190 Musculoskeletal and Neuro

During an annual physical assessment, a client repots not being able to smell coffee and most foods. Which cranial nerve function should the nurse assess?

• Cranial nerve I

• Cranial nerve II

• Cranial nerve XI

• Cranial nerve XII

A client is admitted post traumatic brain injury and multiple fractures. The client's eyes remain closed and there is no evidence of movement when the nurse changes the client position. The client makes unintelligible sounds when turned. What score on the Glasgow Coma Scale should the nurse document? (Look at your GCS sheet to help)

• 3

• 4

• 6

• 8

During a foot and ankle assessment, the nurse notices a bulge on the right great toe that is warm and red. Which abnormality is likely present?

• Hammertoe

• Bunion

• Gout

• Joint Effusion

The nurse notices that a 22-year-old female patient has been to the emergency room 5 times in 3 months with multiple injuries including fractures. She notices a large bruise today on the patient’s neck. What should the nurse suspect might be occurring?

• The patient has osteoporosis.

• The patient may be a victim of abuse.

• The patient is clumsy.

• The patient has a physically demanding job.

The school nurse notices a student has a lateral curvature to his spine. What is the nurse likely observing?

• Juvenile Rheumatoid Arthritis

• Lordosis

• Kyphosis

• Scoliosis

The student nurse instructs the patient to protrude their tongue. The picture below is the result. What cranial nerve does the patient have a dysfunction of?

• CN XII

• CN X

• CN V

• CN II

What question below should be asked to assess a patient’s orientation?

• “What did you watch on TV last week?”

• “What building are we in?”

• “How many dimes are in one dollar?”

• “What’s the difference between a banana and an orange?

The student nurse is assessing reflexes and is unable to elicit a patellar reflex. What should the student nurse do?

• Document no patellar reflex.

• Strike the patella harder to get elicit a reflex.

• Instruct the patient pull on their hands and try again.

• Get the clinical instructor and have them perform the assessment for the student nurse.

The nurse strikes the Achilles tendon with the reflex hammer and notices the foot flexes and extends rapidly. The nurse identifies this as?

• Fasciculation

• Clonus

• Hyperesthesia

• Babinski Response

A female patient reports that she was just diagnosed with rheumatoid arthritis. What assessment findings should the student nurse observe that support this diagnosis?

• Inflammation of the right bursa

• Dupuytren’s Contracture

• Boutonniere Deformity

• Bouchard’s Nodes