A client with congestive heart failure presents with edema of the ankles. When conducting a physical examination of this client, the nurse requires a gooseneck lamp for which purpose?

to check radial pulses

to assess pedal pulses

to assess jugular filling pressure

to auscultate lung sounds

Answer and Explanation

The Correct Answer is C

A) To check radial pulses: Radial pulses are typically assessed by palpation at the wrist. A gooseneck lamp is not necessary for this task; standard lighting and direct palpation are usually sufficient.
B) To assess pedal pulses: Pedal pulses are assessed by palpation on the top of the foot. A gooseneck lamp is not needed for this purpose, as the lighting conditions are generally adequate for palpation in a well-lit room.
C) To assess jugular filling pressure: Assessing jugular venous pressure (JVP) requires good lighting to clearly see the pulsations in the jugular veins. A gooseneck lamp provides focused and adjustable lighting, which is helpful for this assessment. This ensures accurate observation of the jugular veins and helps in evaluating the severity of heart failure.
D) To auscultate lung sounds: Auscultating lung sounds involves using a stethoscope and does not typically require a gooseneck lamp. Proper lighting is not essential for auscultation, as the focus is on auditory assessment rather than visual inspection.

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Correct Answer is A

Explanation

A) Range of motion: Lateral bending of the spine is a movement used to assess the range of motion (ROM) of the spine, specifically the flexibility and mobility of the thoracolumbar region. By asking the client to perform lateral bends, the nurse can evaluate the extent to which the client can bend sideways and assess any limitations or discomfort in the movement.
B) Diaphragmatic excursion: Diaphragmatic excursion refers to the movement of the diaphragm during respiration and is assessed through techniques like percussion and auscultation of the lungs. Lateral bending of the spine does not provide information about diaphragmatic movement.
C) Spinous processes: The spinous processes of the vertebrae can be palpated to assess alignment and tenderness, but lateral bending does not specifically assess the spinous processes. It focuses more on the overall mobility of the spine.
D) Spinal deformities: While lateral bending can reveal limitations in spinal movement that might suggest underlying spinal deformities, it is not a primary diagnostic tool for identifying specific deformities. Other assessments, such as inspection and palpation of the spine, X-rays, or physical

A. Pectoralis major tear B. Arthritis C. Rotator Cuff Tendinitis D. Gout

Correct Answer is C

Explanation

A) Pectoralis major tear: A tear of the pectoralis major muscle would likely cause pain and weakness, particularly in activities involving pushing or lifting. While it may affect shoulder movements, it is less likely to specifically impair the ability to reach behind the back and touch the shoulder blade compared to rotator cuff issues.
B) Arthritis: Arthritis, particularly osteoarthritis, can cause decreased range of motion and pain in the shoulder joint. However, the specific movement described—placing one hand behind the back to touch the shoulder blade—is most commonly affected by issues with the rotator cuff rather than arthritis alone.
C) Rotator Cuff Tendinitis: Rotator cuff tendinitis is a common cause of shoulder pain and decreased range of motion, particularly affecting movements that require lifting the arm or reaching behind the back. Tendinitis in the rotator cuff can lead to pain and difficulty performing the movement described due to inflammation and impingement of the tendons.
D) Gout: Gout is a type of arthritis caused by the accumulation of uric acid crystals in the joints, often affecting the big toe but can affect other joints. While it can cause joint pain and inflammation, it is less likely to specifically impair the shoulder movement described compared to rotator cuff tendinitis.

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A client with congestive heart failure presents with edema of the ankles. When conducting a physical examination of this client, the nurse requires a gooseneck lamp for which purpose?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing a client's musculoskeletal status, the nurse asks the client to perform lateral bends. Which of the following will this movement provide information about?

Correct Answer is A

Explanation

The nurse asks the client to "place one hand behind the back and touch the shoulder blade" in the position shown. The patient explains he cannot perform the movement. What MOST likely is causing the patient decreased range of motion (ROM) in this joint?

Correct Answer is C

Explanation

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