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Exhibits

Nurse reviews data.

For each joint, click to specify what type of range of motion was being assessed based on findings. Each category will have one response.

Joint

Type of range of motion

Shoulder - unable to move the arm away from the body

Flexion-a

Adduction-a

Abduction-a

Extension-a

Elbow - only able to straighten joint 20 degrees

Flexion-b

Adduction-b

Abduction-b

Extension-b

Wrist - able to bend wrist back

Flexion-c

Adduction-c

Abduction-c

Extension-c

Abduction-a

Abduction-b

Abduction-c

Adduction-a

Adduction-b

Adduction-c

Extension-a

Extension-b

Extension-c

Flexion-a

Flexion-b

Flexion-c

Answer and Explanation

The Correct Answer is ["A","H","I"]

Shoulder - unable to move the arm away from the body: Abduction
Rationale: Abduction refers to moving the arm away from the body. If the client is unable to perform this movement, it indicates a limitation in shoulder abduction.
Elbow - only able to straighten joint 20 degrees: Extension
Rationale: Extension involves straightening the joint. The client’s ability to only straighten the elbow 20 degrees suggests limited extension.
Wrist - able to bend wrist back: Extension
Rationale: Extension of the wrist refers to bending the wrist backward, away from the palm. If the client can perform this movement, it indicates functional wrist extension.

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Correct Answer is D

Explanation

A. Vesicular breath sounds are normal lung sounds heard over most of the lung fields, including the bases. Therefore, they do not need to be reported as abnormal.
B. There is no indication that coughing is needed since the breath sounds are normal.
C. Measuring oxygen saturation is not necessary at this moment, as the vesicular sounds are a normal finding.
D. Vesicular sounds are expected, normal breath sounds in the lung bases. The nurse should continue with the remainder of the physical assessment.

A. Instruct the client in distraction and relaxation techniques. B. Obtain a prescription to catheterize the client's bladder. C. Notify the healthcare provider of the rebound tenderness. D. Offer to administer a laxative prescribed for PRN use.

Correct Answer is C

Explanation

A. Distraction and relaxation techniques may help manage general discomfort but are not appropriate when a specific physical finding, such as rebound tenderness, indicates a potential acute abdominal condition.
B. Catheterizing the bladder is not related to the finding of rebound tenderness, which is more likely indicative of an underlying condition such as appendicitis or peritonitis.
C. Rebound tenderness is a significant finding that can indicate peritoneal irritation, such as from appendicitis. The healthcare provider should be notified immediately so that further diagnostic evaluation and appropriate treatment can be initiated.
D. Administering a laxative without further assessment could exacerbate the condition if the underlying cause is an acute abdominal process, such as appendicitis, which requires surgical intervention rather than bowel stimulation.

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Joint	Type of range of motion
Shoulder - unable to move the arm away from the body	Flexion-a Adduction-a Abduction-a Extension-a
Elbow - only able to straighten joint 20 degrees	Flexion-b Adduction-b Abduction-b Extension-b
Wrist - able to bend wrist back	Flexion-c Adduction-c Abduction-c Extension-c

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

Correct Answer is D

Explanation

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation but reports pain when the pressure is released. Which action should the nurse implement?

Correct Answer is C

Explanation

A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client's paresthesia?

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Which assessment finding supports the client statement, "My feet swell all the time?"

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