HA prepU exam 4
- ✔✔
- ✔✔-assess rapid alternating movements, and coordination
- ✔✔A nurse is working with a client who is victim of a shooting. The client has an increased pulse
rate and pupil dilation and is clearly in stress. The nurse recognizes the "fight-or-flight" response in
this client and understands that this represents an activation of which of the following?
- ✔✔A nurse palpates a bulge in the anterior wall of the vagina. The nurse recognizes this finding as
what abnormal finding?
- ✔✔Adult Nursing Health History and Physical Assessment-hand off report
- ✔✔CHAPTER 25:
Assessing Neurologic System
- ✔✔CHAPTER 28:
Pulling It All Together: Integrated Head-to-Toe Assessment
- ✔✔CHAPTER 32:
Assessing Older Adults
- ✔✔Collecting objective data; physical exam preparation for elderly client
- ✔✔Collecting objective data: mental status examination
- ✔✔Collecting subjective data- determining functional status and biographical data
- ✔✔Comprehensive health history- what is involved/ when is it performed?
- ✔✔Cranial Nerve-Assessment procedure -Cranial nerve 1-12- Abnormal and normal findings
- ✔✔Equipment needed for head to toe assessment
- ✔✔Expected physiologic changes of the older adult
- ✔✔Health promotion and disease prevention in the older adult
,- ✔✔History of present health concerns-functional ability to perform ADL's, falls, weakness -fatigue,
dyspnea, nutrition
- ✔✔light touch, pain and temperature
- ✔✔Loss of physiological reserve- atypical presentation of illness
- ✔✔Nuero assesment
- ✔✔pain temperature touch sensory
- ✔✔Physical assessment approach, sequence and integration
- ✔✔Sensory Test- lightlight touch, pain and temperature touch, pain and temperature
- ✔✔Skin inspection - normal and abnormal findings
- ✔✔Understanding urinary incontinence- assessment and interventions
- ✔✔When documenting assessment of the nervous system, a nurse should keep in mind what
important principle?
- assess condition & movement of muscles
- evaluate Balance
- perform Romberg test
-assess coordination - ✔✔motor and cerebellar systems
-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed
-expected finding: client should be able to stand with minimal swaying for at least 5 seconds -
✔✔Romberg test
-orientation of time & place
-attention & calculation of counting backwards by 7
-registration & recalling of objects
-laguage, including naming of objects, following commands & ability to write
10 minute questionnaire test swill test time place repeating
list of words, recall, arithmetic language use and comprehension used to screen
cognitive impairments - ✔✔Mini mental exam
,"Are you having any dizziness or lightheadedness?"
Explanation:
Clients with carotid artery disease may experience dizziness or lightheadedness, especially with
ambulation because of the increased difficulty in circulating enough blood and oxygen to the brain.
Trouble hearing and changes in vision may signal cranial nerve dysfunction. Weakness in the
muscles of the extremities is an indication of a CVA or nerve injury. - ✔✔A client presents to the
health care facility for a routine health checkup. The nurse learns that the client has a long history of
cardiovascular disease, including hypertension and carotid artery disease. When assessing this client
for potential problems in the nervous system, which question by the nurse is appropriate?
"Can you repeat brown, chair, textbook, tomato?"
Explanation:
Remote memory (past dates and historical accounts) may be impaired in cerebral cortex disorders. -
✔✔The nurse is assessing the neurologic system of an adult client. To test the client's use of
memory to learn new information, the nurse should ask the client
"Can you tell me where you are right now?"
Explanation:
The nurse should only assess for orientation to date and place when conducting a mental status
assessment as part of the screening neurological examination. Asking details about mood, history of
psychiatric disorders, and fluctuations in emotions is better done when conducting a full mental status
assessment, not as part of the screening neurological assessment. - ✔✔When the nurse is
assessing a client's mental status as part of the screening neurological examination, which question
would be most appropriate to ask?
"e's" (in decerebate) e=extended
WORSE ONE!!
-"extensor posturing";
-abduction of arms, elbow and wrist extension
damage to brainstem (midbrain/pons)
controls -respirations, cardiac, CNS: sleep/conciousness - ✔✔Decerebrate posturing
"O"'s (in decorticate, to the core)
-"flexor posturing" or "mummy baby" (think Egyptian mummy preservation)
-adduction of arms (arms fold to chest); flexion of elbows and wrists
, damage to cerebral cortex (outer gray matter area, 4 lobes) - ✔✔Decorticate posturing
"Place your hands together, lock your fingers, and squeeze."
Explanation:
If deep tendon reflexes are diminished or absent, a reinforcement technique may be used to enhance
the client's response. When testing the leg reflexes, have the client interlock the hands and squeeze.
Closing the eyes and tightening the thigh muscles of the opposite leg will not aid in eliciting a reflex
response. Clenching the teeth is a reinforcement technique that is helpful to elicit a response when
assessing the arm reflexes. - ✔✔What instruction should a nurse give a client when having trouble
eliciting a response from testing the patellar deep tendon reflex?
"Walk across the room and back."
Explanation:
It is important to ask the client to walk across the room and walk back first because this will reveal
deficits in the gait. This, in turn, will allow the nurse to focus the assessment. Asking the client to walk
across the room and then back assists the nurse in observing posture, balance, swinging of the arms,
and movements of the legs. Asking the client to walk heel to toe is called "tandem walking." It would
be appropriate to instruct the client to do this to determine if there is ataxia that was not previously
obvious. Asking the client to walk on the toes then on the heels assists the nurse in assessing for
plantar flexion of the ankles as well as for balance. The nurse should instruct the client to do this if
problems with balance are noted initially. Asking the client to hop in place provides information about
the client's position sense and cerebellar function. - ✔✔A nurse is assessing a client for
abnormalities of gait due to a concern that the client is at increased risk for a fall. Which instruction
should the nurse give the client first?
"We can take a break anytime."
Explanation:
In order to ensure the client remains comfortable throughout the physical examination, the client's
facial expressions and other cues about pain should be noted. The nurse should offer to take a break
and continue on with the physical examination by assessing other areas in a less invasive way. The
client should be made aware that he or she has the power to take a break from the examination for
some relief if there is pain. Asking the client to deep breaths not helpful in this situation because it
minimizes the client's comfort and does not address the underlying cause of the pain. Taking vital
signs would probably show that the client's blood pressure is higher than normal because pain and
anxiety can increase blood pressure, heart rate, and respiratory rate. Ana assessment of the vital
signs should be complete prior to beginning the physical examination. Stopping the p - ✔✔The nurse
