Patient Data

Exhibits

The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment.
Which assessment(s) should the nurse conduct? Select all that apply.

A. Osteopenia refers to decreased bone density, which is often noted on X-ray or bone mineral density tests rather than through direct visual inspection. However, the nurse may observe signs of frailty or changes in posture that could suggest underlying osteopenia.
B. Contractures, which are abnormal shortening of muscles or tendons leading to limited joint mobility, are often detectable through inspection. The nurse may observe deformities or restricted movement in the joints, especially in patients with neurological or musculoskeletal disorders.
C. Muscle atrophy, or the wasting away of muscle tissue, can be observed during inspection. The nurse may note reduced muscle bulk or asymmetry in muscle size, which is a sign of muscle wasting.
D. Kyphosis, an abnormal curvature of the spine resulting in a hunchback appearance, can be easily observed during inspection of the client’s posture. This condition is common in older adults and may indicate musculoskeletal or age-related changes.
E. Crepitus refers to the grinding or popping sounds felt or heard when moving joints. While crepitus is assessed by palpation or auscultation rather than visual inspection, the nurse may note joint deformities that suggest the presence of crepitus.

A. An extension of the great toe and fanning of other toes is known as a positive Babinski sign, which is abnormal in adults. This response is typically seen in infants but indicates neurological damage or dysfunction in adults.
B. An exaggerated reflex would usually refer to hyperreflexia, but the Babinski sign specifically involves the abnormal extension of the toes, not just an exaggerated reflex. This response is more associated with neurological damage than simple exaggeration.
C. The Babinski sign can sometimes be associated with central nervous system issues, including meningeal irritation. However, meningeal irritation often involves other symptoms such as neck stiffness, fever, and photophobia, which are not mentioned here.
D. A positive Babinski sign is a classic indication of pyramidal tract disease, which affects the corticospinal tract. This type of neurological dysfunction can be seen in conditions like stroke, multiple sclerosis, or brain injury.