NR-304 Health Assessment II - Set 3 - Part 2

Correct Answer: Exaggerated concave curvature of the lumbar spine

The enlarging fetus shifts the center of balance forward, so the lumbar spine curves further inward to keep the woman upright. That exaggerated lumbar concavity is lordosis, and it strains the low back muscles. Option a is incorrect because that describes kyphosis, a rounding of the upper back. Kyphosis accompanies aging and osteoporotic vertebral collapse, and it is not the compensatory postural change that late pregnancy produces. Option b is incorrect because sideways deviation with vertebral rotation defines scoliosis, which pregnancy does not cause. Scoliosis is never a normal finding at any age and would show unequal shoulders and a rib hump. Option d is incorrect because bony union of vertebrae is ankylosis, an outcome of chronic inflammatory spinal disease. A pregnant woman with a new postural complaint has a reversible mechanical change, not a fused and immobile spine.

Correct Answer: Keep the weights hanging freely off the floor

Traction works only while the weights hang free, so they are never lifted, rested on the bed or removed by staff; the assistant repositions the client while the pull is maintained continuously. Option a is incorrect because lifting the weights, even for a moment, releases the pull that holds the fracture aligned and allows muscle spasm; the interruption also causes sharp pain at the pin site. Option b is incorrect because weights resting on the bed frame or mattress stop exerting force, which defeats the whole purpose of the traction and permits the bone ends to shift out of position. Option c is incorrect because taking skeletal traction down and putting it back is outside the assistant's scope and is not a nursing decision either; that adjustment belongs to the provider who prescribed it.

Correct Answer: The arm drops suddenly and cannot be held

A positive drop arm test occurs when the arm falls or the client cannot hold the elevated position. The failure implicates the supraspinatus and supports a rotator cuff tear rather than simple weakness or pain. Option b is incorrect because a controlled smooth descent through the whole arc is the normal response. An intact cuff allows the arm to be lowered under control, so this result argues against a tear. Option c is incorrect because a single discrete click as a tendon slips over bone is a normal sound and is not what this maneuver looks for. A click is the positive finding in the knee meniscus test instead. Option d is incorrect because tremor during descent reflects fatigue or a neurologic cause rather than a torn tendon. The test is scored on whether the position can be held at all, not on the steadiness of the limb.

Correct Answer: Hesitation starting and turning as one unit

The festinating gait includes difficulty getting started, difficulty stopping suddenly, and turning of the whole rigid body as a single unit, all of which follow from the forward-pitched posture and rigidity. Option a is incorrect because a wide base with staggering and trouble on turns marks cerebellar ataxia, where the broad stance compensates for lost coordination; the parkinsonian stride is narrow and shuffling. Option b is incorrect because scraping toes point to foot drop and weak dorsiflexion, a peripheral nerve problem; the shuffle here comes from rigidity and small steps rather than from an inability to lift the foot. Option c is incorrect because a pelvis that drops on the unaffected side during stance is the Trendelenburg sign of hip abductor weakness, seen in dysplasia or hip arthritis rather than in Parkinson disease.

Correct Answer: The restriction lies within the joint itself

Passive range limited to the same degree as active range places the block in the joint, in its capsule, its cartilage, or a bony obstruction. Muscle and nerve have already been taken out of the equation. Option a is incorrect because weak quadriceps would still allow the nurse to carry the knee through a fuller arc. Passive testing removes the muscle from the picture, and the arc did not improve. Option b is incorrect because an interrupted nerve supply shows itself when the client tries to move, not when the examiner does. The passive limitation here cannot be explained by innervation. Option d is incorrect because guarding is a voluntary response that tends to ease once the examiner takes over the movement. A restriction identical in both tests suggests a structural cause.

Correct Answer: A spastic hemiparetic gait from the stroke

An upper motor neuron lesion of the corticospinal tract leaves flexors dominant in the arm and extensors dominant in the leg, so the arm stays flexed and the stiff leg circumducts with the toe dragging. Option a is incorrect because loss of position sense produces a wide-based walk with the eyes fixed on the feet and stamping heels; it does not hold one arm flexed or stiffen a single leg. Option c is incorrect because pain shortens the time spent standing on the sore limb and would not explain a flexed upper extremity; this client shows spasticity in both limbs of one side. Option d is incorrect because weak hip abductors make the trunk lurch from side to side, a bilateral duck-like pattern of proximal muscle disease that has nothing to do with one-sided arm posturing.

Correct Answer: The ballottement test of the patella

Ballottement of the patella is reliable when larger amounts of fluid are present. The examiner compresses the suprapatellar pouch and pushes the patella down, and with a big effusion it sinks, taps the femur and floats back. Option a is incorrect because the McMurray maneuver is a cartilage test. It is performed after trauma with locking or giving way, and its positive result is a click rather than evidence of fluid in the joint. Option b is incorrect because Phalen testing belongs to the wrist and screens for carpal tunnel syndrome. Holding the hands back to back reveals median nerve symptoms and says nothing about swelling in a lower extremity joint. Option c is incorrect because a Tinel sign is elicited by percussing a nerve, not by displacing fluid. Tapping over the median nerve produces tingling along its distribution and has no role in assessing a swollen knee.

Correct Answer: Rheumatoid arthritis sparing the distal interphalangeal joints

Rheumatoid arthritis attacks synovium-rich metacarpophalangeal, proximal interphalangeal and wrist joints symmetrically and characteristically spares the distal interphalangeal joints. Boggy swelling, prolonged morning stiffness, fatigue and weight loss confirm a systemic inflammatory synovitis. Option b is incorrect because osteoarthritis is the arthritis that settles in the distal interphalangeal joints, and it produces hard bony enlargement rather than boggy synovium. It is also asymmetric and causes no fatigue, fever or weight loss. Option c is incorrect because gout strikes suddenly in one joint, most often the great toe, and resolves within a week or two. A year of bilateral hand involvement does not match a crystal-induced monoarticular flare. Option d is incorrect because joint infection presents acutely over hours to days with high fever, marked heat and severe pain, usually in a single large joint. Twelve months of slow bilateral change is not infectious.

Correct Answer: A drop in blood pressure on standing

Orthostatic hypotension reduces blood flow to the brain when an older adult stands, which is a recognised cause of falls in this age group, and rising quickly from a chair is the classic trigger. Option a is incorrect because height decreases with aging through thinning of the intervertebral disks and shortening of the vertebral column; the long bones themselves keep their length throughout adult life. Option c is incorrect because subcutaneous fat is redistributed toward the abdomen and hips with aging rather than lost from them, and fat distribution is not what made this client unsteady on standing. Option d is incorrect because an exaggerated lumbar curve is normal in toddlers and in late pregnancy but is not an expected change of aging; thoracic kyphosis is the curve that develops later in life.

Correct Answer: Lower the arm to the level of the heart

A limb suspected of rising compartment pressure is kept at heart level, because elevating it lowers arterial inflow when perfusion pressure is already marginal and deepens the ischemia the nurse is trying to prevent. Option a is incorrect because more elevation makes the problem worse, not better; raising the arm higher drops inflow pressure still further at the moment the tissue most needs blood delivered to it. Option b is incorrect because documenting alone leaves the client in the position that is harming perfusion; a complaint that the cast is tight and painful calls for repositioning and a full neurovascular check. Option d is incorrect because adding a circumferential wrap raises pressure around the limb rather than relieving it; the nurse removes constriction in this situation instead of applying another layer over swollen fingers.

Correct Answer: Heat, redness, swelling, and pain

The four cardinal signs of acute joint inflammation are heat, redness, swelling and pain. The course uses exactly these words when describing acute gout and rheumatoid arthritis, with loss of function often added. Option a is incorrect because pallor and coolness are the opposite of the warmth and redness that inflammation produces. Muscle wasting and numbness point toward disuse or nerve involvement instead. Option c is incorrect because crepitus and clicking describe how a joint sounds during movement rather than the state of the tissues. Bruising follows trauma and is not one of the cardinal signs. Option d is incorrect because coolness and dryness belong to circulatory or skin assessment, not to an inflamed joint. Tingling and weakness suggest a nerve problem rather than inflammation inside a capsule.

Correct Answer: Check colour, warmth, sensation and finger movement

Colour, warmth, sensation and movement distal to the injury make up the neurovascular check required after any cast, splint or fracture, and each one is compared with the opposite limb. Option b is incorrect because limb circumference is measured to document muscle atrophy, taken at the same distance from the same bony landmark on both sides, and it tells the nurse nothing about perfusion distal to a fresh cast. Option c is incorrect because reflex testing belongs to the neurologic examination and is not part of the neurovascular check; it would not detect the swelling and rising pressure that threaten a newly casted forearm. Option d is incorrect because shoulder strength lies proximal to the cast and is unaffected by it; the nurse must grade movement in the fingers, which are distal to the injury and to the constricting device.

Correct Answer: Grade five, normal, at full resistance

Grade five is full range of motion against gravity with full examiner resistance, rated one hundred percent of normal and called normal. That is the expected finding in a healthy adult. Option a is incorrect because grade three describes full range against gravity with no resistance added at all, rated fifty percent. This client held the movement against the nurse's hand. Option b is incorrect because grade four means the muscle tolerates only some resistance before yielding, rated seventy five percent. The client in this scenario withstood the examiner's full effort. Option c is incorrect because grade two applies when gravity must be eliminated before the client can move the joint through its range. Nothing about a healthy adult fits that description.

Correct Answer: Heberden nodes at the distal interphalangeal joints

Heberden nodes are hard, nontender osteophytes of the distal interphalangeal joints, the knuckles nearest the fingertips, and they are a classic osteoarthritis finding produced by new bone at the worn joint margin. Option a is incorrect because Bouchard nodes sit one joint closer to the palm, at the proximal interphalangeal joints. They are the less common osteoarthritic node, and the stem places the knobs at the fingertip end instead. Option b is incorrect because rheumatoid nodules are subcutaneous granulomatous lumps over pressure points such as the olecranon, with skin sliding freely above them. They belong to rheumatoid arthritis and never form on finger joint margins. Option d is incorrect because tophi are urate crystal deposits of chronic gout, typically hard and painless at the great toe, sometimes ulcerating to discharge chalky material. Nothing in this client's history suggests hyperuricemia.

Correct Answer: Needle-shaped urate crystals in aspirated joint fluid

Gout is confirmed by demonstrating the crystals themselves. Aspirated synovial fluid containing needle-shaped monosodium urate crystals is the definitive test, and a normal serum urate level during a flare does not rule the disease out. Option a is incorrect because a raised sedimentation rate only signals inflammation somewhere in the body. It rises in infection, rheumatoid arthritis and many other conditions, so it cannot identify which process is inflaming this ankle. Option c is incorrect because rheumatoid factor points toward rheumatoid arthritis, where it is present in roughly eight or nine of every ten clients. Crystal arthropathy has no association with that antibody at all. Option d is incorrect because marginal osteophytes on x-ray describe osteoarthritis, the degenerative wear of cartilage with new bone at the joint edge. Spurs develop over years and say nothing about an acute crystal attack.

Correct Answer: "I will sit still most days to avoid falling."

Restricting activity is the wrong response to a fall, because inactivity weakens the legs and worsens balance, raising the risk of the next fall; grab bars, hazard removal and regular walking are what help. Option a is incorrect because grab bars beside the shower and toilet give a secure handhold in the room where many falls happen, so this statement shows the teaching about home hazards was understood. Option b is incorrect because brisk walking builds lower body strength and preserves bone, and a faster pace has a greater protective effect against hip fracture, so this plan should be encouraged rather than corrected. Option d is incorrect because loose rugs are among the environmental hazards most often named in falls, and removing them is exactly the change the nurse wants; the statement needs praise, not further instruction.

Correct Answer: Ask her to bend forward toward her toes

The screening sequence continues with forward bending, which makes vertebral rotation visible as one side of the posterior rib cage rides higher than the other. Standing findings alone cannot separate functional from structural curvature. Option b is incorrect because a lateral curve and a rib hump are posterior findings. The examiner stays behind the client throughout the screen, and viewing from the front would hide the asymmetry being looked for. Option c is incorrect because limb measurement investigates one possible cause of a compensatory curve rather than completing the screen. It comes later, once forward bending has shown whether the curvature is flexible or fixed. Option d is incorrect because extending the lumbar spine exaggerates the normal inward curve and reveals nothing about lateral deviation or rotation. Only flexion at the waist brings the rotated rib cage into view.

Correct Answer: A sac outside the joint is inflamed

A bursa is an enclosed sac of viscous fluid at a site of friction and sits outside the joint cavity. That is why the bursa can be inflamed while the joint itself moves normally. Option a is incorrect because an effusion sits inside the capsule and limits movement in all planes. A joint holding excess fluid does not keep a full painless range in every direction. Option b is incorrect because a thickened synovial lining feels doughy rather than fluctuant and signals disease inside the capsule. Articular problems restrict motion, which this client has not shown. Option c is incorrect because bony enlargement is hard, fixed and nontender under the fingers. The swelling described here is soft and fluid filled, which points away from new bone growth.

Correct Answer: "I will rest the ankle, ice it and wrap it."

Rest, ice, compression and analgesia are the initial measures for a sprain, with physical therapy and exercise added later; that combination limits bleeding into the injured ligament and controls pain and swelling. Option a is incorrect because loading a torn ligament the next day reinjures it and delays healing; a sprain needs a period of rest before graded return to running and other weight-bearing sport. Option c is incorrect because heat increases blood flow into freshly injured tissue and enlarges the swelling; cold is what the initial instructions call for while the acute inflammatory phase is still building. Option d is incorrect because rubbing an acutely injured joint can worsen bleeding and pain rather than disperse the swelling; compression with a bandage, not massage, is the measure taught for the first days.

Correct Answer: Measure and record the client's oral intake

Measuring and recording intake is a routine task with clear limits and no judgement, so it may be assigned; assessment, teaching and evaluation of a response remain nursing responsibilities that cannot be handed to unlicensed staff. Option b is incorrect because inspecting a fresh surgical site and judging whether drainage is expected calls for nursing assessment skill; the assistant may report what is visible but cannot make that determination. Option c is incorrect because client teaching is a licensed function requiring the nurse to check understanding and adapt the explanation; an assistant may reinforce what was taught but may not deliver the instruction. Option d is incorrect because deciding whether analgesia worked is evaluation, the final step of the nursing process, and it rests on comparing the client's report against the expected response to that drug.