muscle testing scale level 3 Right Ans - full ROM with gravity
Muscle testing scale level 2 Right Ans - full ROM with gravity eliminated
(passive motion)
Muscle testing scale level 1 Right Ans - slight contraction
Muscle testing scale level 0 Right Ans - no contraction
Patient position for assessing posture Right Ans - standing w feet together
and sitting upright
How to assess posture Right Ans - inspect alignment of head, trunk, pelvis,
and extremeties
Posture expected findings Right Ans - upright, erect, comfortable
Posture unexpected findings Right Ans - slumped, abnormal curves
How to assess gait Right Ans - have client walk
What to assess for gait Right Ans - base of support, weight bearing stability,
stride length and cadence, arm swing, posture
Gait expected findings Right Ans - evenly distributed, straight, equal, erect,
coordinated, arms swing opposite, appropriate stride length
Gait unexpected findings Right Ans - uneven, toes point in or out, limps,
shuffles, propels forward, wide based gait, off balance
, Active ROM Right Ans - patient moves through full ROM with verbal or
nonverbal direction
Passive ROM Right Ans - nurse moves each joint through full ROM as
tolerated with verbal or visual direction
Abduction Right Ans - moving away
Adduction Right Ans - toward body
Flexion Right Ans - pulling down
Extension Right Ans - extending out
Medial rotation Right Ans - turning in
Lateral rotation Right Ans - turning out
Jaw open Right Ans - open mouth as wide as possible
Jaw lateral Right Ans - move jaw from side to side
Jaw protrude Right Ans - stick lower jaw out
Jaw retract Right Ans - pull lower jaw back
Cervical spine flexion Right Ans - touch chin to chest
Cervical spine hyperextension Right Ans - look up
Cervical spine lateral Right Ans - touch left and right ear to shoulders
Cervical spine rotation Right Ans - look over left and right shoulder
Lumbar spine flexion Right Ans - bend forward touch toes
Lumbar spine hyperextension Right Ans - arch back
Lumbar spine lateral Right Ans - bend at waist side to side
