Chapter 48 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 48

Question 1

Type: MCSA

A patient is newly diagnosed with arthritis of the cervical vertebrae. The nurse plans to assess which type of joint?

1. Spheroidal

2. Synovial

3. Fibrous

4. Cartilaginous

Correct Answer: 4

Rationale 1: Spheroidal joints are located in the hip and shoulder.

Rationale 2: Synovial joints are between bones that do not come in contact with each other, such as in the knee.

Rationale 3: Fibrous joints occur where bones are joined together, such as the sutures of the skull.

Rationale 4: Cartilaginous joints are only slightly movable and are located between the vertebrae.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-1

Question 2

Type: MCSA

A patient tells the nurse that he has damaged cartilage in his knee. How should the nurse respond to this information?

1. It will take a few months for the damage to heal.

2. That is considered a strain and will heal itself in a few weeks.

3. Exercise will increase the healing time for the cartilage.

4. Did the doctor talk with you about treatment options?

Correct Answer: 4

Rationale 1: Once damaged, cartilage does not heal.

Rationale 2: A strain occurs with a tendon.

Rationale 3: Exercise will not increase the healing time for the cartilage.

Rationale 4: In some instances, cartilage damage in the knee requires arthroscopic surgery or knee replacement. Other treatment options may be available. The nurse should establish baseline information for the plan of care.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 48-1

Question 3

Type: MCSA

A patient recovering from hip replacement surgery is prescribed a pillow between the legs. The nurse explains that the pillow will facilitate which positioning?

1. Adduction

2. Abduction

3. Extension

4. Flexion

Correct Answer: 2

Rationale 1: Adduction moves an extremity toward the midline of the body. Placement of a pillow between the legs would not bring them closer together.

Rationale 2: Abduction is the movement of an extremity away from the midline of the body. A pillow between the legs holds them apart, away from the midline, maintaining the integrity of the new hip.

Rationale 3: Extension is straightening the extremity at a joint. Placement of a pillow between the legs will not impact extension.

Rationale 4: Flexion is bending an extremity at a joint. Placement of a pillow between the legs will not impact flexion.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 48-1

Question 4

Type: MCSA

The nurse is preparing to conduct a history on a patient being seen for hip pain and reduced range of motion. For which purpose does the nurse conduct this history?

1. To determine if the patient needs assistive devices

2. To evaluate the degree of pain the patient is experiencing

3. To determine the patients level of function so care can be planned

4. To allow the patient to talk about symptoms

Correct Answer: 3

Rationale 1: The possible use of assistive devices will be discussed during the history, but this is not the primary reason the history is obtained.

Rationale 2: The history may reveal the patients level of pain, but this is not the primary reason the history is obtained.

Rationale 3: A detailed history of the musculoskeletal system determines a patients ability to function, which plays an important role in developing an effective plan of care.

Rationale 4: The nurse should develop a caring relationship so that the patient will talk about the ailment; however, that is not the purpose of the history.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 48-2

Question 5

Type: MCSA

A patient provides the nurse with a list of current medications and adds that she takes glucosamine every day. The nurse would document this information in which part of the health history?

1. Biographical data

2. Chief complaint

3. Past medical history

4. Social history

Correct Answer: 3

Rationale 1: Biographical data includes age, gender, culture, and educational background.

Rationale 2: The chief complaint includes the patients description of the current problem, its duration, and what has been done to try to alleviate the symptoms.

Rationale 3: The past medical history contains the patients current medications, including herbal remedies. This is where the nurse should document this information.

Rationale 4: The social history describes lifestyle aspects such as smoking and alcohol intake.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-2

Question 6

Type: MCSA

A patient tells the nurse that she is tired of having leg pain because it gets in the way of enjoying the activities that she wants to do with her family. What is the nurses best response?

1. How does your family react when you are having the pain and cant participate in activities?

2. At least you are able to do regular activities around the house.

3. Everyone has some degree of pain every day, and Im sure your family understands.

4. But you are still working, so you are productive.

Correct Answer: 1

Rationale 1: The nurse should ask the patient how she copes with the pain and whether it affects her personal relationship with her family.

Rationale 2: Referring to regular activities around the house does not address the patients concern about missing family activities.

Rationale 3: The nurse should not presume to understand how this family feels about the mothers inability to participate in activities.

Rationale 4: Referring to the patients ability to continue working does not address her frustration about missing family activities.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-2

Question 7

Type: MCSA

The nurse assesses that a patient is unable to completely straighten the right arm. The nurse conducts additional assessment for which condition?

1. Muscle atrophy

2. The presence of nodules

3. Gout

4. Muscle fasciculation

Correct Answer: 1

Rationale 1: Muscle atrophy is the shortening of a muscle, which is evidenced by the patients inability to completely straighten the arm.

Rationale 2: Nodules are small raised areas that are found upon palpation. It is unlikely that the presence of nodules would keep the patient from straightening the arm.

Rationale 3: Gout is an inflammation of a toe, heel, elbow, or ankle. Although gout in the elbow might make that movement painful, it is not likely to prevent straightening the arm.

Rationale 4: Muscle fasciculations are abnormal contractions or twitches within a muscle. It would be unlikely that these contractions would prevent the patient from straightening the arm.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-3

Question 8

Type: MCSA

The nurse rates a patients biceps muscle strength at 3. Another nurse reading this rating would expect the patients best movement of the muscle to be at which functional level?

1. Passive ROM

2. Active ROM with gravity and moderate weakness

3. Complete active ROM with minimal weakness

4. Complete ROM with no weakness

Correct Answer: 2

Rationale 1: A muscle that moves only during passive ROM by the examiner is documented as grade 2.

Rationale 2: If the patient has active ROM with gravity but the muscle is moderately weak, it is documented as grade 3.

Rationale 3: Complete active ROM in a muscle with only minimal weakness is documented as grade 4.

Rationale 4: If the patient has complete ROM against gravity and resistance, the muscle strength is normal and is documented as grade 5.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-3

Question 9

Type: MCSA

A patient tells the nurse that he has had increasing difficulty bending his knees to pick objects up from the floor since he got a desk job about 10 months ago. The nurse suspects that the patients loss of knee and hip range of motion would be due to which condition?

1. Gout

2. Muscle spasms

3. Pain

4. Atrophy

Correct Answer: 4

Rationale 1: Gout is an inflammation of the great toe, heel, elbow, or ankles and would not cause difficulty bending the knee or hip.

Rationale 2: The patients complaint is not typical of muscle spasms.

Rationale 3: The patient does not use the word pain or discomfort in his description, but describes difficulty.

Rationale 4: Reduced ROM can occur from disuse of the muscles, leading to atrophy.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-3

Question 10

Type: MCSA

The nurse asks the patient to shrug the shoulders while the nurse applies pressure to keep the shoulders from moving. The nurse would document the results of this test as indicating strength of which muscle?

1. Sternocleidomastoid

2. Triceps

3. Biceps

4. Trapezius

Correct Answer: 4

Rationale 1: The sternocleidomastoid muscle is assessed with the neck; the patient is asked to turn the head against resistance applied by the nurses hand.

Rationale 2: The triceps muscle is assessed by having the patient extend the arm while the nurse tries to flex it.

Rationale 3: The biceps muscle is assessed by asking the patient to flex the arm while the nurse tries to extend it.

Rationale 4: The trapezius muscle is assessed to determine the status of the patients shoulder functioning. The patient is asked to shrug the shoulders while the nurse tries to hold the shoulders down.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-3

Question 11

Type: MCSA

The nurse wishes to test opposition ability in the patients thumb. How would the nurse instruct the patient?

1. Touch each one of your fingertips with your thumb.

2. Move your thumb across your palm away from the rest of your fingers.

3. Move your thumb across your palm and touch your fifth finger.

4. Move your thumb anteriorly away from the palm and then back.

Correct Answer: 1

Rationale 1: Opposition is assessed by asking the patient to touch each of the fingertips with the thumb.

Rationale 2: Extension is assessed by asking the patient to move the thumb across the palm away from the rest of the fingers.

Rationale 3: Flexion is assessed by asking the patient to move the thumb across the palm and touch the fifth finger.

Rationale 4: Moving the thumb anteriorly away from the palm and then back tests adduction and abduction.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-3

Question 12

Type: MCSA

During a physical assessment, the patient walks to the door of the examination room as the nurse watches the patient switch the weight on the feet. The nurse would document assessment of which part of the musculoskeletal status?

1. Knee extension

2. Second-phase gait

3. Hip flexion

4. First-phase gait

Correct Answer: 2

Rationale 1: Walking is not the best method of assessing knee extension.

Rationale 2: The assessment of gait has two phases. The second phase is the swing phase, in which the patient moves the foot forward and is not bearing weight on the moving foot. Weight is supported on the nonmoving foot. This is the phase the nurse is observing.

Rationale 3: Walking is not the most efficient way to assess hip flexion.

Rationale 4: The assessment of gait has two phases. The first phase is the stance of gait, in which the foot is on the ground and the patient is bearing weight or walking on the foot.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-4

Question 13

Type: MCSA

The nurse assessing a patients musculoskeletal status notes that the left shoulder does not have its normal curvature and fullness. The nurse would conduct additional assessment for which disorder?

1. Scoliosis

2. Arthritis

3. Rotator cuff tear

4. Dislocation

Correct Answer: 4

Rationale 1: Patients with scoliosis may have one shoulder higher than the other.

Rationale 2: Flatness is not associated with arthritis. The patient with arthritis may be reluctant to move a joint due to pain.

Rationale 3: Rotator cuff tears result in inability to move the shoulder through all ROM.

Rationale 4: Shoulders that appear flat or asymmetrical may be dislocated. The normal structure of the shoulder is disrupted in a manner that affects external appearance.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-3

Question 14

Type: MCSA

The nurse is assessing a patient who complains of numbness and tingling in the hands. When the patient bends the wrist downward and presses the backs of the hands together, there is numbness and tingling in the wrists and fingers. The nurse would conduct additional assessment for which condition?

1. Arthritis

2. Dislocation

3. Fracture

4. Carpel tunnel syndrome

Correct Answer: 4

Rationale 1: The maneuver described will not help the nurse assess for arthritis.

Rationale 2: The maneuver described will not help the nurse assess for dislocation and may be contraindicated, as additional damage may occur.

Rationale 3: The maneuver described will not help the nurse assess for fracture and may be contraindicated, as additional damage might occur.

Rationale 4: The nurse would have the patient perform the Phalens test to help diagnose carpal tunnel syndrome. Numbness, tingling, and pain in the wrist and fingers would suggest this condition.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-3

Question 15

Type: MCSA

During assessment of a patients knee, the nurse tests for the bulge sign. Which technique is the nurse using?

1. The nurse is tapping lightly over the nerve running next to the patella.

2. The nurse strokes the medial aspect of the knee upward and observes for changes.

3. The nurse feels for a fluid wave while moving the patella up and against the femur.

4. The nurse places a thumb and finger on either side of the patella and assesses for fluid in the spaces next to the patella.

Correct Answer: 2

Rationale 1: This is not a description of a test used to assess the knee.

Rationale 2: The bulge sign is used to detect fluid in the knee. After stroking the medial aspect of the knee upward to displace the fluid, the nurse places a hand on the lateral side of the knee while looking for a bulge of fluid in the hollow area medial to the patella.

Rationale 3: The ballottement test is used to assess for fluid in the suprapatellar pouch.

Rationale 4: This technique tests for the balloon sign.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-3

Question 16

Type: MCSA

A patient is complaining of a fever and a stiff neck. Upon assessment, the patient is unable to rotate the neck. The nurse would conduct additional assessment for which condition?

1. Gout

2. Cervical vertebrae fracture

3. Infectious process

4. Arthritis

Correct Answer: 3

Rationale 1: Gout is not known to affect the cervical vertebrae.

Rationale 2: The patient would have pain, tingling, and numbness in addition to a change in range of motion if cervical vertebrae were fractured.

Rationale 3: Neck pain with a decreased range of motion accompanied by a fever may be due to an infectious process.

Rationale 4: Arthritis is not typically associated with fever.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-3

Question 17

Type: MCSA

While assessing a patients left knee for range of motion, the nurse hears clicking. The patient says that at times the knee locks. The nurse would conduct additional assessment for which condition?

1. Rheumatoid arthritis

2. Fluid in the knee

3. Dislocation

4. Damage to the meniscus

Correct Answer: 4

Rationale 1: Clicking sounds are not typically associated with rheumatoid arthritis.

Rationale 2: Clicking sounds are not typically associated with fluid in the knee; however, the knee may lock due to pain.

Rationale 3: If the patients knee were dislocated, the patient would experience pain, and deformity would likely be obvious.

Rationale 4: Clicking sounds with knee movement in addition to the patients description of locking may indicate damage to the meniscus.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-3

Question 18

Type: MCSA

While assessing a patients hands, the nurse notes that the patient is unable to fully extend the ring or fifth finger. The nurse would suspect which condition?

1. Dupuytrens contracture

2. Bouchards nodes

3. Swan neck deformity

4. Heberdens nodes

Correct Answer: 1

Rationale 1: Difficulty extending or the inability to extend the ring or fifth finger is a sign of Dupuytrens contracture, a thickening of the connective tissue in the palm.

Rationale 2: Bouchards nodes are hard, painless nodules over the proximal interphalangeal joints of the fingers.

Rationale 3: In a swan neck deformity, the proximal interphalangeal joint is hyperextended and the distal joint is fixed in flexion.

Rationale 4: Heberdens nodes are hard, painless nodules over the distal interphalangeal joints of the fingers.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-5

Question 19

Type: MCMA

The nurse is assessing an older adults musculoskeletal system. The nurse would evaluate that which findings represent normal age-related changes?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Slightly reduced ROM of the shoulder

2. Slower gait

3. Redness and crepitus of the knee joint

4. Inability to abduct the thumb

5. Asymmetry of the pelvis

Correct Answer: 1,2

Rationale 1: Normal changes of aging include some reduction of ROM in joints. Significant ROM changes are not normal and should be further evaluated.

Rationale 2: Slowing of the gait and maintaining a wider base of support are normal age-related changes.

Rationale 3: A small amount of knee joint crepitus may be attributed to normal aging-related changes, but redness over the joint is not normal.

Rationale 4: The degree of abduction may be slightly decreased due to normal aging, but the patient should still be able to make this motion.

Rationale 5: Pelvic asymmetry may indicate hip dislocation or fracture, severe degenerative joint disease, or severe muscle atrophy. It is not a part of normal aging and should be evaluated.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-5

Question 20

Type: MCMA

The nurse has just begun testing range of motion in a patients right knee when the patient says, That really hurts. Which interventions should be implemented?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Continue to try to achieve normal ROM.

2. Stop the test on that joint.

3. Massage the knee for 20 minutes.

4. Call the health care provider.

5. Test ROM in the left knee and compare findings.

Correct Answer: 2,5

Rationale 1: Pain indicates ROM limitation.

Rationale 2: When pain occurs, ROM has been tested, so further attempts to increase ROM are not indicated.

Rationale 3: Massaging the knee may cause further pain and discomfort to the patient and has no therapeutic benefit at this time.

Rationale 4: The extent of ROM should be documented, but there is no reason to call the health care provider at this point.

Rationale 5: ROM should be compared on both sides of the body.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 48-3

Question 21

Type: MCMA

The patient with an old knee injury says, I think I have water on my knee again. The nurse would prepare to conduct which tests to assess for that finding?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Ballottement

2. Bulge sign

3. Phalens test

4. Thomas test

5. Heberdens sign

Correct Answer: 1,2

Rationale 1: To assess for larger amounts of fluid in the knee, the nurse should conduct the ballottement testapplying downward pressure on the knee with one hand while pushing the patella backward against the femur with the other hand. There should be no movement of the patella; it should rest firmly over the femur.

Rationale 2: The bulge sign indicates increased fluid in the knee joint and is used to assess for smaller amounts of fluid on the knee.

Rationale 3: Phalens test is an assessment tool for carpal tunnel syndrome.

Rationale 4: The Thomas test does not assess for fluid on the knee.

Rationale 5: Heberdens nodes are arthritic changes to the fingers.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-3

Question 22

Type: MCMA

The nurse is assessing a patients gait. Which findings would the nurse consider normal?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient walks with a wide base of support.

2. The arms swing according to gait phase.

3. The patient shuffles when walking.

4. The gait is jerky, with quick movements.

5. The patient holds the arms out from the body in slight extension.

Correct Answer: 1,2

Rationale 1: The patient should walk with a wide base of support to prevent falls.

Rationale 2: Coordinated arm swings are considered a normal part of the gait.

Rationale 3: A shuffling gait may indicate neurological disorders such as Parkinsons disease.

Rationale 4: The gait should be smooth and rhythmic, despite speed.

Rationale 5: Some neurological disorders are characterized by a slight extension of the arms to maintain balance.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-4

Question 23

Type: MCSA

When assessing a 68 year-old female patient, the nurse notes an exaggerated curvature of the thoracic spine when the patient bends at the waist. How would the nurse evaluate this finding?

1. It represents kyphosis and is a common curvature in older patients.

2. It represents kyphosis, for which emergency surgery is indicated.

3. It is called scoliosis and is a normal curvature in the elderly.

4. This is an expected finding in all women.

Correct Answer: 1

Rationale 1: Kyphosis is common in older adult patients but can also result from poor posture that leads to a rounding of the back. Kyphosis may also be secondary to another spinal problem.

Rationale 2: Kyphosis is present and is related to aging. It is not an emergency.

Rationale 3: This finding does not indicate scoliosis. Scoliosis is not a normal curvature in the elderly or any other population.

Rationale 4: This is not a normal finding is all women.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-5

Question 24

Type: MCMA

The nurse determines that a patient has pain when turning the hand palm down and then palm up. Which documentation is appropriate?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Pain on forearm supination

2. Cannot extend hand without pain

3. Pain on circumduction of the forearm

4. Pain on pronation of the hand

5. Unable to circumduct the forearm

Correct Answer: 1,4

Rationale 1: Supination means facing upward and in this scenario describes the position of the forearm when the hand turns to the palm-up position.

Rationale 2: Extension means straightening a joint. The patient is not extending the hand in this assessment.

Rationale 3: Circumduction indicates a circular motion from a joint, in this case the elbow.

Rationale 4: Pronation means facing downward. The patient experiences pain when pronating the hand.

Rationale 5: Circumduction is moving the entire limb in a circular motion, as from the shoulder. The patient is not circumducting the arm in this assessment.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-1

Question 25

Type: MCMA

The nurse plans to use a goniometer during assessment of a patients musculoskeletal system. Which technique should the nurse use?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Document the angle of the joint in range of degrees.

2. Place the fulcrum of the goniometer on the joint.

3. Place the movable arm of the goniometer on the stationary part of the joint.

4. Place the stationary arm of the goniometer on the part of the limb that will not move.

5. Move the patients arm through the normal full range of motion.

Correct Answer: 1,2,4

Rationale 1: The nurse should document the angle of the joint in a range, e.g., 30 to 50 degrees.

Rationale 2: The fulcrum of the goniometer is placed exactly at the fulcrum of the joint.

Rationale 3: The movable arm of the goniometer is placed on the movable part of the joint.

Rationale 4: The stationary arm of the goniometer is placed on the stationary part of the limb.

Rationale 5: The patient moves the arm through as much range of motion as possible. This may not be the normal full range of motion.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-3

Question 26

Type: MCSA

A 70-year-old woman is diagnosed with a pathologic fracture of the fibula. The nurse would assess for which most common condition?

1. Elder abuse

2. Osteoporosis

3. An unreported fall or injury

4. Cancer of the bone

Correct Answer: 2

Rationale 1: A pathologic fracture occurs without trauma, so elder abuse is not the cause.

Rationale 2: Pathologic fractures occur without trauma and are more common when bones are thinned from conditions such as osteoporosis.

Rationale 3: Pathologic fractures occur without trauma so there would be no reason to expect an unreported injury.

Rationale 4: Pathologic fractures occur without trauma and are more common when bones are thinned. Cancer of the bone or bone cysts may cause thinning but are not the most common etiology.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-5

Question 27

Type: MCSA

The nurse is assessing a patients ability to internally rotate the shoulders. Which direction would the nurse provide?

1. Place your hands behind your lower back.

2. Raise your arms to shoulder level.

3. Place both your hands behind your neck with your elbows out to the side.

4. Raise your arms above your head with your palms facing each other.

Correct Answer: 1

Rationale 1: To follow this instruction, the patient internally rotates the shoulders.

Rationale 2: This motion tests abduction.

Rationale 3: This motion requires external rotation.

Rationale 4: This motion tests adduction.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-3

Question 28

Type: FIB

The nurse determines that a patients shoulder muscle strength is normal when it is graded as _______ or better.

Standard Text:

Correct Answer: 3

Rationale : Shoulder muscle strength graded at 3, 4, or 5 is considered normal.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-3

Question 29

Type: MCSA

The nurse wishes to assess the anatomic snuffbox of a patients wrist. Which instruction should the nurse provide?

1. Place your hand palm-up on the table.

2. Make a tight fist as I palpate your wrist.

3. Extend your thumb fully to the side.

4. Flex your wrist as much as possible.

Correct Answer: 3

Rationale 1: The nurse will not be able to assess the anatomic snuffbox with the hand in this position.

Rationale 2: The patient does not need to make a tight fist for this assessment.

Rationale 3: The anatomic snuffbox is the hollow seen at the base of the thumb when it is fully extended to the side.

Rationale 4: Flexing the wrist will not fully reveal the anatomic snuffbox.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-3

Question 30

Type: MCSA

During an assessment of the feet, the nurse asks the patient to sit, feet dangling, and point the toes toward the nose. The nurse is assessing which movement?

1. Plantar flexion

2. Dorsiflexion

3. Eversion

4. Inversion

Correct Answer: 2

Rationale 1: Plantar flexion is assessed by asking the patient to point the toes toward the floor.

Rationale 2: Dorsiflexion is assessed by having the patient point the toes toward the nose.

Rationale 3: Eversion is assessed by having the patient turn the soles of the feet out.

Rationale 4: Inversion is assessed by having the patient turn the soles of the feet in.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 48-3

 

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