NR-304 Health Assessment II - Set 3 - Part 1

Correct Answer: Grade four, some resistance, seventy five percent

Grade four is full range against gravity with some resistance, rated seventy five percent of normal and worded good. The client overcame gravity and light pressure but could not hold against full resistance. Option a is incorrect because grade five requires the client to hold full range against the examiner's full resistance. Giving way under firm pressure rules the top of the scale out. Option b is incorrect because grade three describes a limb that moves through full range against gravity and nothing more. This client added light pressure to gravity, which lifts the score above the hinge point. Option d is incorrect because grade two applies when gravity must be removed before the client can move the joint actively through its range. This client lifted the leg against gravity without help.

Correct Answer: Eversion of the right foot

Eversion turns the sole of the foot outward, away from the midline, at the subtalar joint. Steadying the ankle keeps the client from substituting hip rotation for the small foot movement. Option a is incorrect because inversion carries the sole inward toward the midline, the direction of the classic ankle sprain. The client was asked to move the sole in the opposite direction. Option c is incorrect because plantar flexion points the toes down toward the floor. It moves the whole foot at the ankle mortise rather than tilting the sole to one side. Option d is incorrect because dorsiflexion lifts the toes up toward the shin. Like plantar flexion it occurs in the up and down plane and produces no sideways tilt of the sole.

Correct Answer: Dorsiflexion of the right foot

Dorsiflexion bends the foot up at the ankle so the toes move toward the shin. The course teaches this as one of the four ankle movements performed during the head to toe check off. Option a is incorrect because plantar flexion points the foot downward at the ankle, carrying the toes toward the floor rather than the shin. The client moved in the opposite direction from the one described. Option b is incorrect because inversion turns the sole of the foot inward at the ankle. No sideways tilting of the sole took place in this scenario, only an upward pull of the toes. Option d is incorrect because eversion tilts the sole outward, away from the body midline, and is produced at the subtalar joint. Lifting the forefoot toward the leg is a separate ankle movement.

Correct Answer: Acute compartment syndrome of the forearm

A tense compartment with disproportionate pain hours after casting is acute compartment syndrome; the unyielding fascia traps swelling, and the distal pulse commonly remains palpable because the artery carries systolic pressure through the compartment. Option a is incorrect because acute arterial occlusion presents suddenly with a cold, pale, pulseless limb and no initial compartment tenseness; that picture belongs to the client with the foot, not the casted forearm. Option b is incorrect because venous thrombosis produces unilateral swelling, warmth, redness and deep muscle pain while pulses stay intact; that description fits the swollen calf and does not make a compartment feel wood-like. Option c is incorrect because ordinary injury swelling is soft and the pain eases with analgesia and rest; severe pain that opioids do not touch, with a rigid compartment, has moved beyond an uncomplicated sprain.

Correct Answer: Barlow adducts and pushes the hip out

Barlow dislocates a reducible hip by adducting the thigh while pressing posteriorly on the trochanter, producing a clunk as the head slips out, whereas Ortolani abducts and lifts to put a dislocated head back in. Option b is incorrect because abducting and lifting describes Ortolani, the maneuver that returns a dislocated femoral head to the socket; the student has the two movements reversed, which is the commonest error here. Option c is incorrect because comparing knee heights with the feet flat on the table is the Allis or Galeazzi test, a separate screen in which a lower knee signals a shortened femur. Option d is incorrect because neither maneuver grades strength against resistance; limited abduction of the flexed thigh is assessed by moving the hips passively and becomes the key sign once the infant is older.

Correct Answer: Elevation and depression of the girdle

Elevation is raising a body part and depression is lowering it. A shoulder shrug lifts the girdle straight up and releasing it lowers the girdle, which is the vertical pair the course names. Option a is incorrect because protraction and retraction slide a body part forward and backward parallel to the ground. Rounding the shoulders forward would be protraction, but the client moved straight up and down. Option b is incorrect because flexion bends a limb at a joint and extension straightens it. Those terms describe the angle between two bones and are not used for the shoulder girdle itself. Option d is incorrect because internal and external rotation turn a limb inward or outward around its long axis. The course applies that pair to the shoulder and the hip, not to a shrug.

Correct Answer: Place a pillow supporting the resting arm

Positioning a limb comfortably on a pillow is a standardized comfort measure with a predictable outcome and no nursing judgment, so it falls within the scope of unlicensed assistive personnel. Option a is incorrect because palpating for warmth and fluctuance is an assessment requiring clinical interpretation. Assessment cannot be delegated, and the texture of the swelling is exactly what the nurse uses to characterize the problem. Option b is incorrect because client education is a licensed nursing responsibility. Explaining how repetitive pressure and leaning inflame the bursa requires teaching skill and evaluation of understanding, neither of which belongs to unlicensed staff. Option c is incorrect because distinguishing a discrete lump over the bursa from fullness in the grooves beside the olecranon is a diagnostic judgment. Drawing that conclusion demands the nurse's own examination and reasoning.

Correct Answer: Clear loose rugs from the walking path

Removing environmental hazards such as loose rugs is a concrete safety task with no assessment or judgment attached, so it is appropriate for unlicensed assistive personnel under the nurse's direction. Option b is incorrect because weighing risk factors and reaching a conclusion about fracture likelihood is clinical judgment reserved for the licensed nurse. Unlicensed staff may report observations but cannot interpret what those observations mean. Option c is incorrect because explaining a diagnostic procedure is teaching, and teaching belongs to the nurse. The client may ask what the result means, which requires knowledge of bone density categories that assistive staff do not hold. Option d is incorrect because new back pain in a client with fragile bone may signal a vertebral compression fracture. Characterizing that pain is an assessment, and assessment is never transferred to unlicensed personnel.

Correct Answer: An antalgic gait caused by pain

An antalgic gait is the limp of pain, in which the stance phase on the painful side is shortened because the client unloads that limb as quickly as possible, typically with hip or knee arthritis. Option a is incorrect because steppage gait comes from foot drop, in which weak dorsiflexors force the client to lift the hip and knee high so the toes clear the floor. Option b is incorrect because a waddling gait reflects weak hip girdle muscles and produces a duck-like lurch from side to side with every step, not a shortened time on one painful leg. Option d is incorrect because scissoring describes legs that cross at the knees and thighs with each step, a picture of bilateral spasticity such as cerebral palsy rather than of a single painful joint.

Correct Answer: Excessive backward translation indicates a posterior cruciate injury

The posterior drawer is performed with the hip flexed about forty five degrees and the knee at ninety degrees. A tibia that shifts backward more than the opposite side indicates posterior cruciate injury, since that ligament resists backward movement. Option a is incorrect because forward translation is sought when the tibia is pulled toward the examiner during the anterior drawer. Pushing the bone away cannot demonstrate anterior laxity and names the wrong cruciate ligament. Option c is incorrect because drawer maneuvers produce laxity, not sound. A click belongs to the cartilage test performed by extending a fully flexed knee while the tibia is held in rotation, which is a different examination. Option d is incorrect because a boggy doughy feel comes from thickened synovium found on palpation rather than from a ligament test. Stability maneuvers measure how far a bone slides, not the texture of the tissue.

Correct Answer: Stop the movement if the client reports pain.

The safety rule is absolute. A joint is never forced past the point of pain and is never moved passively beyond its normal range, so stopping at pain is what assistive personnel must be told. Option a is incorrect because pushing through stiffness forces the joint past its safe limit and can injure the capsule. Resistance and pain both mark the end of the movement for an unlicensed helper. Option b is incorrect because measuring joint angles with a goniometer is an assessment skill that stays with the nurse. Delegating a measurement that guides clinical judgment falls outside the assistant's scope. Option d is incorrect because side to side comparison is useful but is not the safety instruction that matters most here. Comparing shoulders will not stop a helper from injuring a painful joint.

Correct Answer: The client turns the palm toward the floor

Pronation turns the forearm so the palm faces down. Pinning the elbow against the side prevents the client substituting shoulder rotation, so the palm position alone confirms that true forearm rotation occurred. Option b is incorrect because a palm turned upward is supination, the opposite half of the pair. Both motions are performed at the elbow station, so naming them accurately matters during the graded check off. Option c is incorrect because moving the hand toward the thumb is radial deviation, one of the wrist movements. The check off tests deviation at the wrist station and not at the elbow. Option d is incorrect because lifting the arm out to the side is shoulder abduction. Tucking the elbow against the trunk is done precisely to block that substitution during forearm testing.

Correct Answer: Internal and external rotation of the shoulder

Hands behind the back test internal rotation and hands behind the head test external rotation. Both turn the arm around its long axis, inward toward the midline or outward away from it. Option a is incorrect because forward flexion and hyperextension are tested by carrying the arms forward and up overhead and then back behind the body. Neither hand position in the scenario does that. Option c is incorrect because abduction and adduction are checked with the arms out to the side and then across the front of the body. Placing a hand behind the back is not either motion. Option d is incorrect because elevation and depression raise and lower the shoulder girdle, as in a shrug. That vertical pair involves no turning of the humerus on its own axis.

Correct Answer: A fluid filled cavity inside a capsule

A synovial joint has a fluid filled cavity wrapped in a fibrous capsule and lined by synovial membrane. Nonsynovial joints have no cavity at all and are bound by fibrous tissue or cartilage. Option a is incorrect because dense fibrous tissue binding two bones describes the fibrous class of nonsynovial joint, such as a skull suture. That arrangement leaves no space for fluid between the bones. Option b is incorrect because cartilage bridging two bone ends defines the cartilaginous nonsynovial group, which includes the pubic symphysis. These joints allow slight motion but contain no capsule and no lubricating fluid. Option c is incorrect because articulating bones are never left bare. Every joint is bound by fibrous tissue, by cartilage, or by a capsule, and synovial surfaces are capped with hyaline cartilage.

Correct Answer: Pain below forty five degrees supports a positive test

The sourced threshold places a positive straight leg raise when pain is elicited below forty five degrees of hip flexion. The commonly taught interpretive band runs from about thirty to seventy degrees, so pain outside it is less likely radicular. Option a is incorrect because elevation of only a few degrees is generally too early to place tension on a nerve root. Pain that begins almost immediately usually reflects guarding or another source rather than radiculopathy. Option b is incorrect because discomfort appearing only near the end of a full range is usually hamstring tightness. No source sets the threshold that high, and a figure of eighty degrees would label normal tissue stretch as disease. Option d is incorrect because the maneuver is judged while the examiner raises the limb, not while returning it to the table. Lowering releases the stretch on the root, so any pain reported then carries no interpretive weight.

Correct Answer: Record full range of motion, equal bilaterally

Where the course states no degrees, the expected answer is descriptive. Full range of motion, with paired joints described as equal bilaterally, is the wording the documentation model uses for the shoulder, hip, knee and ankle. Option a is incorrect because guessing a number invents data. Published norms differ between references and shift with age, so an unmeasured figure entered in the record is both unsupported and potentially misleading to the next examiner. Option b is incorrect because the four cervical values belong to the neck alone. Flexion, hyperextension, lateral bending and rotation of the cervical spine describe head movement and cannot be transferred to a limb joint. Option c is incorrect because a grade from zero to five belongs to muscle strength, not to motion. Charting a grade in place of range confuses two separate measurements that should appear as distinct entries.

Correct Answer: Grade two, full range with gravity eliminated

Grade two is active movement through full range once gravity is removed. Sliding the arm across the bed is the classic example, and the client generated that motion without assistance from anyone. Option b is incorrect because grade one means only a flicker of contraction with no useful movement. This client carried the limb through a complete arc, which is well beyond a trace. Option c is incorrect because zero means no contraction can be seen or felt at all. Limb motion produced only by an examiner scores zero or one, but this client moved the arm herself. Option d is incorrect because grade three requires the limb to move through full range against gravity, which means lifting it off the bed. This client could not raise the arm at all.

Correct Answer: Correct the position to backs of hands with wrists flexed

The described position reverses the test. Phalen requires the backs of the hands held together with both wrists flexed about ninety degrees, not palms together in extension. The one minute hold the student named is correct. Option a is incorrect because agreeing with the plan leaves the wrong wrist position uncorrected. Sixty seconds is indeed the right duration, but hyperextension with the palms touching will not compress the median nerve and the screen would fail. Option c is incorrect because the duration the student gave matches the published technique. Extending the hold to three minutes would not rescue a position that opens the tunnel instead of narrowing it, so timing is not the error. Option d is incorrect because percussion is directed over the median nerve, not the ulnar nerve, when eliciting a Tinel sign. Swapping nerves would test a territory that carpal tunnel compression does not involve.

Correct Answer: Flexion and extension of the lower leg

The knee is a hinge joint, so it permits flexion and extension of the lower leg on a single plane. Hinge joints are uniaxial, which is why no other movement belongs at the knee. Option b is incorrect because circumduction requires a ball and socket or condyloid joint, such as the shoulder or a knuckle. A uniaxial hinge cannot trace the cone shaped path the term describes. Option c is incorrect because inversion and eversion happen at the subtalar joint below the ankle and tilt the sole sideways. The lower leg does not perform them at the knee. Option d is incorrect because pronation and supination are forearm rotations produced at the radioulnar joints. The course lists them among the distractors that belong to a different limb entirely.

Correct Answer: Limited painful abduction with fairly normal forward flexion

The rotator cuff pattern is limited and painful abduction with muscle spasm while forward flexion stays fairly normal. Added to hunched posture, shoulder girdle atrophy and a positive arm drop test, this combination identifies the lesion. Option a is incorrect because adduction brings the arm across the body and does not load the supraspinatus tendon. Cuff lesions leave adduction essentially free, so limited adduction points toward a different shoulder problem. Option c is incorrect because the relationship is reversed here. Forward flexion remains relatively intact in a cuff lesion while abduction is the motion that becomes restricted and painful, so preserved abduction argues against the diagnosis. Option d is incorrect because a fluctuant feel on palpation indicates fluid under the fingers rather than a torn tendon. Cuff tears produce painful restricted motion and atrophy, not a boggy fluctuant swelling over the joint.