A&P Overview
State one lobe of the cerebrum and what it is primarily responsible for.
Frontal lobes - voluntary movement, speech, emotions, intellectual activity
Parietal lobes - sensory information: touch, temperature, proprioception, & stereognosis.
Occipital lobe-contains visual cortex, receives & interpret stimuli from retina
Temporal lobe - interprets auditory & smell stimuli
Cerebellum - coordination of movement, equilibrium, proprioception, & muscle tone
Diencephalon - autonomic control center, sleep, mood, body control; contains thalamus, hypothalamus, and epithalamus
Brainstem - autonomic control center d/t 10 cranial nerves originating here.
State an expected finding of the head and neck upon inspection.
Equal movement on the right and left side of the face.
Protract, Retract, Elevate, and Depress the jaw (TMJ)
Symmetrical muscles of the neck
Aligned vertebrae in the neck
Head held erect and in line with the trunk.
State an expected variation of the head and neck during palpation.
Jaw clicking without pain or joint locking with protraction, retraction, elevation, &/or depression.
Expected finding: Vertebrae is in alignment, without masses or deformity. Neck muscles are symmetrical bilaterally, full and firm, without masses or tenderness.
State one thing the nurse will have the client perform when assessing ROM and muscle strength of the head and neck.
-Jaw: protraction, Retraction, elevation, and depression
-Neck: Flexion, extension, hyperextension, lateral flexion, rotation
Due to time constraints: ROM perform while palpating, then repeat with pressure against hand.
A nurse will be performing a MS assessment. The nurse enters the room and washes hands. What is the next priority?
A. Ask "are you in any pain or hurting anywhere?"
B. Assess in a cephalocaudal manner.
C. Assess symmetry going from distal to proximal.
D. Support the joints as they are assessed.
A. Ask "are you in any pain or hurting anywhere?" Asking about pain will alert the nurse to be cautious in those areas before palpating and performing ROM. It could also represent a serious medical condition Continue to ask questions/educate throughout the assessment.
B - is correct but not the next priority.
C - Symmetry assessment should be performed in proximal to distal manner.
D - is correct, but not the next priority.
Name one cluster of vertebrae and how many spinal nerves that vertebrae contains.
There are 31 pairs of spinal nerves that have a motor and sensory function.
Cervical = 8 (C1-C8)
Thoracic = 12 (T1-T12)
Lumbar = 5 (L1-L5)
Sacral = 5 (S1-S5)
Coccygeal = 1
State an unexpected finding of the shoulders during inspection.
Erythema, pigmentation changes, muscle atrophy, deformity, irregularities, swelling.
Muscle spasms, tenderness, discomfort
Inspecting: trapezius muscles, acromion process, scapulae, and clavicles.
State an expected finding of the shoulders and upper extremities during palpation.
full, firm, relaxed, symmetrical bilaterally
Expected variation: slightly larger muscle on the dominate side.
State one thing the nurse will have the client perform when assessing ROM and muscle strength of the shoulder and upper extremities.
Arms/Shoulder: Flex, extend, hyperextend, rotation, elevate, depress, abduction, and adduct.
Elbows: Extend, Flex, supination, pronation
Wrist/Hands: Flex, Extend, Hyperextend, rotate
Fingers: flex, extend, abduction, adduction, opposition (thumb)
Due to time constraints: ROM perform while palpating, then repeat with pressure against hand. Goal: 5 (0-5 scale)
A 70-year-old is in the emergency department after striking their head on the dashboard from a motor vehicle accident. The spouse of the client states "what is wrong, usually their very kind and gentle spirit but today they are cursing like I have never heard before." What would be the nurse's best reply?
A. "The behavior may be a result of damage to the frontal lobe."
B. "I am trying to get their pain under control."
C. "I need to administer the sedative to calm them down."
D. "Yes, the cursing is excessive."
A. "The behavior may be a result of damage to the frontal lobe." - it answers the question and provides education.
Sedatives & some pain meds would be held to not depress the neuro system.
D is non-therapeutic that does not address the spouses concerns.
Explain the function of one of the following:
A. Joints
B. Ligaments
C. Tendons
D. Periosteum
Joints: Connect bones, aid in mobility. Divides into 3 categories & further into 3 subjoints (fibrous, cartilage, synovial-> hinge, ball & socket, condyloid)
Ligaments: flexible strong bands of connective tissue, serves to support the joints to bone.
Tendons: nonelastic collagen connecting muscle to bone or muscle to muscle.
Periosteum: bone nourishment & waste removal. It contains blood vessels, nerves, and lymphatic tissue. tissue.
Describe one of the following spinal deformities.
Kyphosis
Lordosis
Scoliosis
Kyphosis - aging, exaggerated curvature of thoracic spine. Complications?
Lordosis - exaggerated curvature of the lumbar spine (expected variation during pregnancy)
Scoliosis - exaggerated lateral curvature of the spine, assessed in preteen/adolescent years.
Inspection/Palpation of the hips should occur while inspecting the spine.
State an unexpected finding of the spine or hips during palpation that requires further investigation.
Spinal curvature, Tenderness, Spasm of muscles,
Chronic skeletal pain
Hips: tenderness, pain, crepitus, swelling, nodules
Requires further investigation
State one thing the nurse will have the client perform when assessing ROM of the spine.
Flexion (aligned, equal, C-shape)
Lateral flexion
Hyperextension
Rotation of 30 degrees
A nurse is performing a health assessment on a client who reports leg pain and inability to perform ADL's. Which questions would be appropriate to ask about the client's ability to carry out ADLs? (Select all that apply).
A. "Tell me how the pain is affecting your life?"
B. "Do you know what is causing the problem?"
C. "Does anyone in your family have any musculoskeletal problems?"
D. "Describe how your activity level has changed?"
E. "Tell me about your hobbies?"
A, D
B. Would not provide information about ADL's
C. Does not address the ADL dysfunction.
E. Hobbies is great psychosocial/mental health, but not for an ADL assessment.
State two (2) functions of bones.
Body framework
Structure protection
Movement lever
Fat and mineral storage (ex. Calcium)
Hematopoiesis (RBC production)
There are 206 bones and 600+ muscles in the adult. You have to know each and every single one ;)
State the unexpected findings of the knees.
Erythema, pigmentation changes
joint: heat, swelling, nodules
muscle atrophy
Alignment deviation, movement limitation, asymmetry
-Genu varum: bowing out
-Genu valgum: bowing in
Contractures
Femur, Knees, Tibia, Fibula; Quadriceps
State how the nurse would palpate the knees.
Have the client's legs dangle off the edge of the bed/table.
Palpate the quadriceps, feeling consistency
Using thumbs & finger pads, palpate the sides of the patella
State one thing the nurse will have the client perform when assessing ROM and muscle strength of the hips and knees.
Hips: Flexion, Extension, Hyperextend, Abduction, Adduction, Circumduction, Rotation
Knees: Flex, Extension
Due to time constraints: Hip/Knee ROM & muscle strength are perform simultaneously.
When testing ROM of a client's shoulder, the nurse hears a grating sound. State how the nurse would document this finding. (Select all that apply)
A. Clicking
B. Crepitus
C. Bruit
D. Strain
E. Sprain
B. Crepitus is a grating sound
Clicking is a crack or pop sound when the joint is open / closed (valve replacement).
Bruit is a whoosing sound
Strain is overstretching of muscle (muscle training)
Sprain is overstretching of ligament
There are multiple movements associated with joint range of motion. State 1 movement and a joint it pertains to.
Flexion / Extension: Neck, Shoulders, Elbows, Wrist, Fingers, Thumb, Hip, Knee, Toes
-Hyperextension: Neck, Shoulder, Wrist, Fingers, Hips
-Dorsiflexion / Plantar flexion (point): Ankle
-Lateral flexion: Neck
Abduction / Adduction: Shoulders, Wrists, Fingers, Thumbs, Hips, Toes
-Opposition: Thumb
Pronation / Supination: Forearm
Circumduction: Shoulders, Hips
Inversion / Eversion: Ankles
Internal / External Rotation: Neck, Shoulders, Wrists, Thumbs, Hips
Retraction / Protraction: Jaw (TMJ assessment)
Elevation / Depression: Jaw, Shoulders
State an expected variation of the ankle and foot during inspection.
Arch: high, little, or no longitudinal arch.
Expected finding: feet and toes are in a straight position along the axis of the lower leg, with the medial and lateral malleoli being smooth.
The nurse is going to palpate the feet and ankles. State an unexpected finding that requires further evaluation.
Joint fullness, swelling, or tenderness.
State one thing the nurse will have the client perform when assessing ROM and muscle strength of the ankles and feet.
Ankle: Plantar flexion, dorsiflexion, eversion, inversion
Toes: flexion, extension, hyperextension, abduction, adduction
Romberg test, Babinski reflex
Due to time constraints: ROM perform while palpating, then repeat with pressure against hand.
A client reports shoulder pain without palpation or movement. The nurse should evaluate this client further for which health problem?
A. Gastrointestinal problem
B. Sprain
C. Cardiac problem
D. Rotator cuff tear
C. Cardiac problem (Coronary Artery Disease: Angina or MI) produces referred pain that is unrelated to movement or touch.
Tears, Strains, and/or Sprain causes pain with movement.
GI pain may occur with cardiac problems (women)