Questions and Answers
What sound is typically heard when examining solid organs such as the liver and spleen?
Which joint movement allows the knee to bend and straighten?
What common condition is characterized by the loss of bone mass and an increased risk of fractures?
What is the expected outcome when a patient is asked to perform lateral flexion of the neck?
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Which of the following is a symptom of rheumatoid arthritis?
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Which movement is described as turning the soles of the feet in toward the midline of the body?
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What condition may cause an apparent deformity in the fingers known as swan neck deformity?
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Which term describes the lateral curvature of the spine, often present in adolescents?
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What is a common preventive measure for osteoarthritis and osteoporosis?
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What is the expected finding for the temporomandibular joint when assessed?
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What does the term fasciculation refer to in a muscular context?
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During shoulder assessment, how should external rotation be tested?
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What indicates hypotonia during a muscular assessment?
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What is the expected joint pain presentation during examination?
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What does the term crepitation signify during a joint assessment?
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In assessing elbow joint flexion, what is the correct starting position?
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What action is being performed when a patient turns their palms downward?
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What is the expected muscle strength rating for biceps when assessed correctly?
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What is the correct range of motion expected for internal rotation during shoulder assessment?
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What should be monitored for a patient undergoing cold therapy after an injury?
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What are expected findings when inspecting the abdomen?
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Which signs indicate the presence of an abdominal aortic aneurysm (AAA)?
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What is the appropriate technique for palpating the abdomen?
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How should abdominal girth be measured?
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Which of the following findings indicates abnormal bowel sounds?
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What is a common technique to relax the abdomen during assessment?
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What abnormal sign might indicate a hernia when examining the umbilicus?
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Which sound is typically heard over areas filled with gas during abdominal percussion?
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Which condition is associated with Rovsing's sign during examination?
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What is an expected sign of liver disease during abdominal inspection?
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Study Notes
Hotspot Identification
- Locate the posterior tibial pulse during assessment.
Abdominal Inspection Findings
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Expected:
- Striae alba (associated with pregnancy or weight gain)
- Silver striae, healed scars, moles
- Symmetry: abdomen may appear flat, rounded, or scaphoid
- Movement should be smooth and even with respiration
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Unexpected:
- Taut skin indicative of ascites
- Presence of rashes
- Dilated veins and spider angiomas suggestive of liver disease
Umbilicus Assessment
- Expected: Mole, scaphoid shape, scar
- Unexpected: Swelling indicating a possible hernia (protrusion of abdominal viscera).
Signs of Abdominal Aortic Aneurysm (AAA)
- Recognize signs and symptoms consistent with AAA during examination.
Abdominal Palpation Technique
- Use light pressure with one hand; client’s arm at their side.
- Utilize finger pads for light palpation; employ a dipping motion.
- Move fingers in a clockwise direction across the abdomen; focus on painful areas.
- Abnormal findings: Involuntary rigidity, board-like quality, hardness, pain indicate peritoneal inflammation.
Measuring Abdominal Girth
- Use measuring tape around the abdomen at the level of superior iliac crests to assess girth, particularly when distention is noted.
Auscultation of Bowel Sounds
- Hypoactive: Less than 5 sounds per minute, indicating possible impairment.
- Absent: No sounds after 5 minutes, may indicate intestinal obstruction.
- Hyperactive/Borborygmi: Increased peristalsis, audible without a stethoscope.
- Normoactive: 5 to 34 high-pitched gurgles per minute.
Patient Abdominal Relaxation Technique
- Instruct the patient to bend their knees to facilitate relaxation during assessment.
Appendicitis Signs
- Rovsing’s sign: Pressure applied to the left lower quadrant may cause pain in the right lower quadrant.
- Blumberg’s sign: Rebound tenderness in the abdomen.
Liver Palpation
- Palpate in the right upper quadrant (RUQ).
Percussion Sounds in Abdomen
- Tympanic: Heard over gas-filled areas (stomach, intestines).
- Dull: Indicates solid organs (liver, spleen) or fluid-filled areas such as ascites.
Organ Locations by Quadrant
- RUQ: Liver, gallbladder, pylorus, duodenum, head of pancreas, right adrenal gland, portions of right kidney, and ascending/transverse colon.
- LUQ: Left lobe of liver, spleen, stomach, body of pancreas, left adrenal gland, portions of left kidney, and transverse/descending colon.
- RLQ: Lower pole of right kidney, cecum, appendix, bladder (if distended), right ureter, right ovary, uterus (if enlarged), right spermatic cord.
- LLQ: Lower pole of left kidney, sigmoid colon, descending colon, bladder (if distended), left ureter, left ovary, uterus (if enlarged), left spermatic cord.
Musculoskeletal System Observations
- Gait Evaluation: Observe for conformity and rhythmic symmetry; measure leg lengths if unequal.
Joint Functionality and Assessment
- Perform movements: flexion, extension, hyperextension, palpation, and assessment for abnormal conditions like genu varum (bowlegged) or genu valgum (knock-kneed).
Age-Related Changes in Musculoskeletal System
- Decrease in muscle mass and balance, reduced bone density, joint stiffness.
Osteoarthritis and Osteoporosis Prevention
- Maintain a balanced diet rich in calcium (1000-1200mg daily) and vitamin D (800 IU daily).
- Engage in weight-bearing exercise, avoid smoking and excessive alcohol intake.
Key Characteristics of Common Joint Conditions
- Osteoarthritis: Degenerative disease causing cartilage breakdown, associated with morning stiffness lasting less than 30 minutes.
- Osteoporosis: Loss of bone density, often leads to kyphosis.
- Rheumatoid Arthritis: Autoimmune disease causing pain, edema, prolonged morning stiffness, and deformities like ulnar deviation.
Assessment of Mobility and Activities of Daily Living (ADL)
- Assess self-care deficits and mobility through patient interaction and observation.
Neck and Temporomandibular Joint (TMJ) Assessment
- Check range of motion (ROM) for neck and jaw movements; listen for clicks or pops that may indicate TMJ dysfunction.
Spinal Assessment
- Inspect for symmetry, curvature (normal findings include slight protrusions at C7/T1), and ability to perform movements like hyperextension and lateral flexion.
Lower Extremity Movement Assessments
- Assess ankle/foot movements (eversion, inversion, dorsiflexion, plantarflexion) and fingers (abduction, adduction, flexion).
Arm and Shoulder Muscle Strength Testing
- Test deltoid, biceps, and triceps strength bilaterally; ensure equal resistance and movement without pain.
Treatment and Rehabilitation Principles
- Apply cold therapy for 24 to 72 hours to manage swelling, and utilize compression techniques to limit edema and provide support.
Assessment of Pain
- Deep, dull, and boring pain can indicate bone injuries; monitor for signs like redness, heat, and deformities in joint pain cases.
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Description
This quiz reviews key concepts related to nursing assessments, including the posterior tibial pulse location and expected findings during abdominal inspections. It covers normal and unexpected findings to enhance clinical skills and knowledge. Use this quiz to prepare for practical nursing assessments.
