Ch. 24

A nurse is providing health education about osteoporosis to a community group. What ethnicity is considered to be an independent risk factor for osteoporosis? A. Caucasian B. African American C. South Asian D. Native American

Answer: A Rationale: Caucasian ethnicity is a risk factor for osteoporosis. This is not true of the other listed ethnicities. Reference: p. 540, Box 24-3 Evidence-Based Health Promotion and Disease Prevention: Osteoporosis

When testing the range of motion of the cervical spine, the nurse notes impaired range of motion and neck pain. A review of the client's history reveals fever, chills, and headache. What would the nurse suspect? A. Meningitis B. Cervical strain C. Compression fracture D. Cervical disc degeneration

Answer: A Rationale: Impaired range of motion and neck pain associated with fever, chills, and headache could be indicative of a serious infection such as meningitis. Cervical strain is characterized by impaired range of motion and neck pain. Compression fracture is characterized by pain and tenderness of the spinal processes and the paravertebral muscles. Cervical disc degeneration is associated with impaired range of motion and pain that radiates to the back, shoulder, or arms.

During the physical exam, the nurse notes a very tender and painful, reddened, hot, and swollen metatarsophalangeal joint of the client's great toe. What would the nurse suspect? A. Gouty arthritis B. Rheumatoid arthritis C. Degenerative joint disease D. Plantar fasciitis

Answer: A Rationale: In gouty arthritis, the metatarsophalangeal joint of the great toe is tender, painful, red, hot, and swollen. Nodules of the posterior ankle may be seen with rheumatoid arthritis. Pain and tenderness of the metatarsophalangeal joints are seen with inflammation, rheumatoid arthritis, and degenerative joint disease. Tenderness of the calcaneus of the bottom of the foot may indicate plantar fasciitis.

The nurse is caring for a client who reports low back pain. Which test would be most appropriate for the nurse to perform? A. Lasegue B. muscle leg strength C. lateral bending of cervical spine D. internal rotation of the shoulders

Answer: A Rationale: Lasegue test, or straight leg raising, will check for a herniated nucleus pulposus, which is a cause of low back pain. Testing muscle leg strength, lateral bending of the cervical spine, or internal

The nurse is performing the bulge test during the assessment of a client's knee. This test will allow the nurse to make what determination? A. Whether the client's swollen knee is caused by tissue swelling or by fluid accumulation B. Whether the size of the client's knee changes throughout the joint's range of motion C. Whether swelling in the knee joint is a normal age-related change or a pathological finding D. Whether the client's knee joint is capable of adduction and abduction

Answer: A Rationale: The bulge test is used to determine if knee swelling is due to accumulation of fluid or soft tissue swelling. It does not address range of motion. Knee swelling is never considered to be an age-related change. Reference: p. 546, Collecting Objective Data: Physical Examination

The nurse is performing a shoulder assessment and asks a client to bring the hands together behind the head with elbows flexed, then asks the client to bring the hands behind the back, then repeats the process with resistance. Which finding requires further follow-up by the nurse? A. Flat appearance B. External and internal rotation of about 90 degrees C. Can rotate shoulders without difficulty D. Able to shrug shoulders against resistance E. Clavicles and scapula being symmetric

Answer: A Rationale: The shoulders appearing flat is an abnormal finding that requires further follow-up by the nurse. External and internal rotation of about 90 degrees, being able to rotate the shoulders, being able to shrug the shoulders against resistance, and symmetric clavicles and scapula are expected findings that do not require further follow-up by the nurse. Reference: p. 552, Inspection and Palpation

When assessing the elbow, a nurse asks a client to hold the arm out and turn the palm down. The nurse is testing which of the following? A. Pronation B. Flexion C. Rotation D. Supination

Answer: A Rationale: Turning the palm down tests pronation. Having the client turn the palm up would test supination. Flexion is tested by having the client bend the elbow and bring the hand to the forehead. Rotation is not assessed for the elbow.

What would the nurse interpret as a positive response to the Phalen test for a client suspected of having carpal tunnel syndrome? A. Numbness B. Atrophy of the thenar prominence C. No tingling D. Hard, painless Bouchard nodes

Answer: A Rationale: With Phalen test, the client places the backs of both hands against each other while flexing the wrists 90 degrees downward. Complaints of numbness, tingling, and pain indicate a positive response, suggesting carpal tunnel syndrome. Atrophy of the thenar prominence would be seen with carpal tunnel syndrome but not associated with Phalen test. Hard painless Bouchard nodes suggest osteoarthritis.

Assessment reveals that an older client has osteomalacia. Which of the following would be most important to include in the client's teaching plan? A. Practice risk prevention for fractures. B. Keep exercise to a minimum to decrease pain. C. Minimize movements to maintain joint stability. D. The risk for arthritis increases with age.

Answer: A Rationale: Bones lose density with age, which puts the older client at greater risk for fractures. If the older client has osteomalacia, the risk for fracture is even greater. Therefore, the nurse needs to emphasize fracture prevention. Exercise promotes bone density and would be encouraged. The client needs to maintain joint mobility with movement. Age is not a risk factor for arthritis.

The nurse is assessing a client's range of motion of the lumbar spine. Which finding(s) require further follow-up by the nurse? Select all that apply. A. Flexion of 60 degrees B. Incremental movements while bending C. Lumbar concavity flattening out D. Spinal processes being in alignment E. Unilateral exaggerated thoracic convexity

Answer: A, B, E Rationale: The findings of flexion of 60 degrees, incremental movement while bending, and unilateral exaggerated thoracic convexity are abnormal findings that require further follow-up by the nurse. The lumbar concavity flattening out and the spinal processes being in alignment are expected findings. Reference: p. 549, Inspection and Palpation

The nurse is planning the care of a 77-year-old woman who has recently been diagnosed with osteoporosis. What nursing diagnoses should the nurse address in the client's plan of care? Select all that apply. A. Risk for injury related to osteoporosis B. Risk for infection related to osteoporosis C. Activity intolerance related to osteoporosis D. Impaired physical mobility related to osteoporosis E. Disturbed sensory perception related to osteoporosis

Answer: A, C, D Rationale: Osteoporosis creates risks for injury, activity intolerance, and impaired mobility as consequences of musculoskeletal changes. The disease does not normally result in infection or impaired sensation. Reference: p. 540, Box 24-3 Evidence-Based Health Promotion and Disease Prevention: Osteoporosis

A nursing student is preparing to demonstrate how to test the range of motion for the elbow. Which of the following would the student include? Select all that apply. A. Flexion B. Abduction C. Extension D. Rotation E. Supination F. Circumduction

Answer: A, C, E Rationale: When testing the range of motion of the elbow joint, the nurse would test flexion and extension, and supination and pronation of the forearm. Abduction, rotation, and circumduction would be tested in the shoulder or the hip. Reference: p. 546, Collecting Objective Data: Physical Examination

Inspection of a client's foot reveals an enlarged, painful, inflamed bursa on the medial side of the foot. The nurse should make a referral for what health problem? A. Osteomalacia B. Hallux valgus C. Pes planus D. Gouty arthritis

Answer: B Rationale: Bunions are the characteristic sign of hallux valgus. They are not indicative of osteomalacia or gouty arthritis. Pes planus is flat feet. Reference: p. 546, Collecting Objective Data: Physical Examination

When testing muscle strength, a client has difficulty moving her right arm against resistance. What would the nurse to do next? A. Move the part passively through its range of motion. B. Ask the client to move the part against gravity. C. Inspect by touch for a palpable contraction of the muscle. D. Percuss the client's shoulder joint

Answer: B Rationale: If the client cannot move the part against resistance when testing muscle strength, then the nurse should ask the client to move the part against gravity and, if that is not possible, attempt to passively move the part through its full range of motion. Percussion is not indicated. Reference: p. 546, Assessment Guide 24-1 Assessing Joints and Muscles

When asked to touch the ear to the shoulder, a client reports pain. Which of the following would the nurse do next? A. Perform muscle strength against resistance. B. Refer the client for further evaluation. C. Flex and then hyperextend the neck. D. Palpate the paravertebral muscles for pain.

Answer: B Rationale: Pain when touching the ear to the shoulder indicates a problem with lateral bending so the client should be referred for further evaluation. Performing muscle strength against resistance, flexing and then hyperextending the next, and palpating the paravertebral muscles for pain would not be performed next by the nurse because the client has a medical problem that requires diagnosis by a primary care provider.

The nurse is assessing a client's gait. Which finding would alert the nurse to the need for a referral for further evaluation? A. Weight evenly distributed B. Shuffling of feet C. Stands on heels and toes D. Arms swinging in opposition

Answer: B Rationale: Shuffling of the feet suggest a problem that would most likely require a referral for further evaluation. Evenly distributed weight, ability to stand on heels and toes, and arms swinging in opposition are considered normal findings.

While assessing the knee joint of a client, a nurse also explains about the typical motions associated with that joint. What would the nurse include? A. Circumduction B. Flexion C. Abduction D. Internal rotation

Answer: B Rationale: The knee joint is capable of flexion and extension. Circumduction, abduction, and internal rotation are motions associated with the shoulder or hip joint.

After teaching a group of students about the bones and their functions, the instructor determines that the teaching was successful when the students state that blood cells are produced in which of the following? A. Compact bone B. Red marrow C. Yellow marrow D. Spongy bone

Answer: B Rationale: The red marrow of the bone is responsible for producing red blood cells. Compact bone is hard and dense and makes up the shaft and outer layers. Yellow marrow is mostly fat. Spongy bone contains numerous spaces and makes up the ends and center of the bone.

When inspecting a client's feet, the nurse observes that the toes point inward. The nurse documents this finding as which of the following? A. Hallus valgus B. Pes varus C. Verruca vulgaris D. Pes cavus

Answer: B Rationale: Toes that point in are termed pes varus. Hallux valgus is noted as the great toe deviating laterally and possibly overlapping the second toe. Verruca vulgaris are painful warts that often occur under a callus. Pes cavus refers to feet with high arches.

A nurse practitioner refers clients for osteoporosis screening according to the latest U.S. Preventive Services Task Force (USPSTF) recommendations. According to these recommendations, what client should be screen for osteoporosis? A. A 71-year-old man who has type 2 diabetes B. A 69-year-old woman with no major risk factors for osteoporosis C. A 37-year-old woman who takes oral contraceptives D. A 49-year-old African-American woman who is obese

Answer: B Rationale: USPSTF (2011) recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men. Oral contraceptive use is a risk factor for osteoporosis, but screening is not recommended for 37-year-old clients. A 49-year-old African-American woman would similarly not be a candidate for routine screening. Reference: p. 540, Box 24-3 Evidence-Based Health Promotion and Disease Prevention: Osteoporosis

During the nursing history of a newly admitted client, the nurse is reviewing a client's current medication regimen. What medication category creates a risk for decreased bone density? A. Beta-adrenergic blockers B. Corticosteroids C. Nonsteroidal anti-inflammatories (NSAIDs) D. Calcium channel blockers

Answer: B Rationale: Steroids can deplete bone mass, thereby contributing to osteoporosis. This is not true of beta blockers, calcium channel blockers, or NSAIDs. Reference: p. 541, Collecting Subjective Data: The Nursing Health History

What would the nurse expect to find when examining a client with a herniated lumbar disc? A. Rounded thoracic convexity B. Lumbar lordosis C. Flattened lumbar curve D. Lateral curvature of the spine

Answer: C Rationale: In a client with a herniated lumbar disc, flattening of the lumbar curve may be seen. A rounded thoracic convexity or kyphosis is commonly seen in older adults. Lumbar lordosis or an exaggerated lumbar curve is often seen in pregnancy and obesity. Lateral curvature of the spine is seen with scoliosis.

A nurse is preparing a program on osteoporosis for a local women's group. Which of the following would the nurse include as a modifiable risk factor? A. Small-boned, thin frame B. Personal history of fractures C. Vitamin D deficiency D. Age

Answer: C Rationale: Modifiable risk factors include vitamin D deficiency. Small-boned thin frame, personal history of fractures, and age cannot be modified.

Assessment reveals that a client has slight weakness with active range of motion against some resistance. How would the nurse document this finding? A. 2/5 B. 3/5 C. 4/5 D. 5/5

Answer: C Rationale: Muscle strength is rated on a 5-point scale, with specific defining characteristics for each. Slight weakness with active motion against some resistance is 4 of 5 points. 2 of 5 points would indicate passive and poor range of motion. 3 of 5 points would indicate average weakness with active motion against gravity. 5 of 5 points would indicate normal findings, with active motion against full resistance. Reference: p. 546, Assessment Guide 24-1 Assessing Joints and Muscles

After assessing a client's musculoskeletal system, the nurse is preparing to document the data gathered. Which of the following would the nurse document as objective data? A. Denies pain in hips or legs B. Complains of burning in lower back C. Neck rotation limited to 50 degrees D. History of osteoporosis

Answer: C Rationale: Neck rotation limitation would be objective data because it was measurable and obtained during the physical examination. Client reports such as denial of pain, complaints of burning, and a history of osteoporosis are subjective data

When examining a client with a rotator cuff tear, which of the following would the nurse expect to find? A. Limitation of all shoulder motion B. Chronic pain C. Limited abduction D. Sharp catches of pain with movement

Answer: C Rationale: Painful and limited abduction accompanied by muscle weakness and atrophy are seen with a rotator cuff tear. Chronic pain and limitation of all shoulder motion is seen with calcified tendonitis. Sharp catches of pain are associated with rotator cuff tendonitis.

A client is diagnosed with osteomalacia. Which of the following would a nurse include in the client's teaching plan? A. Decreasing purine intake can reduce the risk of osteomalacia. B. An increased amount of vitamin C intake is recommended. C. At least 20 minutes of sunlight each day is recommended D. Reduce the amount of protein intake.

Answer: C Rationale: Sunlight will stimulate the body's production of vitamin D. Vitamin D deficiency can increase the incidence of osteomalacia. A decreased purine intake is suggested for gout. Increased vitamin C intake would be appropriate to promote bone and tissue healing. Adequate protein intake is needed to promote muscle tone and bone growth

A female client tells the nurse that she has been diagnosed with systemic lupus erythematosus. The nurse would assess the client for which common complication? A. Diabetes mellitus B. Urinary tract infection C. Osteoporosis D. Early menopause

Answer: C Rationale: Systemic lupus erythematosus places a client at risk for developing osteoporosis and osteomyelitis. Urinary tract infection, diabetes, and early menopause are unrelated to systemic lupus erythematosus.

A group of students is reviewing information related to the major bones of the skeleton. The students demonstrate understanding of the material when they identify which of the following as part of the axial skeleton? A. Humerus B. Femur C. Vertebral column D. Carpals

Answer: C Rationale: The axial skeleton consists of the head and the trunk and includes the cranium, facial bones, mandible, ribs, sternum, and vertebral column. The appendicular skeleton consists of the bones of the extremities, shoulders, and hips.

Inspection of a client's knee reveals swelling, and the nurse suspects that there is significant fluid in the knee. What test would the nurse perform to confirm the suspicion? A. Phalen test B. Tinel test C. Ballottement test D. Lasegue test

Answer: C Rationale: The ballottement test is used to detect large amounts of fluid in the knee. Phalen test and Tinel test would be used to assess for carpal tunnel syndrome. Lasegue test is used to detect low back pain.

The nurse has had a client place the backs of both her hands against each other while flexing her wrists 90 degrees with fingers pointed downward and wrists dangling. The presence of pain or tingling during this test suggests what health problem to the nurse? A. Osteoarthritis B. Diabetic neuropathy C. Carpal tunnel syndrome D. Gouty arthritis

Answer: C Rationale: The nurse has performed Phalen test, which assesses for carpal tunnel syndrome. A positive result is not suggestive of neuropathy, osteoarthritis, or gouty arthritis. Reference: p. 546, Collecting Objective Data: Physical Examination

The nurse notes limitation in active range of motion of a client's right shoulder. What would the nurse to do next? A. Test muscle strength. B. Perform passive range of motion test. C. Measure range of motion with a goniometer. D. Ask the client which is the dominant side.

Answer: C Rationale: When limited range of motion is noted, the nurse should measure range of motion with a goniometer to provide information about the joint motion in degrees. Testing muscle strength may be done later once the measurement is obtained. Asking the client about his or her dominant side would be important to know when testing muscle strength, not joint motion. If the client cannot move the part against resistance when testing muscle strength, then the nurse would ask the client to move the part against gravity, and if not possible, attempt to passively move the part through its full range of motion.

A nurse is preparing a program on osteoporosis for a local women's group. What would the nurse cite as a risk factor? A. Obesity B. Multiparity (multiple births) C. Smoking D. African American ethnicity

Answer: C Rationale: Smoking is a risk factor for osteoporosis. Obesity, multiparity, and African American ethnicity are not noted risk factors for this disease. Reference: p. 540, Box 24-3: Evidence-Based Health Promotion and Disease Prevention: Osteoporosis

A client complains of temporomandibular joint (TMJ) pain. What would the nurse most likely assess? A. Knife-like pain B. History of fracture C. Recent weight gain D. Difficulty chewing

Answer: D Rationale: A client with temporomandibular joint problems may describe the jaw "getting locked" or difficulty chewing. Jaw tenderness, pain, or clicking sound may be present with range of motion. Knife-like pain, history of fracture, and recent weight gain are not associated with TMJ pain.

The nurse is performing an assessment of a client's musculoskeletal system. What would the nurse examine first? A. The client's leg length B. The client's lateral bending ability C. The client's cervical range of motion D. The client's gait

Answer: D Rationale: Gait inspection provides a valuable overview of musculoskeletal function. For this reason, gait inspection is usually performed at the beginning of the objective exam and prior to more detailed assessments, such as leg length, lateral bending ability, and cervical range of motion. Reference: p. 546, Collecting Objective Data: Physical Examination

The nurse is conducting a musculoskeletal assessment of an older adult client. What aspect of the client's medical history requires the nurse to alter the usual sequence or content of this assessment? A. The client takes medications to treat hypertension. B. The client suffered a fractured humerus 1 year earlier. C. The client has a diagnosis of type 1 diabetes. D. The client had a total hip replacement 2 years ago.

Answer: D Rationale: If the client has had a total hip replacement, do not test ROM unless the physician gives permission to do so, due to the risk of dislocating the hip prosthesis. A 1-year-old arm fracture is likely to have healed fully and would not normally affect the content of the assessment. Diabetes can affect various aspects of the musculoskeletal system, but it does not likely require the nurse to modify the assessment. Antihypertensives are unlikely to affect assessment. Reference: p. 546, Collecting Objective Data: Physical Examination

The nurse is assessing a client's ability to shrug her shoulders against resistance. The nurse is assessing which cranial nerve? A. III B. V C. VII D. XI

Answer: D Rationale: Inability to shrug shoulders against resistance suggests a lesion of cranial nerve XI (spinal accessory nerve). Cranial nerve III is involved with extraocular eye movements. Cranial nerve V is involved with facial sensation. Cranial nerve VII is associated with facial muscles.

The nurse is preparing to palpate the anatomic snuffbox. At which location would the nurse palpate? A. At the anterior area of the sternoclavicular joint B. At the posterior temporomandibular joint C. At the olecranon process of the elbow D. At the back of the wrist and extended thumb

Answer: D Rationale: The anatomic snuffbox is located at the hollow area on the back of the wrist at the base of the fully extended thumb. It is not located at the sternoclavicular, temporomandibular, or elbow joints.

During the history, a young adult woman asks the nurse, "My mother has osteoporosis. What can I do to help reduce my risk?" Which response by the nurse would be most appropriate? A. "Increase the amount of non-weight-bearing physical activity that you do." B. "Keep your calcium intake at about 800 milligrams each day." C. "Avoid being out in the sun for long periods of time." D. "Avoid smoking and using alcohol."

Answer: D Rationale: To reduce the risk of osteoporosis, the nurse should instruct the client to avoid smoking or alcohol consumption. The nurse should instruct the client to increase physical exercise or activity, especially weight-bearing activities; therefore, instructing the client to increase non-weight-bearing physical activity is not the nurse's most appropriate response. The nurse should instruct the client to consume approximately 1000 to 1500 mg of calcium daily; therefore, the recommendation of keeping the calcium intake at about 800 milligrams is too low. Avoiding long periods of sun exposure is not the most appropriate response, because the nurse should inform the client that sunlight can increase vitamin D levels to promote calcium absorption. Reference: p. 540, Box 24-3 Evidence-Based Health Promotion and Disease

A nurse asks a client to bring the hands together behind the head with the elbows flexed. The nurse is testing which of the following? A. Abduction B. Adduction C. Internal rotation D. External rotation

Answer: D Rationale: When the client brings the hands together behind the head with the elbows flexed, the nurse is testing external rotation. Abduction is tested by having the client bring both hands together overhead with the elbows straight; adduction is tested by having the client bring both hands together in front of the body past the midline with the elbows straight. Internal rotation is tested by having the client bring the hands together behind the back with the elbows flexed.

The nurse is performing an assessment on an adolescent client and notes a 45-degree flexion of the cervical spine. What should the nurse do next? A. Assess the thoracic and lumbar spine. B. Palpate the spinous processes. C. Perform the Lasegue test. D. Continue the exam because this curve is normal.

Answer: D Rationale: Normal flexion of the cervical spine is 45 degrees. Because the finding is normal, assessing the thoracic and lumbar spine, palpating the spinous processes, and performing the Lasegue test would be unnecessary.