NURSINGTB Show
MULTIPLE CHOICE
Test Bank - Physical Examination and Health Assessment 8e (by Jarvis) 358 NURSINGTB b. The hypothalamus controls body temperature and regulates sleep. c. The basal ganglia are responsible for controlling voluntary movements. d. Motor pathways of the spinal cord and brainstem synapse in the thalamus. ANS: B The hypothalamus is a vital area with many important functions: body temperature controlleanterior and posterior pituitary gland regulator, and coordinator of autonomic nervous system actr, sleep center,ivity and emotional status. The cerebellum controls motor coordination, equilibrium, and balance. The control autonomic movements of the body. The motor pathways of the spinal cord synapse in various areas ofbasal ganglia the spinal cord, not in the thalamus. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General 4. The area of the nervous system that is responsible for mediating reflexes is the: a. Medulla. b. Cerebellum. c. Spinal cord. d. Cerebral cortex. ANS: C The spinal cord is the main highway for ascending and descending fiber tracts that connect the spinal nerves; it is responsible for mediating reflexes. brain to the DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: General 5. While gathering equipment after an injection, a nurse accidentally received a prick frcapped needle. To interpret this sensation, which of these areas must be intact? om an improperly a. Corticospinal tract, medulla, and basal ganglia b. Pyramidal tract, hypothalamus, and sensory cortex c. Lateral spinothalamic tract, thalamus, and sensory cortex d. Anterior spinothalamic tract, basal ganglia, and sensory cortex ANS: C Test Bank - Physical Examination and Health Assessment 8e (by Jarvis) 359 NURSINGTB DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General 8. A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintainingher balance. Which area of the brain that is related to these findings would concern the nurse? a. Thalamus b. Brainstem c. Cerebellum d. Extrapyramidal tract ANS: C The cerebellar system coordinates movement, maintains equilibrium, and helps maintais the primary relay station where sensory pathways of the spinal cord, cerebellum, and brain posture. The thalamusinstem form synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, anhas various functions, especially concerning autonomic centers. The extrapyramidal tract maintains muscled medulla and tone for gross automatic movements, such as walking. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 9. Which of these statements about the peripheral nervous system is correct? a. The CNs enter the brain through the spinal cord. b. Efferent fibers carry sensory input to the central nervous system through the spinal cord. c. The peripheral nerves are inside the central nervous system and carry impulses thfibers. rough their motor d. The peripheral nerves carry input to the central nervous system by afferent fibers anthe central nervous system by efferent fibers. d away from ANS: D A nerve is a bundle of fibers outside of the central nervous system. The peripheral nerves cacentral nervous system by their sensory afferent fibers and deliver output from the central nervous system byrry input to the their efferent fibers. The other responses are not related to the peripheral nervous system. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: General 10. A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation? a. Because there are 31 pairs of spinal nerves, no effect results if only one nerve is severed. Test Bank - Physical Examination and Health Assessment 8e (by Jarvis) 361 NURSINGTB b. The dermatome served by this nerve will no longer experience any sensation. c. The adjacent spinal nerves will continue to carry sensations for the dermatome sesevered nerve. rved by the d. A severed spinal nerve will only affect motor function of the patient because spinal nersensory component. ves have no ANS: C A dermatome is a circumscribed skin area that is primarily supplied from one spinalparticular spinal nerve. The dermatomes overlap, which is a form of biologic insurance; cord segment through athat is, if one nerve is severed, then most of the sensations can be transmitted by the spinal nerve above and the spinal the severed nerve. nerve below DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 11. A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are injuries. During the assessment what would the nurse expect to find when testing the patients deep tendonno other reflexes? a. Reflexes will be normal. b. Reflexes cannot be elicited. c. All reflexes will be diminished but present. d. Some reflexes will be present, depending on the area of injury. ANS: A A reflex is a defense mechanism of the nervous system. It operates below the level of permits a quick reaction to potentially painful or damaging situations. conscious control and DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 12. A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn to roll over. Thenurse knows that the reason for this is: a. A demyelinating process must be occurring with her infant. b. Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated. c. The cerebral cortex is not fully developed; therefore, control over motor function gradually occurs. Test Bank - Physical Examination and Health Assessment 8e (by Jarvis) 362 NURSINGTB DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Health Promotion and Maintenance 15. During the taking of the health history, a patient tells the nurse that it feels like thme. The nurse would document this finding as: e room is spinning around a. Vertigo. b. Syncope. c. Dizziness. d. Seizure activity. ANS: A True vertigo is rotational spinning caused by a neurologic dysfunction or a problem in the vestibular apparatusor the vestibular nuclei in the brainstem. Syncope is a sudden loss of strength or a temporary loss of consciousness. Dizziness is a lightheaded, swimming sensation. Seizure activity isloss of consciousness, involuntary muscle movements, and sensory disturbances. characterized by altered or DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 16. When taking the health history on a patient with a seizure disorder, the nurse assesses has an aura. Which of these would be the best question for obtaining this information? whether the patient a. Does your muscle tone seem tense or limp? b. After the seizure, do you spend a lot of time sleeping? c. Do you have any warning sign before your seizure starts? d. Do you experience any color change or incontinence during the seizure? ANS: C Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or questions do not solicit information about an aura. motor. The other DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 17. While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the infantsability to suck and grasp the mothers finger. What is the nurse assessing? a. Reflexes Test Bank - Physical Examination and Health Assessment 8e (by Jarvis) 364 NURSINGTB b. Intelligence c. CNs d. Cerebral cortex function ANS: A Questions regarding reflexes include such questions as, What have you noticed about the infants behthe infants sucking and swallowing seem coordinated, and Does the infant grasp your finger? The othavior, Areer responses are incorrect. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance 18. In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and thathe has noticed a tremor in his hands that affects his ability to hold things. With this information, what response should the nurse make? a. Does your family know you are drinking every day? b. Does the tremor change when you drink alcohol? c. Well do some tests to see what is causing the tremor. d. You really shouldnt drink so much alcohol; it may be causing your tremor. ANS: B Senile tremor is relieved by alcohol, although not a recommended treatment. The nurse should asthe person is abusing alcohol in an effort to relieve the tremor. sess whether DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Health Promotion and Maintenance 19. A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has notiweek. The nurse should perform which type of neurologic examination? ced for the past a. Glasgow Coma Scale b. Neurologic recheck examination c. Screening neurologic examination d. Complete neurologic examination ANS: D Test Bank - Physical Examination and Health Assessment 8e (by Jarvis) 365 NURSINGTB MSC: Client Needs: Health Promotion and Maintenance 22. During the neurologic assessment of a healthy 35-year-old patient, the nurse asks him to relcompletely. The nurse then moves each extremity through full range of motion. Which of these resuax his muscleslts would the nurse expect to find? a. Firm, rigid resistance to movement b. Mild, even resistance to movement c. Hypotonic muscles as a result of total relaxation d. Slight pain with some directions of movement ANS: B Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It showspassive stretching. Normally, the nurse will notice a mild, even resistance to movement. The other responses a mild resistance to are not correct. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 23. When the nurse asks a 68-year-old patient to stand with his feet together and arms at his closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:side with his eyes a. Ataxia. b. Lack of coordination. c. Negative Homans sign. d. Positive Romberg sign. ANS: D Abnormal findings for the Romberg test include swaying, falling, and a widening base of the feet falling. A positive Romberg sign is a loss of balance that is increased by the closing of the eyes. Ataxia is anto avoid uncoordinated or unsteady gait. Homans sign is used to test the legs for deep-vein thrombosis. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Health Promotion and Maintenance 24. The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaalways dropping things and falling down. While testing rapid alternating movements, the nurse noticining ofes that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently missshould the nurse suspect? es. What a. Vestibular disease Test Bank - Physical Examination and Health Assessment 8e (by Jarvis) 367 NURSINGTB b. Lesion of CN IX c. Dysfunction of the cerebellum d. Inability to understand directions ANS: C When a person tries to perform rapid, alternating movements, responses that are slow, clindicative of cerebellar disease. The other responses are incorrect. umsy, and sloppy are DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 25. During the taking of the health history of a 78-year-old man, his wife states that he occasiproblems with short-term memory loss and confusion: He cant even remember how to button his shonally hasirt. When assessing his sensory system, which action by the nurse is most appropriate? a. The nurse would not test the sensory system as part of the examination because the resunot be valid. lts would b. The nurse would perform the tests, knowing that mental status does not affect sensory ability. c. The nurse would proceed with an explanation of each test, making certain that the wifeunderstands. d. Before testing, the nurse would assess the patients mental status and ability to follow directions. ANS: D The nurse should ensure the validity of the sensory system testing by making certain that the patcooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading andient is alert, invalid results. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Health Promotion and Maintenance 26. The assessment of a 60-year-old patient has taken longer than anticipated. In testing histhe nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin pain perception, on his arm several times, he is only able to identify these as one very sharp prick. What would be accurate explanation for this? the most a. The patient has hyperesthesia as a result of the aging process. b. This response is most likely the result of the summation effect. c. The nurse was probably not poking hard enough with the pin in the other areas. Test Bank - Physical Examination and Health Assessment 8e (by Jarvis) 368 NURSINGTB DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 29. The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for physical examination. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit aan annual reflex. The nurses next response should be to: a. Ask the patient to lock her fingers and pull. b. Complete the examination, and then test these reflexes again. c. Refer the patient to a specialist for further testing. d. Document these reflexes as 0 on a scale of 0 to 4+. ANS: A Sometimes the reflex response fails to appear. Documenting the reflexes as the examination. The nurse should try to further encourage relaxation, varying the persons position or absent is inappropriate this soon in increasing the strength of the blow. Reinforcement is another technique to relax the musclresponse. The person should be asked to perform an isometric exercise in a muscle group somewhes and enhance theat away from the one being tested. For example, to enhance a patellar reflex, the person should be asked to lock the fingerstogether and pull. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 30. In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the sided weakness. What might the nurse expect to find when testing his reflexes on the right sidnurse notices right-e? a. Lack of reflexes b. Normal reflexes c. Diminished reflexes d. Hyperactive reflexes ANS: D Hyperreflexia is the exaggerated reflex observed when the monosynaptic reflex arc is influence of higher cortical levels. This response occurs with upper motor neuron lesions (ereleased from the., a cerebrovascular accident). The other responses are incorrect. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 31. When the nurse is testing the triceps reflex, what is the expected response? Test Bank - Physical Examination and Health Assessment 8e (by Jarvis) 370 NURSINGTB a. Flexion of the hand b. Pronation of the hand c. Extension of the forearm d. Flexion of the forearm ANS: C The normal response of the triceps reflex is extension of the forearm. The normal respcauses flexion of the forearm. The other responses are incorrect. onse of the biceps reflex DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 32. The nurse is testing superficial reflexes on an adult patient. When stroking up the laterand across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse documental side of the sole this finding? a. Positive Babinski sign b. Plantar reflex abnormal c. Plantar reflex present d. Plantar reflex 2+ on a scale from 0 to 4+ ANS: C With the same instrument, the nurse should draw a light stroke up the lateral side of the soacross the ball of the foot, similar to an upside-down J. The normal response is plantar flexion of the toes andle of the foot and sometimes of the entire foot. A positive Babinski sign is abnormal and occurs with the resof the big toe and fanning of all toes. The plantar reflex is not graded on a 0 to 4+ scale. ponse of dorsiflexion DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 33. In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or stmother reports that in the last week he has been sleeping all of the time, and when he is awake all he does isimulation. The cry. The nurse hears that the infants cries are very high pitched and shrill. What should be the appropriate response to these findings? nurses a. Refer the infant for further testing. b. Talk with the mother about eating habits. c. Do nothing; these are expected findings for an infant this age. Test Bank - Physical Examination and Health Assessment 8e (by Jarvis) 371 NURSINGTB MSC: Client Needs: Health Promotion and Maintenance 36. While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following reabduction and flexion of the arms and legs; fanning of the fingers, and curling of the index finger and thumb insponse: a C position, followed by the infant bringing in the arms and legs to the body. What does the nurse know aboutthis response? a. This response could indicate brachial nerve palsy. b. This reaction is an expected startle response at this age. c. This reflex should have disappeared between 1 and 4 months of age. d. This response is normal as long as the movements are bilaterally symmetric. ANS: C The Moro reflex is present at birth and usually disappears at 1 to 4 months. Absence of the Moro renewborn or its persistence after 5 months of age indicates severe central nervous system injury. The otherflex in the responses are incorrect. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Health Promotion and Maintenance 37. To test for gross motor skill and coordination of a 6-year-old child, which of these techniques appropriate? Ask the child to: would be a. Hop on one foot. b. Stand on his head. c. Touch his finger to his nose. d. Make funny faces at the nurse. ANS: A Normally, a child can hop on one foot and can balance on one foot for approximately 5 seconds by 4 years ofage and can balance on one foot for 8 to 10 seconds at 5 years of age. Children enjoy performing these tests. Failure to hop after 5 years of age indicates incoordination of gross motor skills. Asking the or her finger to the nose checks fine motor coordination; and asking the child to make funny faces tests CNchild to touch his VII. Asking a child to stand on his or her head is not appropriate. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 38. During the assessment of an 80-year-old patient, the nurse notices that his hands show tremreaches for something and his head is always nodding. No associated rigidity is observed with moors when hevement. Which of these statements is _most _ accurate? Test Bank - Physical Examination and Health Assessment 8e (by Jarvis) 373 NURSINGTB a. These findings are normal, resulting from aging. b. These findings could be related to hyperthyroidism. c. These findings are the result of Parkinson disease. d. This patient should be evaluated for a cerebellar lesion. ANS: A Senile tremors occasionally occur. These benign tremors include an intention tremor of nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease includethe hands, head rigidity, slowness, and a weakness of voluntary movement. The other responses are incorrect. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Health Promotion and Maintenance 39. While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, hetells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of a(n): a. Great sense of humor. b. Uncooperative behavior. c. Inability to understand questions. d. Decreased level of consciousness. ANS: D A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness,disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 40. The nurse is caring for a patient who has just had neurosurgery. To assess for increased inpressure, what would the nurse include in the assessment? tracranial a. CNs, motor function, and sensory function b. Deep tendon reflexes, vital signs, and coordinated movements c. Level of consciousness, motor function, pupillary response, and vital signs d. Mental status, deep tendon reflexes, sensory function, and pupillary response Test Bank - Physical Examination and Health Assessment 8e (by Jarvis) 374 NURSINGTB DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 43. During an assessment of a 62-year-old man, the nurse notices the patient has a stooped posturewalk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be, shuffling consistent with: a. Parkinsonism. b. Cerebral palsy. c. Cerebellar ataxia. d. Muscular dystrophy. ANS: A The stooped posture, shuffling walk, short steps, flat facial expression, and pill-rolling fiall found in parkinsonism. nger movements are DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 44. During an assessment of a 32-year-old patient with a recent head injury, the nurse noticesresponds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower that the patient extremities extend with plantar flexion. Which statement concerning these findings ispatients response: _most _ accurate? This a. Indicates a lesion of the cerebral cortex. b. Indicates a completely nonfunctional brainstem. c. Is normal and will go away in 24 to 48 hours. d. Is a very ominous sign and may indicate brainstem injury. ANS: D These findings are all indicative of decerebrate rigidity, which is a very ominous conditibrainstem injury. on and may indicate a DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 45. A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adductiwalks, his lefton of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gaiindividual experiencing? t disturbance is this Test Bank - Physical Examination and Health Assessment 8e (by Jarvis) 376 NURSINGTB a. Scissors gait b. Cerebellar ataxia c. Parkinsonian gait d. Spastic hemiparesis ANS: D With spastic hemiparesis, the arm is immobile against the body. Flexion of the shoulder, elfingers occurs, and adduction of the shoulder, which does not swing freely, is observed. The leg is stiff andbow, wrist, and extended and circumducts with each step. Causes of this type of gait include cerebrovascular accident. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 46. In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of theseassessment findings should the nurse expect? physical a. Hyperreflexia b. Fasciculations c. Loss of muscle tone and flaccidity d. Atrophy and wasting of the muscles ANS: A Hyperreflexia, diminished or absent superficial reflexes, and increased muscle expected with upper motor neuron lesions. The other options reflect a lesion of lower motor neurotone or spasticity can bens. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 47. A 59-year-old patient has a herniated intervertebral disk. Which of the following findings expect to see on physical assessment of this individual? should the nurse a. Hyporeflexia b. Increased muscle tone c. Positive Babinski sign d. Presence of pathologic reflexes Test Bank - Physical Examination and Health Assessment 8e (by Jarvis) 377 What term would be used to describe when the nurse places a key in the hand of a client and they identify it as a penny?Cortical sensory function is evaluated by asking the patient to identify a familiar object (eg, coin, key) placed in the palm of the hand (stereognosis) and numbers written on the palm (graphesthesia) and to distinguish between 1 and 2 simultaneous, closely placed pinpricks on the fingertips (2-point discrimination).
What response would be expected on testing the triceps reflex?The test can be performed by tapping the triceps tendon with the sharp end of a reflex hammer while the forearm is hanging loose at a right angle to the arm. A sudden contraction of the triceps muscle causes extension, and indicates a normal reflex.
Which of the following would the nurse use to test the motor coordination of an 11 month old infant?Which of these tests would the nurse use to check the motor coordination of an 11-month-old infant? To screen gross and fine motor coordination, the nurse should use the Denver II with its age-specific developmental milestones.
Which of the following statements about the peripheral nervous system is true?The correct answer is (D): It includes a sensory division and a motor division. The peripheral nervous system includes all nervous tissue located outside the brain and the spinal cord.
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During an assessment of an 80-year-old patient, the nurse notices the following
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