The nurse assesses a client using the Glascow Coma Scale (GCS). Which of the following indicators will be used to determine the score?
What is eye opening, verbal, and motor response
100
The nurse moves the client's arm awat from the midline of the body. The nurse is performing
What is abduction?
100
A client visits a clinic and reports joint pain in her hands, especially is the morning. This symptoms indicate this.
What is rheumatoid arthritis?
100
The nurse is examining a client's ROM in the shoulders. The client is unable to shrug her shoulder against resistance. The nurse suspects a lesion of which cranial nerve?
What is CN XI?
100
Sensations of temperature, pain, and crude and light touch are carried by way of this tract?
What is the spinothalmic tract?
200
The nurse documents findings from the client's Mini-Mental State Examination. The following information will be documented as a result of this test.
What is orientation, memory, and cognitive function
200
The nurse moves a client's leg upward, the nurse is performing
What is supination?
200
When performing the musculoskeletal exam, this population may have difficulty with ROM in the hips and knees.
What is the aging adult?
200
The cranial nerve that has sensory fibers for taste that result in the "gag reflex" is this.
What is the glossopharyngeal nerve (CN IX)
200
The Glascow Coma Scale measures LOC in client's who are at high risk for rapid deterioration of the nervous system. A score of 13 indicates
What is some impairment?
300
As a part of assessing LOC, the nurse asks questions related to person, place, and time. Orientation to ____ is lost first, and orientation to ____ is lost last.
What is time and person?
300
To turn the forearm so that the palm is down
What is pronation?
300
While assessing muscle strength, the nurse determines the knee joint has a rating of 3 and exhibits active motion against gravity. This should be documented as
What is average weakness?
300
The nurse is assessing the neurologic system. The nurse asks the client to "purse the lips". Which CN is being evaluated?
What is the facial nerve (CN VII)
300
The nurse is preparign to perform the Romberg test on an adult client. The nurse should instruct the client to
What is stand erect with the arms at the sides and the feet together?
400
The nurse asks a client to explain similarities and differences between 2 objects, what ability is being tested?
What is abstract reasoning?
400
Moving the arn in a circle around the shoulder
What is circumduction?
400
While assessing the musculoskeletal system of an adult client, the nurse observes has painless nodules over the distal interphalangeal joints. The nurse should document the presence of
What is osteoarthritis (Herbeden's nodes)?
400
Assessing extraocular movement by the cardinal positions of gaze assess these cranial nerves
What are CN III, IV, and VI?
400
While assessing the plantar reflex of a client the nurse observes a +Babinski reflex. This is a _______ finding indicating ________.
What is abnormal and drug intoxication?
500
Apprehension from the anticipation of danger whose source is unknown
What is anxiety?
500
To bend a limb at a joint
What is flexion?
500
While reviewing a client's chart, the nurse notes that the client has a diagnosis of pes planus. The nurse anticipates that the client has
What are flat feet?
500
When asking the client to say, "light, tight, dynamite" this CN is being evaluated.
What is the hypoglossal nerve (CN XII)?
500
A husband notices a change in his wife's personality and understanding ability. She cries often and has angry outburst. The nurse suspects a deficit in which cerebral lobe?