Chapter 49

The nurse is using a common scale to grade a client's muscle strength. The client is able to complete range of motion (ROM) only with gravity eliminated. Which grade does the nurse document in this client's record?

2 The nurse documents a grade of two (2) for this client because it indicates poor muscle strength. The client can complete ROM only with gravity eliminated.Grade zero (0) indicates no evidence of muscle contractility. Grade one (1) indicates trace muscle strength and shows that the client has no joint motion and slight evidence of muscle contractility. Grade three (3) indicates fair muscle strength, where the client can complete ROM against gravity.

5. A client is distressed at body changes related to kyphosis. What response by the nurse is best? a. Ask the client to explain more about these feelings. b. Explain that these changes are irreversible. c. Offer to help select clothes to hide the deformity. d. Tell the client safety is more important than looks.

ANS: A Assessment is the first step of the nursing process, and the nurse should begin by getting as much information about the clients feelings as possible. Explaining that the changes are irreversible discounts the clients feelings. Depending on the extent of the deformity, clothing will not hide it. While safety is more objectively important than looks, the client is worried about looks and the nurse needs to address this issue.

9. The clients chart indicates genu varum. What does the nurse understand this to mean? a. Bow-legged b. Fluid accumulation c. Knock-kneed d. Spinal curvature

ANS: A Genu varum is a bow-legged deformity. A fluid accumulation is an effusion. Genu valgum is knock-kneed. A spinal curvature could be kyphosis or lordosis.

3. A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to be pale and cool, with 1+/4+ pedal pulses. What action by the nurse is best? a. Assess the neurovascular status of the right leg. b. Document the findings in the clients chart. c. Elevate the left leg on at least two pillows. d. Notify the provider of the findings immediately.

ANS: A The nurse should compare findings of the two legs as these findings may be normal for the client. If a difference is observed, the nurse notifies the provider. Documentation should occur after the nurse has all the data. Elevating the left leg will not improve perfusion if there is a problem.

4. A hospitalized clients strength of the upper extremities is rated at 3. What does the nurse understand about this clients ability to perform activities of daily living (ADLs)? a. The client is able to perform ADLs but not lift some items. b. No difficulties are expected with ADLs. c. The client is unable to perform ADLs alone. d. The client would need near-total assistance with ADLs.

ANS: A This rating indicates fair muscle strength with full range of motion against gravity but not resistance. The client could complete ADLs independently unless they required lifting objects.

8. A school nurse is conducting scoliosis screening. In screening the client, what technique is most appropriate? a. Bending forward from the hips b. Sitting upright with arms outstretched c. Walking across the room and back d. Walking with both eyes closed

ANS: A To assess for scoliosis, a spinal deformity, the student should bend forward at the hips. Standing behind the student, the nurse looks for a lateral curve in the spine. The other actions are not correct.

7. A nurse is providing community education about preventing traumatic musculoskeletal injuries related to car crashes. Which group does the nurse target as the priority for this education? a. High school football team b. High school homeroom class c. Middle-aged men d. Older adult women

ANS: A Young men are at highest risk for musculoskeletal injury due to trauma, especially due to motor vehicle crashes. The high school football team, with its roster of young males, is the priority group.

1. A nursing student studying the musculoskeletal system learns about important related hormones. What information does the student learn? (Select all that apply.) a. A lack of vitamin D can lead to rickets. b. Calcitonin increases serum calcium levels. c. Estrogens stimulate osteoblastic activity. d. Parathyroid hormone stimulates osteoclastic activity. e. Thyroxine stimulates estrogen release.

ANS: A, C, D Vitamin D is needed to absorb calcium and phosphorus. A deficiency of vitamin D can lead to rickets. Estrogen stimulates osteoblastic activity. Parathyroid hormone stimulates osteoclastic activity. Calcitonin decreases serum calcium levels when they get too high. Thyroxine increases the rate of protein synthesis in all tissue types.

4. When assessing gait, what features does the nurse inspect? (Select all that apply.) a. Balance b. Ease of stride c. Goniometer readings d. Length of stride e. Steadiness

ANS: A, B, D, E To assess gait, look at balance, ease and length of stride, and steadiness. Goniometer readings assess flexion and extension or joint range of motion.

2. A student nurse learns about changes that occur to the musculoskeletal system due to aging. Which changes does this include? (Select all that apply.) a. Bone changes lead to potential safety risks. b. Increased bone density leads to stiffness. c. Osteoarthritis occurs due to cartilage degeneration. d. Osteoporosis is a universal occurrence. e. Some muscle tissue atrophy occurs with aging.

ANS: A, C, E Many age-related changes occur in the musculoskeletal system, including decreased bone density, degeneration of cartilage, and some degree of muscle tissue atrophy. Osteoporosis, while common, is not universal. Bone density decreases with age, not increases.

2. A client is undergoing computed tomography (CT) of a joint. What action by the nurse is most important before the test? a. Administer sedation as prescribed. b. Assess for seafood or iodine allergy. c. Ensure that the client has no metal on the body. d. Provide preprocedure pain medication.

ANS: B Because CT uses iodine-based contrast material, the nurse assesses the client for allergies to iodine or seafood (which often contains iodine). The other actions are not needed.

1. A client is having a myelography. What action by the nurse is most important? a. Assess serum aspartate aminotransferase (AST) levels. b. Ensure that informed consent is on the chart. c. Position the client flat after the procedure. d. Reinforce the dressing if it becomes saturated.

ANS: B This diagnostic procedure is invasive and requires informed consent. The AST does not need to be assessed prior to the procedure. The client is positioned with the head of the bed elevated after the test to keep the contrast material out of the brain. The dressing should not become saturated; if it does, the nurse calls the provider.

6. The nurse knows that hematopoiesis occurs in what part of the musculoskeletal system? a. Cancellous tissue b. Collagen matrix c. Red marrow d. Yellow marrow

ANS: C Hematopoiesis occurs in the red marrow, which is part of the cancellous tissues containing both types of bone marrow.

3. An older clients serum calcium level is 8.7 mg/dL. What possible etiologies does the nurse consider for this result? (Select all that apply.) a. Good dietary intake of calcium and vitamin D b. Normal age-related decrease in serum calcium c. Possible occurrence of osteoporosis or osteomalacia d. Potential for metastatic cancer or Pagets disease e. Recent bone fracture in a healing stage

ANS: B, C This slightly low calcium level could be an age-related decrease in serum calcium or could indicate a metabolic bone disease such as osteoporosis or osteomalacia. A good dietary intake would be expected to produce normal values. Metastatic cancer, Pagets disease, or healing bone fractures will elevate calcium.

10. The nurse is assessing four clients with musculoskeletal disorders. The nurse should assess the client with which laboratory result first? a. Serum alkaline phosphatase (ALP): 108 units/L b. Serum aspartate aminotransferase (AST): 26 units/L c. Serum calcium: 10.2 mg/dL d. Serum phosphorus: 2 mg/dL

ANS: D A normal serum phosphorus level is 3 to 4.5 mg/dL; a level of 2 mg/dL is low, and this client should be assessed first. The values for serum ALP, AST, and calcium are all within normal ranges.

A 65-year-old female client has chronic hip pain and muscle atrophy from an arthritic disorder. Which musculoskeletal assessment finding does the nurse expect to see in the client?

Antalgic gait The client with chronic hip pain and muscle atrophy from an arthritic disorder would likely have a lurch in the gait (antalgic gait).Midswing gait is not a term used to assess a client's gait. This client would likely have a wide-based stance because of the musculoskeletal disorder.

Which diagnostic test requires the nurse to know whether the client is allergic to iodine-based contrast?

Computed tomography (CT) A CT scan creates three-dimensional images and may be done with iodine-based contrast.Arthroscopy involves inserting a fiber optic tube into a joint for direct visualization of ligaments, menisci, and articular surfaces of the joint. An EMG evaluates diffuse or localized muscle weakness by testing nerve conduction. Tomography identifies locations, or "slices," for focus and blurs the images of other structures. Arthroscopy, EMG, and tomography do not use iodine-based contrast.

The nurse is attempting to perform a quick assessment of a client's hip discomfort. The client is sitting upright in a wheelchair. What is the nurses initial action?

Flex and extend the client's knee to assess for discomfort. Hip pain can radiate to the groin and knee, so a rapid initial assessment for a client who is sitting with knees flexed may be performed by flexing and extending the client's knee.Flexing and extending the foot does not assess hip pain. If the knee assessment does not yield information about hip discomfort, the client may be transferred to the bed for a more complete examination of the hip. It is not possible to perform abduction and adduction of the client's hips while the client is sitting in a wheelchair.

The nurse is conducting a musculoskeletal history in an older adult client who requires a caregiver to perform all activities of daily living (ADLs). Which level of functioning does the nurse record in the client's history using Gordon's Functional Health Patterns?

Level IV Gordon's Functional Health Pattern Level IV indicates that the client is dependent and does not participate in ADLs such as dressing him or herself.Level 0 indicates a client who is able to perform full self-care. Level II indicates a client who requires assistance or supervision of another person without assistive equipment or devices. Level III indicates that the client requires the assistance or supervision of another person, as well as assistive equipment or devices.

The ambulatory surgery post anesthesia care unit (PACU) nurse has just received report about clients who had arthroscopic surgery. Which client will the nurse plan to assess first?

Middle-aged adult client who returned to the PACU 25 minutes ago after left knee arthroscopic surgery under epidural anesthesia The client who had knee arthroscopic surgery under epidural anesthesia is at greatest risk for complications and should be assessed first. After epidural anesthesia, frequent assessments for the return of sensation and movement of the leg will be important.The clients who had local anesthesia for knee arthroscopy, the client who had a synovial biopsy of the right knee, and the client who had multiple right knee incisions are all at less risk for developing complications.

A client is suspected of having muscular dystrophy (MD). Which laboratory test result does the nurse anticipate with this disease?

Moderately elevated aspartate aminotransferase (AST) The AST level is moderately elevated (three to five times normal) in certain musculoskeletal diseases, such as MD.The CK level is elevated in musculoskeletal diseases such as MD. ALP is an enzyme normally present in blood, and the concentration of ALP increases with bone or liver damage. It is not associated with MD. A decreased CK-MM level is not associated with MD.

The charge nurse in the hospital-based day surgery center is making client assignments for the staff. Which client is most appropriate to assign to a nurse who has floated from the general surgical unit?

Older adult who has undergone arthroscopic surgery of the shoulder under local anesthesia The postoperative older client who had arthroscopic surgery is most appropriate for the surgical floor nurse to care for. Arthroscopic surgery and local anesthesia have low complication rates. The float nurse would be expected to know how to assess neurovascular status.The young, newly admitted client requires assessment that will be best performed by nurses with more experience in day surgery. Client teaching for the adult client who has had arthroscopic knee surgery is best completed by nurses with more experience in day surgery. The middle-aged adult who needs a pneumatic tourniquet requires an intervention that is best performed by nurses with more experience in day surgery.

The nurse is reviewing the medication history for a client scheduled for a left total hip replacement. The nurse plans to contact the health care provider if the client is taking which medication?

Prednisone (Deltasone) to treat asthma Long-term use of steroids such as prednisone is strongly associated with osteoporosis and will increase the risk for prolonged recovery after the hip replacement.Taking acetaminophen for pain relief, bupropion for smoking cessation, or magnesium hydroxide to treat heartburn will not influence the potential success of the surgery.

The nurse is completing an admission assessment on a client scheduled for arthroscopic knee surgery. Which information will be most essential for the nurse to report to the health care provider?

Warm, red, and swollen knee Findings such as swelling, heat, and redness may indicate infection in the knee joint and is most essential for the nurse to report to the health care provider. These findings will help the health care provider determine whether there may be a need to cancel the procedure.Having knee pain before surgery is not unexpected but will not affect whether the client will have surgery. Allergy to shellfish and iodine will need to be reported, but also will not affect whether the client will have surgery. Having previous surgery on the other knee does not preclude the client from having this surgery.