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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.
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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.
The nurse's musculoskeletal assessment of a patient reveals involuntary twitching of muscle groups. How would the nurse document this observation in the patient's chart?
- A. Tetany
- B. Atony
- C. Clonus
- D. Fasciculations
Correct Answer: D
Rationale: Fasciculation is involuntary twitching of muscle fiber groups. Clonus is a series of involuntary, rhythmic, muscular contractions and tetany is involuntary muscle contraction, but neither is characterized as twitching. Atony is a loss of muscle strength.
The nurse is assessing a patient for dietary factors that may influence her risk for osteoporosis. What nutrients should the nurse question the patient about her intake of?
- A. Calcium
- B. Simple carbohydrates
- C. Vitamin D
- D. Protein
- E. Soluble fiber
Correct Answer: A,C
Rationale: A patient's risk for osteoporosis is strongly influenced by vitamin D and calcium intake. Carbohydrate, protein, and fiber intake do not have direct effect on the development of osteoporosis.
A nurse is caring for a patient whose cancer metastasis has resulted in bone pain. Which of the following are typical characteristics of bone pain?
- A. A dull, deep ache that is boring in nature
- B. Soreness or aching that may include cramping
- C. Sharp, piercing pain that is relieved by immobilization
- D. Spastic or sharp pain that radiates
Correct Answer: A
Rationale: Bone pain is characteristically described as a dull, deep ache that is boring in nature, whereas muscular pain is described as soreness or aching and is referred to as muscle cramps. Fracture pain is sharp and piercing and is relieved by immobilization. Sharp pain may also result from bone infection with muscle spasm or pressure on a sensory nerve.
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.