Nokea
A nurse is assessing a patient who is experiencing peripheral neurovascular dysfunction. What assessment findings are most consistent with this diagnosis?
- A. Hot skin with a capillary refill of 1 to 2 seconds
- B. Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin
- C. Pain, diaphoresis, and erythema
- D. Jaundiced skin, weakness, and capillary refill of 3 seconds
Correct Answer: B
Rationale: Indicators of peripheral neurovascular dysfunction include pale, cyanotic, or mottled skin with a cool temperature; capillary refill greater than 3 seconds; weakness or paralysis with motion; and paresthesia, unrelenting pain, pain on passive stretch, or absence of feeling. Jaundice, diaphoresis, and warmth are inconsistent with peripheral neurovascular dysfunction.
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While assessing a patient, the patient tells the nurse that she is experiencing rhythmic muscle contractions when the nurse performs passive extension of her wrist. What is this pattern of muscle contraction referred to as?
- A. Fasciculations
- B. Contractures
- C. Effusion
- D. Clonus
Correct Answer: D
Rationale: Clonus may occur when the ankle is dorsiflexed or the wrist is extended. It is characterized as rhythmic contractions of the muscle. Fasciculation is involuntary twitching of muscle fiber groups. Contractures are prolonged tightening of muscle groups and an effusion is the pathologic escape of body fluid.
The nurse's comprehensive assessment of an older adult involves the assessment of the patient's gait. How should the nurse best perform this assessment?
- A. Instruct the patient to walk heel-to-toe for 15 to 20 steps.
- B. Instruct the patient to walk in a straight line while not looking at the floor.
- C. Instruct the patient to walk away from the nurse for a short distance and then toward the nurse.
- D. Instruct the patient to balance on one foot for as long as possible and then walk in a circle around the room.
Correct Answer: C
Rationale: Gait is assessed by having the patient walk away from the examiner for a short distance. The examiner observes the patient's gait for smoothness and rhythm. Looking at the floor is not disallowed and gait is not assessed by observing balance on one leg. Heel-to-toe walking ability is not gauged during an assessment of normal gait.
A nurse is taking a health history on a patient with musculoskeletal dysfunction. What is the primary focus of this phase of the nurse's assessment?
- A. Evaluating the effects of the musculoskeletal disorder on the patient's function
- B. Evaluating the patient's adherence to the existing treatment regimen
- C. Evaluating the presence of genetic risk factors for further musculoskeletal disorders
- D. Evaluating the patient's active and passive range of motion
Correct Answer: A
Rationale: The nursing assessment of the patient with musculoskeletal dysfunction includes an evaluation of the effects of the musculoskeletal disorder on the patient. This is a vital focus of the health history and supersedes the assessment of genetic risk factors and adherence to treatment, though these are both valid inclusions to the interview. Assessment of ROM occurs during the physical assessment, not the interview.
A patient has been experiencing an unexplained decline in knee function and has consequently been scheduled for arthrography. The nurse should teach the patient about what process?
- A. Injection of a contrast agent into the knee joint prior to ROM exercises
- B. Aspiration of synovial fluid for serologic testing
- C. Injection of corticosteroids into the patient's knee joint to facilitate ROM
- D. Replacement of the patient's synovial fluid with a synthetic substitute
Correct Answer: A
Rationale: During arthrography, a radiopaque contrast agent or air is injected into the joint cavity to visualize the joint structures such as the ligaments, cartilage, tendons, and joint capsule. The joint is put through its range of motion to distribute the contrast agent while a series of x-rays are obtained. Synovial fluid is not aspirated or replaced and corticosteroids are not administered.
A nurse is explaining a patient's decreasing bone density in terms of the balance between bone resorption and formation. What dietary nutrients and hormones play a role in the resorption and formation of adult bones?
- A. Thyroid hormone
- B. Growth hormone
- C. Estrogen
- D. Vitamin B12
- E. Luteinizing hormone
Correct Answer: A,B,C
Rationale: The balance between bone resorption and formation is influenced by the following factors: physical activity; dietary intake of certain nutrients, especially calcium; and several hormones, including calcitriol (i.e., activated vitamin D), parathyroid hormone (PTH), calcitonin, thyroid hormone, cortisol, growth hormone, and the sex hormones estrogen and testosterone. Luteinizing hormone and vitamin B12 do not play a role in bone formation or resorption.