D443 Health Assessment - Set 5 - Part 2

Correct Answer: It suggests splenomegaly (an enlarged spleen)

Normally, the lowest left interspace in the anterior axillary line remains tympanic during inspiration because it overlies air-filled bowel. When the percussion note changes to dullness on deep inspiration, it is a positive splenic percussion sign suggesting splenomegaly, as the enlarged spleen descends and replaces the air-filled stomach and colon. This finding warrants further assessment for the underlying cause.

Correct Answer: Grade 3 out of 5

On the 0 to 5 manual muscle strength scale, a grade of 3 indicates the patient can achieve full range of motion against gravity but cannot tolerate any added resistance. Grade 4 is full range against gravity with some resistance, grade 5 is full range against full resistance (normal), and grade 2 is full range only when gravity is eliminated. Because this patient moves fully against gravity yet fails as soon as resistance is applied, the correct documentation is 3 out of 5.

Correct Answer: Grade 2 out of 5

A grade of 2 on the 0 to 5 scale means the muscle can produce full range of motion only when gravity is removed. Grade 1 represents a barely detectable flicker or trace of contraction with no joint movement, grade 0 is complete absence of any muscle contraction, and grade 3 is movement against gravity without resistance. Because this patient achieves full movement solely with gravity eliminated, the correct grade is 2 out of 5.

Correct Answer: Supination

Supination is the rotational movement of the forearm that turns the palm to face upward or anteriorly. Pronation is the opposite movement, turning the palm downward. Eversion refers to turning the sole of the foot outward, and circumduction is a circular movement combining flexion, extension, abduction, and adduction. Because the patient turns the palm to face up, the correct term is supination.

Correct Answer: Cranial nerve XI (spinal accessory)

The spinal accessory nerve, cranial nerve XI, innervates the trapezius and sternocleidomastoid muscles, so it is tested by having the patient shrug the shoulders and turn the head against resistance. The vagus nerve controls swallowing and the gag reflex, the hypoglossal nerve controls tongue movement, and the trigeminal nerve controls facial sensation and the muscles of mastication. Because shoulder shrug and head rotation depend on the trapezius and sternocleidomastoid, cranial nerve XI is being assessed.

Correct Answer: Cranial nerve XII (hypoglossal)

Cranial nerve XII, the hypoglossal nerve, controls the muscles that move the tongue, so impairment causes the tongue to deviate toward the weak side and may produce atrophy or fasciculations. The glossopharyngeal nerve is involved in taste and swallowing, the facial nerve controls facial expression, and the spinal accessory nerve controls the trapezius and sternocleidomastoid. Because the tongue deviates and is atrophied, the hypoglossal nerve is the affected cranial nerve.

Correct Answer: Ask the patient to identify a familiar odor with each nostril occluded one at a time and the eyes closed

Cranial nerve I, the olfactory nerve, is tested by having the patient close the eyes, occlude one nostril, and identify a familiar non-irritating odor such as coffee or vanilla, then repeat on the other side. Taste testing evaluates cranial nerves VII and IX, the Snellen chart tests cranial nerve II (optic), and jaw clenching tests the motor component of cranial nerve V. Because smell is the function in question, occluding each nostril and presenting an odor is the correct technique.

Correct Answer: 2+

On the deep tendon reflex scale of 0 to 4+, a grade of 2+ represents a normal, average, expected response. A 1+ indicates a diminished or low-normal response, 3+ indicates a brisker than average response that may or may not be abnormal, and 4+ indicates a very brisk hyperactive response often with clonus, suggesting upper motor neuron disease. Because the patellar response is normal, the nurse should document 2+.

Correct Answer: 4+, indicating a hyperactive response associated with upper motor neuron disease

A deep tendon reflex graded 4+ is a very brisk, hyperactive response frequently accompanied by clonus, and it is associated with upper motor neuron lesions. A 2+ is normal, a 1+ is diminished and may suggest lower motor neuron problems, and a 0 indicates an absent reflex. Because the response is very brisk with clonus, the correct grade and interpretation is 4+ reflecting upper motor neuron disease.

Correct Answer: A positive Babinski sign indicating an upper motor neuron lesion

Dorsiflexion of the great toe with fanning of the other toes in response to plantar stimulation is a positive Babinski sign, which is abnormal in adults and indicates an upper motor neuron lesion. The normal adult response is plantar flexion (curling) of the toes. While a positive Babinski is a normal finding in infants due to immature myelination, in an adult it signals central nervous system pathology, making it the correct interpretation here.

Correct Answer: Romberg test, with a positive result suggesting a problem with proprioception or vestibular function

The Romberg test evaluates balance and proprioception by comparing steadiness with eyes open versus closed. A positive Romberg sign occurs when the patient maintains balance with eyes open but loses it with eyes closed, indicating a deficit in proprioceptive or vestibular input rather than pure cerebellar dysfunction. Because the patient sways only when visual input is removed, this is a positive Romberg test suggesting a proprioceptive or vestibular problem.

Correct Answer: Cerebellar function

The finger-to-nose test assesses cerebellar function, specifically coordination and the smoothness and accuracy of movement. Inaccurate or overshooting movements, called dysmetria, suggest cerebellar dysfunction. This maneuver does not evaluate the optic nerve, deep tendon reflexes, or peripheral sensation. Because the test targets coordination and precision of voluntary movement, it is primarily an assessment of cerebellar function.

Correct Answer: 12

The Glasgow Coma Scale sums eye opening, verbal response, and motor response. Eye opening to speech scores 3, a confused verbal response scores 4, and localizing to pain scores 5, for a total of 12. A score of 15 would require spontaneous eye opening (4), oriented speech (5), and obeying commands (6). Because this patient scores 3 for eyes, 4 for verbal, and 5 for motor, the correct total is 12.

Correct Answer: 3

The Glasgow Coma Scale ranges from a minimum of 3 to a maximum of 15. Each of the three components (eye opening, verbal response, and motor response) has a minimum score of 1, so even a completely unresponsive patient scores 3, not 0 or 1. A score of 15 indicates full alertness. Because the lowest score on each subscale is 1 and there are three subscales, the minimum total is 3.

Correct Answer: Orientation

Asking a patient to identify person, place, and time evaluates orientation, a core component of the mental status examination. Remote memory involves recall of past events, abstract reasoning is tested by interpreting proverbs or similarities, and judgment is assessed by evaluating responses to hypothetical situations. Because the nurse is checking awareness of self, place, and time, orientation is the component being assessed.

Correct Answer: Ask the patient to repeat a series of numbers forward and backward (digit span)

Repeating a series of digits forward and backward, known as digit span, is a standard test of immediate recall and attention. Interpreting a proverb assesses abstract thinking, describing yesterday's breakfast assesses recent memory, and naming presidents tests remote memory and general knowledge. Because immediate attention and recall are the focus, the digit span task is the appropriate assessment.

Correct Answer: Concrete thinking, which may indicate impaired abstract reasoning

Interpreting a proverb literally rather than grasping its figurative meaning reflects concrete thinking, which can indicate impaired abstract reasoning seen in certain neurological or psychiatric conditions. An intact abstract response would capture the underlying moral about change and stability. This response does not directly measure judgment, and flight of ideas refers to rapidly shifting connected thoughts. Because the patient gives a literal interpretation, the finding is concrete thinking.

Correct Answer: 'What would you do if you smelled smoke in a crowded theater?'

Judgment is assessed by asking how a patient would respond to a realistic problem or hypothetical situation, such as what to do if they smelled smoke in a theater, which reveals reasoning and decision-making. Counting backward by sevens tests attention and calculation, asking the date and location tests orientation, and repeating three words tests immediate recall. Because judgment involves evaluating decision-making in a scenario, the smoke-in-theater question is the best choice.

Correct Answer: Blunted or flat affect

A near-absence of emotional expression, with a flat facial appearance and monotone speech, is described as blunted or flat affect. Labile affect refers to rapidly shifting, unstable emotional expression, euphoria is an exaggerated feeling of well-being, and congruent affect means the emotional expression matches the stated mood. Because the patient displays minimal outward emotional expression, blunted or flat affect is the correct descriptor.

Correct Answer: Acute onset with fluctuating level of consciousness

Delirium is characterized by an acute, often sudden onset and a fluctuating level of consciousness and attention, and it is frequently reversible when the underlying cause is treated. Dementia, by contrast, typically has a gradual onset over months to years, a slowly progressive and usually irreversible course, and relatively stable consciousness early on. Because acute onset with fluctuating consciousness is the hallmark of delirium, it is the distinguishing feature.