NR-304 Health Assessment II - Set 3 - Part 3

Correct Answer: Pain sharply increased by passive finger extension

Pain that worsens markedly when the muscles in the compartment are passively stretched is the earliest reliable sign of acute compartment syndrome, and with pain unrelieved by opioids it demands immediate provider notification. Option a is incorrect because pink fingertips with brisk refill describe intact skin perfusion, which persists early in compartment syndrome; reassuring colour cannot outweigh disproportionate pain and delays the call that saves the limb. Option b is incorrect because a palpable pulse is expected here; compartment pressure collapses capillaries and venules long before it can obstruct an artery carrying systolic pressure, so pulselessness is a late finding. Option d is incorrect because some swelling follows every fracture and casting, so it does not by itself signal rising compartment pressure; the nurse reports the pain pattern that separates this emergency from ordinary injury swelling.

Correct Answer: The acromion process of the scapula

The bump felt at the very top of the shoulder is the acromion process of the scapula. It is the lateral end of the scapular spine and the landmark from which palpation of the shoulder proceeds. Option a is incorrect because the nucleus pulposus is the gelatinous centre of an intervertebral disk and lies deep within the spinal column. It can never be felt through the skin and has nothing to do with the shoulder. Option b is incorrect because the medial epicondyle is a bony prominence of the distal humerus at the elbow. It is a site of tenderness in epicondylitis, well below the shoulder girdle the client is pointing to. Option c is incorrect because articular processes are projections that lock one vertebra onto the next and stabilise the spinal column. They are spinal structures, not palpable surface landmarks of the upper extremity.

Correct Answer: Seventy degrees of cervical rotation

The course states cervical rotation as seventy degrees, elicited with the instruction to turn the chin toward each shoulder. Rotation is the largest of the four cervical values and is the only one measured by turning the head. Option b is incorrect because fifty five degrees belongs to cervical hyperextension, which is elicited by asking the client to lift the chin toward the ceiling. That motion moves the head backward rather than around a central axis. Option c is incorrect because forty five degrees is the expected value for cervical flexion, obtained when the client touches the chin to the chest. Flexion bends the neck forward and is not tested by chin rotation. Option d is incorrect because forty degrees describes lateral bending, in which the client brings each ear toward the corresponding shoulder. Lateral bending tilts the head sideways in the frontal plane and is a separate cervical measurement.

Correct Answer: Hold both hands back to back with wrists flexed

Phalen testing requires the dorsal surfaces of both hands held together with the wrists flexed about ninety degrees for sixty seconds. Sustained flexion raises pressure inside the carpal tunnel and reproduces median nerve numbness and burning. Option a is incorrect because palms together with the wrists extended is the mirror image of the required position. Extension opens rather than narrows the tunnel, so median nerve symptoms will not be provoked. Option b is incorrect because percussing the wrist describes the Tinel sign, a separate maneuver. Tinel is a tap delivered over the median nerve, while Phalen is a position the client sustains without any percussion. Option c is incorrect because spreading the fingers tests finger abduction as part of routine range of motion. Abducting the digits places no compressive load on the carpal tunnel and therefore cannot provoke the symptoms described.

Correct Answer: The muscle, tendon or nerve is failing

When passive range exceeds active range, the joint and its capsule are intact, because the nurse moved them freely. The limitation then lies in the muscle, tendon or nerve that should have produced the motion. Option a is incorrect because a contracted capsule would block the examiner as well as the client. A joint that yields a full, easy passive arc has no capsular restriction. Option c is incorrect because worn cartilage creates a bony or grating block that appears in passive movement too. This shoulder moved through its whole arc under the nurse's hand without crepitus. Option d is incorrect because a difference between the two measurements points to one problem, not two. Naming the joint as well ignores the free passive range the nurse just demonstrated.

Correct Answer: Check circulation, sensation and movement distally

A shortened, externally rotated limb that cannot bear weight indicates hip fracture, and the first and repeated assessment after any fracture is the neurovascular status distal to the injury, compared with the opposite limb. Option a is incorrect because straightening a deformed limb can drive bone ends into vessels and nerves and causes severe pain. The limb is immobilized as found, with support given to the joints above and below. Option b is incorrect because weight bearing on a fractured femur risks displacing the fragments and worsening the injury. Inability to walk is itself part of the classic presentation and is not something to test at the bedside. Option d is incorrect because warmth increases bleeding into already traumatized tissue and delays the evaluation this client needs. Comfort measures follow the assessment and the imaging, never replacing them in the first minutes of care.

Correct Answer: Ankylosis of the radiocarpal joint

Ankylosis is stiffening and fusion of a joint so that it becomes immobile. Bone grows across the joint and neither active nor passive movement is possible, which is exactly what this wrist demonstrates. Option a is incorrect because subluxation is partial displacement in which the joint surfaces still touch each other. A subluxed joint remains mobile and misaligned rather than fused, and imaging would show malalignment instead of bony union. Option c is incorrect because dislocation means the articulating surfaces have lost contact completely. That produces obvious deformity and severe pain with attempted movement, not the silent rigid fusion seen after years of inflammatory joint destruction. Option d is incorrect because a contracture is fixed shortening of soft tissue that limits range in one direction, usually holding the joint flexed. Radiographic fusion of the joint surfaces points to bone, not to shortened tendon.

Correct Answer: Assess the toes for colour and sensation

Neurovascular assessment requires nursing judgement and comparison with the opposite limb, so it stays with the nurse; assistive personnel may carry out supportive tasks but cannot interpret colour, sensation or movement distal to a cast. Option a is incorrect because positioning a casted limb on pillows is a routine comfort measure within the assistant's role once the nurse has specified how the leg should lie and what to report back. Option b is incorrect because delivering fluids and a meal tray involves no assessment or judgement, which makes it a standard assignment for unlicensed staff caring for a stable postoperative client. Option d is incorrect because measuring and recording oral intake is data collection with fixed rules, not interpretation; the assistant reports the totals and the nurse decides what those numbers mean.

Correct Answer: "Screening usually begins at sixty-five without added risk factors."

Current recommendations call for bone density screening in all women sixty-five and older, and earlier only for postmenopausal women under sixty-five whose risk assessment shows increased risk. This client has no added risk factors. Option a is incorrect because menopause alone does not trigger universal testing. Younger postmenopausal women are screened selectively, after a clinical risk tool identifies increased fracture risk, rather than automatically at the time their periods stop. Option b is incorrect because women are precisely the group with the strongest screening recommendation. The insufficient-evidence statement applies to men, not to women, and telling this client she will never be screened is inaccurate. Option c is incorrect because postmenopausal status by itself is not the trigger for early testing. A risk assessment tool must first identify something that raises her fracture risk, such as low body weight or steroid use.

Correct Answer: Walk briskly on most days each week

Weight-bearing activity such as fast walking loads the skeleton, and bone remodels in response to that load. The faster the pace, the greater the protective effect on hip fracture risk in perimenopausal women. Option b is incorrect because measuring bone density only monitors what is happening to the skeleton. A scan detects loss after it occurs and changes nothing by itself, so it cannot serve as a prevention strategy. Option c is incorrect because that intake sits below the recommended daily allowance for adult women, which is at least one thousand milligrams and rises to twelve hundred after age fifty. Restricting calcium accelerates bone loss. Option d is incorrect because avoiding load on the skeleton is exactly what causes bone to thin. Inactivity and prolonged sedentary behavior are established modifiable risk factors for osteoporosis, not protective measures for the joints.