Nokea
A nurse on the orthopedic unit is assessing a patient's peroneal nerve. The nurse will perform this assessment by doing which of the following actions?
- A. Pricking the skin between the great and second toe
- B. Stroking the skin on the sole of the patient's foot
- C. Pinching the skin between the thumb and index finger
- D. Stroking the distal fat pad of the small finger
Correct Answer: A
Rationale: The nurse will evaluate the sensation of the peroneal nerve by pricking the skin centered between the great and second toe. None of the other listed actions elicits the function of one of the peripheral nerves.
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A patient is receiving ongoing nursing care for the treatment of Parkinson's disease. When assessing this patient's gait, what finding is most closely associated with this health problem?
- A. Spastic hemiparesis gait
- B. Shuffling gait
- C. Rapid gait
- D. Steppage gait
Correct Answer: B
Rationale: A variety of neurologic conditions are associated with abnormal gaits, such as a spastic hemiparesis gait (stroke), steppage gait (lower motor neuron disease), and shuffling gait (Parkinson's disease). A rapid gait is not associated with Parkinson's disease.
A patient has been experiencing progressive increases in knee pain and diagnostic imaging reveals a worsening effusion in the synovial capsule. The nurse should anticipate which of the following?
- A. Arthrography
- B. Knee biopsy
- C. Arthrocentesis
- D. Electromyography
Correct Answer: C
Rationale: Arthrocentesis (joint aspiration) is carried out to obtain synovial fluid for purposes of examination or to relieve pain due to effusion. Arthrography, biopsy, and electromyography would not remove fluid and relieve pressure.
A nurse is caring for a patient who has an MRI scheduled. What is the priority safety action prior to this diagnostic procedure?
- A. Assessing the patient for signs and symptoms of active infection
- B. Ensuring that the patient can remain immobile for up to 3 hours
- C. Assessing the patient for a history of nut allergies
- D. Ensuring that there are no metal objects on or in the patient
Correct Answer: D
Rationale: Absolutely no metal objects can be present during MRI their presence constitutes a serious safety risk. The procedure takes up to 90 minutes. Nut allergies and infection are not contraindications to MRI.
The nurse is performing an assessment of a patient's musculoskeletal system and is appraising the patient's bone integrity. What action should the nurse perform during this phase of assessment?
- A. Compare parts of the body symmetrically.
- B. Assess extremities when in motion rather than at rest.
- C. Percuss as many joints as accessible.
- D. Administer analgesia 30 to 60 minutes before assessment.
Correct Answer: A
Rationale: When assessing bone integrity, symmetric parts of the body, such as extremities, are compared. Analgesia should not be necessary and percussion is not a clinically useful assessment technique. Bone integrity is best assessed when the patient is not moving.
A nurse is caring for a patient who has just had an arthroscopy as an outpatient and is getting ready to go home. The nurse should teach the patient to monitor closely for what postprocedure complication?
- A. Fever
- B. Crepitus
- C. Fasciculations
- D. Synovial fluid leakage
Correct Answer: A
Rationale: Following arthroscopy, the patient and family are informed of complications to watch for, including fever. Synovial fluid leakage is unlikely and crepitus would not develop as a postprocedure complication. Fasciculations are muscle twitches and do not involve joint integrity or function.