Musculoskeletal System Assessment
A patient is scheduled to undergo closed magnetic resonance imaging (MRI) without contrast medium. Which information does the nurse give to the patient before the test?
"All jewelry and clothing with zippers or metal fasteners must be removed." The patient must remove all metal objects on clothing and all jewelry before undergoing MRI. The patient having a closed MRI will lie still in a supine position for 45-60 minutes, not 20 minutes, and may require sedation. It is not necessary for the patient to be NPO before an MRI. The patient cannot undergo MRI when an internal pacemaker or any other metal object is present in the body.
The patient is preparing for an arthroscopy of the knee. What does the nurse teach the patient about the postoperative phase?
"Severe pain is abnormal and you should contact your doctor if you experience it." Severe joint or limb pain after discharge may indicate a complication and should be reported to the provider immediately. The patient should be encouraged to perform exercises of the affected limb as taught preoperatively. Ice is often used for 24 hours following the procedure. The surgeon will usually want to see the patient about 1 week postoperatively.
The nurse is assessing the skeletal system of an African-American patient. What must the nurse know to assess the patient correctly?
African Americans have a decreased incidence of osteoporosis. African Americans tend to have a decreased incidence of osteoporosis because they often have greater bone density than Asians and other ethnic groups. Egyptian Americans often have a shorter stature than African Americans. Irish Americans tend to have less bone density than African Americans.
A 65-year-old female patient has chronic hip pain and muscle atrophy from an arthritic disorder. Which musculoskeletal assessment finding does the nurse expect to see in the patient?
Antalgic gait The patient 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 patient's gait. This patient would likely have a wide-based stance because of the musculoskeletal disorder.
A patient has undergone arthroscopy of the knee. What care does the nurse provide to the patient after the procedure?
Assess neurovascular status of the extremity every hour. Arthroscopy is performed on an ambulatory basis. After the procedure, the nurse assesses the neurovascular status of the extremity every hour or according to facility protocol. Neurovascular assessment includes palpation of the distal pulses of the extremity below the level of injury and assessment of sensation, movement, color, temperature, and pain at the surgical site. An ice pack is often applied for 24 hours to reduce swelling. The dressing need not be changed every hour as there is no discharge or major bleeding. The extremity is kept elevated for 12 to 24 hours.
Which hormone increases the renal excretion of calcium?
Calcitonin Calcitonin produced by the thyroid gland decreases the serum calcium concentration if it increases above its normal level. It inhibits bone resorption and increases the renal excretion of calcium. Thyroxine produced by the thyroid gland increases the rate of protein synthesis in bone and all other types of tissue. Parathormone, or parathyroid hormone, promotes osteoclastic activity of the bone, releases calcium into the blood, and reduces the renal excretion of calcium. Insulin works with growth hormone to build and maintain healthy bone tissue.
What statement about the procedure for magnetic resonance imaging (MRI) is correct?
Gadolinium contrast agent may cause problems in patients with kidney disease. Gadolinium contrast agents may cause severe systemic complications in patients with chronic kidney disease. MRI with or without the use of contrast media can diagnose musculoskeletal disorders. MRI is more accurate than computed tomography (CT) and myelography for evaluating many spinal and knee problems. The patient must lie still in the supine position for about 45 to 60 minutes for an MRI; if the patient is unable to do this, sedation may be needed.
While evaluating the stance of a patient, the nurse observes a bow-legged deformity. How does the nurse document this condition?
Genu varum The nurse documents a bow-legged deformity as genu varum. Effusion is the accumulation of fluid in the knee joint. A grating sound in the knee is documented as crepitus; it indicates a joint irregularity. Poor alignment of the knees, or "knock-knee," is documented as genu valgum.
The nurse plans to use which tool to measure joint range of motion (ROM)?
Goniometer A goniometer provides an exact measurement of flexion and extension or joint ROM. A Doppler is used to check and find pulses. A reflex hammer is used to test and elicit reflexes and is used in neurologic examinations. A tonometer is used to measure tension or pressure in the eye.
Computed tomography (CT) is the best diagnostic test for evaluating which problem?
Injuries of bone CT is used to assess injuries or pathology that involves only bone. Magnetic resonance imaging (MRI) is most appropriate for joint and soft tissue problems and bony tumors that involve soft tissue.
When assessing a female patient, the nurse learns that the patient has several risk factors for osteoporosis. Which risk factor will be the priority for patient teaching?
Low calcium intake The patient's calcium intake is the only risk factor that the patient can change. The nurse will discuss the other risk factors as contributing to osteoporosis, but the teaching will focus on ways to increase calcium intake. Postmenopausal status, positive family history, and previous use of steroids are not risk factors that the patient can change. These risk factors should be discussed, but are not the priority for this patient.
A patient 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 nurse is reviewing the laboratory reports of four patients in a clinical care setting. Which patient is at risk for osteomalacia?
Patient B The laboratory reports of patient B show decreased serum calcium of 6 mg/dL, decreased serum phosphorous of 1.5 mg/dL, and increased alkaline phosphatase of 145 units/L. These decreased levels of serum calcium and serum phosphorous and elevated alkaline phosphatase levels indicate defective bone mineralization and softening of the bones, leading to osteomalacia; therefore, the nurse suspects patient B is at risk for osteomalacia. The laboratory parameters of patient A are all within the normal range and do not indicate any risk for osteomalacia. The laboratory reports of patient C show increased serum calcium of 13.2 mg/dL; therefore, the nurse does not suspect risk of osteomalacia in patient C. The laboratory reports of patient D show increased serum phosphorus of 5.7 mg/dL; however, increased serum phosphorous does not indicate risk of osteomalacia.
Which body part has an amphiarthrodial joint?
Pelvis An amphiarthrodial joint is a slightly movable joint such as is found in the pelvis. A diarthrodial or synovial joint is a freely movable joint like the knee and elbow. A synarthrodial joint is completely immovable; the cranium is a good example.
The nurse is reviewing the medication history for a patient scheduled for a left total hip replacement. The nurse plans to contact the health care provider if the patient is taking which medication?
Prednisone to treat asthma Long-term steroid use is strongly associated with osteoporosis and will increase the risk for poor wound healing and 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 assessing an older patient for changes in the musculoskeletal system. What does the nurse teach the patient for proper self-care at home?
Prevent pressure on bone prominences. The nurse should teach the patient to prevent pressure on bone prominences while sleeping or sitting. Older patients have less soft tissue and are therefore prone to skin breakdown. The patient should be encouraged to perform weight-bearing exercises such as walking which slows bone loss. The patient with cartilage degeneration is advised to apply warm, moist compresses to the joints to increase blood flow. The patient should perform isometric exercises to increase muscle strength; increased activity and exercise can slow the progression of atrophy.
Which is an example of a flat bone that protects the vital organs?
Scapula The scapula is a flat bone that protects vital organs. The femur is a long bone with cylindrical shape and rounded ends, and it bears weight. A phalange is a short bone that is small and bears little or no weight. The patella is a sesamoid bone that develops within a tendon.
Which voluntary muscle is controlled by the central and peripheral nervous system?
Skeletal Skeletal muscle is striated, voluntary muscle that is controlled by the central and peripheral nervous systems. Smooth muscle or non-striated muscle is involuntary muscle that is responsible for contractions of organs and blood vessels; it is controlled by the autonomic nervous system. Cardiac muscle is striated, involuntary muscle which is also controlled by the autonomic nervous system.
What statement about myelography is correct?
The head of the bed is elevated to 30 to 50 degrees during the test. During myelography, the head of the bed is elevated to 30 to 50 degrees to prevent the entry of contrast medium into the brain. It is an invasive procedure where a contrast medium is injected into the subarachnoid space of the spine by spinal puncture. The vertebral column, intervertebral disks, spinal nerve roots, and blood vessels can be visualized with myelography. Xeroradiography highlights the contrast between structures.
The nurse is preparing a patient with osteosarcoma for a nuclear bone scan. What information about this test should be taught to the patient?
The isotope is excreted through the intestinal tract. The isotope from a nuclear bone scan is excreted through the intestinal tract in the urine and stool. No special precautions are taken in handling the excreta. The isotope is administered 4 to 6 hours before the scan, because the bone takes up the isotope very slowly. The procedure takes about 30 to 60 minutes during which the patient is expected to lie absolutely still. The procedure may be repeated at 24, 48, and 72 hours. The patient will need to push fluids to facilitate urinary excretion.
What abnormalities can be diagnosed by ultrasonography? Select all that apply.
Traumatic joint injury Fluid accumulation Mass accumulation Ultrasonography can be used to diagnose traumatic joint injuries and soft-tissue disorders such as masses and fluid accumulation. Electromyography is used to evaluate diffuse or localized muscle weakness. Muscle biopsy is used to diagnose muscle atrophy.
A nursing student is studying the skeletal system. Which statement indicates to the nursing instructor that the student understands a normal physiologic function of the skeletal system?
"Hematopoiesis occurs in the red marrow, which is where blood cells are produced." Hematopoiesis is the production of blood cells in the red marrow and is the correct statement. Volkmann's canals connect bone marrow vessels with the haversian system. In the deepest layer of the periosteum are osteogenic cells that differentiate into osteoblasts and osteoclasts. The cortex is the outer layer of the bone that consists of dense, compact bone tissue. Deposits of inorganic calcium salts (carbonate and phosphate) in the matrix of the bone are what provide the hardness of bone.
A patient experiencing kyphosis appears withdrawn and does not initiate any conversation with the nurse when medications are given each day. Which statement by the nurse is most supportive of this patient?
"How do you feel about the pain in your spine? I am here if you want to talk." Asking the patient about his or her pain and offering to listen is most supportive because it allows the patient to discuss his or her feelings and informs the patient that the nurse is available to listen. Telling the patient that it is normal to feel depressed is a leading statement and is not supportive; the patient may not be depressed. Suggesting that the patient exercise more often is not a supportive statement because it avoids the opportunity to support the patient and diverts the subject to exercise. Asking what the patient's family has to say is not supportive because it is the nurse's way of avoiding the issue.
A patient recently has had an amputation of the right hand. Which statement by the patient, who was right-handed, indicates that he or she is coping effectively?
"I can learn to write with my left hand." The patient's willingness to learn to write with his or her left hand indicates that the patient is coping effectively by planning to adapt to the loss of the right hand. The patient can adapt to the use of assistive devices to be independent in personal care. The patient's desire for help with all personal care indicates lack of willingness or information or both. Wanting to cover the missing hand with clothing indicates that the patient is not adjusting to the loss of the hand. Concern over people looking at him or her differently is a realistic concern for the patient, but it also indicates that the patient is not coping effectively regarding the amputated limb.
A patient is scheduled to undergo arthroscopy of the knee. What does the nurse teach the patient about the procedure? Select all that apply.
"You must be able to flex the knee." "Physical therapy sessions will be needed before the procedure." "The procedure is performed on an ambulatory basis." During an arthroscopy, the patient must flex the knee so the arthroscope can be inserted into the joint space to allow visualization. The patient must attend physical therapy sessions before the surgery to learn leg exercises to perform after the procedure. The procedure is performed on an ambulatory basis. The patient is usually given local, light general, or epidural anesthesia, depending on the purpose of the procedure. The procedure may require multiple incisions to allow inspection at a variety of angles.
A patient is scheduled for an electromyography (EMG) and nerve conduction test. What information does the nurse give the patient about these tests?
"You will be subjected to episodes of electric current during the EMG." Nerve conduction is tested by placing flat electrodes along the nerve to be evaluated, and low electric currents are passed through the electrodes to the nerve and muscle innervated. The health care provider will prescribe a temporary discontinuation of skeletal muscle relaxants several days before the procedure; this prevents the drugs from affecting the test results. Multiple small needles are inserted during the EMG which may affect the nerve conduction test, so the nerve conduction test is performed before the EMG. Neither test involves the use of iodine contrast dye, so patients with iodine allergy are not at risk.
The nurse uses the 0-5 scale for grading muscle strength of a patient around the knee joint. If the patient can complete range of motion (ROM) against gravity but only without any resistance, what rating does this signify?
3 A rating of 3 on a 0-5 scale indicates fair muscle strength; the patient can complete ROM against gravity but is unable to complete it when some resistance is applied. A rating of 2 indicates poor muscle strength. With this rating, the patient is able to complete ROM when gravity is totally eliminated. A rating of 4 indicates the patient has good muscle strength and can complete ROM against gravity even when some resistance is applied. A rating of 5 indicates the patient has normal muscle strength — ROM is unimpaired against gravity even when full resistance is applied.
Which diagnostic test requires the nurse to know whether the patient 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 fiberoptic 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 studies. Tomography identifies places, or slices, for focus and blurs the images of other structures. Arthroscopy, EMG, and tomography do not use iodine-based contrast.
A patient reports severe pain and a grating sound in the knee. How does the nurse document this condition?
Crepitus A grating sound in the knee is documented as crepitus which indicates joint irregularities. Effusion is the accumulation of fluid in the knee joint. Poor alignment of the knees, or knock-knee, is known as genu valgum. Bow-legged deformities are known as genu varum.
Care of the older adult may be affected by which physiologic change in the musculoskeletal system?
Decreased range of motion (ROM) Decreased ROM occurs in older adults and they may need assistance with self-care skills. Cartilage degeneration is an age-related change that occurs in the musculoskeletal system. Decreased bone density occurs with musculoskeletal system aging, and porous bones are more likely to fracture. The older adult experiences kyphotic posture, widened gait, and a shift in the center of gravity.
The nurse is assessing the lab reports of a patient suspected of having osteomalacia. Which abnormal levels indicate the presence of osteomalacia? Select all that apply.
Decreased serum calcium Decreased serum phosphorous Elevated alkaline phosphatase Decreased serum calcium, decreased serum phosphorous, or elevated levels of alkaline phosphatase may indicate the presence of osteomalacia. Elevated levels of aldolase may indicate polymyositis and dermatomyositis or muscular dystrophy. Elevated levels of aspartate aminotransferase may indicate skeletal muscle trauma or progressive muscular dystrophy.
What does the nurse assess to evaluate a patient's gait?
Ease and length of a stride The nurse assesses the ease and length of the patient's stride, balance, and steadiness to evaluate the patient's gait. Abnormal gait occurs when a leg is painful or when muscles in the leg and buttocks are too weak to allow the patient to change weight from one foot to the other. The curvature, length, and shape of the spine is assessed for problems with posture. Muscle mass is assessed for size and symmetry to evaluate for the presence of deformities or impairment.
The nurse is assessing a patient who sustained a crush injury when a tree fell and trapped his leg for several hours. What lab values does the nurse expect to see? Select all that apply.
Elevated creatinine kinase (CK-MM) Elevated aspartate aminotransferase (AST) The major muscle enzymes affected in skeletal muscle disease or injuries are creatine kinase (CK-MM), aspartate aminotransferase (AST), aldolase (ALD), and lactic dehydrogenase (LDH). As a result of damage, the muscle tissue releases additional amounts of these enzymes, which increases serum levels. Disorders of bone and the parathyroid gland are often reflected in an alteration of the serum calcium or phosphorus level. In metabolic bone disease and bone cancer, alkaline phosphatase (ALP) rises in proportion to the osteoblastic activity, which indicates bone formation.
A patient is scheduled for an arthroscopy for surgical repair of the knee. What action does the nurse take?
Ensure that the patient can flex the knee. The patient must be able to flex the knee so the arthroscope can be inserted into the joint space to allow visualization. The patient should be taught straight leg exercises and quadriceps sitting exercises before the procedure is done so these exercises can be performed by the patient after the arthroscopy, though not immediately. Likewise, the patient attends physical therapy sessions before the surgery to learn leg exercises to be performed after the procedure. The patient is usually given local, light general, or epidural anesthesia, depending upon the purpose of the procedure.
What statement related to musculoskeletal assessment is accurate?
Knowledge of a patient's occupation is helpful for musculoskeletal assessment. Knowledge of the patient's occupation is helpful for musculoskeletal assessment because occupations involving heavy labor, like mechanics and industrial workers, are prone to fractures while patients who work on computers are prone to carpel tunnel syndrome or neck pain. A 30-year-old injury can easily be responsible for current musculoskeletal problems. A motor vehicle crash may lead to osteoarthritis later in life, not osteomalacia, which results from a decrease in the body's vitamin D levels. Weight-bearing activities, such as walking, decrease the risk of osteoporosis as they maintain muscle strength.
While assessing a patient the nurse observes a widened gait and a shift in the center of gravity. What does the nurse suspect?
Kyphosis A patient with kyphosis has a widened gait and a shift in the center of gravity. This is often observed in older patients. Scoliosis is a lateral curve of the spine. This deformity is observed when the patient flexes forward from the hips. Lurch is an abnormal gait that occurs in the swing phase of walking, and often develops when muscles in the buttocks or legs are too weak to allow the change of weight from one foot to another. Lordosis is often seen in patients with abdominal obesity.
A diabetic older adult patient who had arthroscopic surgery on the right knee the previous day has a red, swollen, and painful right knee. The nurse anticipates that the health care provider will request which medication?
Levofloxacin The patient's symptoms indicate a possible right knee infection, so the first action will be to start antibiotic therapy, especially because the patient is diabetic and is at greater risk for infection. Enoxaparin is an anticoagulant that can increase the risk for postoperative bleeding; the health care provider usually requests an opioid analgesic combination following arthroscopic surgery. Oxycodone is used for more invasive surgical procedures and is not indicated for this patient. Prednisone is a glucocorticoid used to treat inflammation; it increases blood sugar and increases susceptibility to infection. Prednisone is not indicated for this patient because the patient is diabetic and is susceptible to infection.
The ambulatory surgery postanesthesia care unit (PACU) nurse has just received report about patients who had arthroscopic surgery. Which patient will the nurse plan to assess first?
Middle-aged adult patient who returned to the PACU 25 minutes ago after left knee arthroscopic surgery under epidural anesthesia After epidural anesthesia, frequent assessments for the return of sensation and movement of the leg will be important. The patient who had knee arthroscopic surgery under epidural anesthesia is at greatest risk for complications and should be assessed first. The patients who had local anesthesia for knee arthroscopy, a synovial biopsy of the right knee, and multiple right knee incisions are all at less risk for developing complications.
Which procedure does the nurse anticipate for the patient with suspected muscular dystrophy?
Muscle biopsy Muscle biopsy is done for the diagnosis of atrophy or inflammation (such as muscular dystrophy or polymyositis). Arthroscopy is done for direct visualization of the ligaments, menisci, and articular surfaces of the joints. Myelography is done to evaluate the structures of the spinal column. MRI is most appropriate for visualizing joints, soft tissue, and bony tumors that involve soft tissue.
A diabetic patient is admitted to the health care facility with a foot ulcer. The nurse teaches wound care to the patient and the caregiver to prevent the risk for which condition?
Osteomyelitis The diabetic patient with a foot ulcer is at high risk for osteomyelitis or bone infection. Diabetes also slows down the healing process. As a person ages, the cartilages at the synovial joints lose their elasticity and become compressible which leads to osteoarthritis. Joint dislocations and joint traumas also lead to osteoarthritis. Osteoporosis may occur due to age-related bone loss, or decreased intake of calcium and vitamin D. Osteomalacia or softening of the bone is caused by the deficiency of vitamin D in the body.
Which patient information is most essential for the nurse to report to the health care provider before a patient with knee pain undergoes magnetic resonance imaging (MRI)?
Presence of a permanent pacemaker Having a permanent pacemaker is a contraindication for MRI because metallic implants are present within the patient. Taking a daily dose of aspirin does not affect or interact with the MRI test. A swollen and tender knee does not warrant cancellation of an MRI. A history of claustrophobia will be reported, but does not indicate that cancellation of the MRI is necessary because sedatives can be given to manage claustrophobia.
The nurse is assessing a patient to evaluate the movements of the wrist. What movement does the nurse assess?
Pronation and supination Pronation and supination is used to determine the movements of the wrist. The patient's neck is assessed by rotating the head and determining the ease and extent with which the patient performs the rotation. Eversion and inversion is used to assess the movements of the feet from the ankle joint. Circumduction is used to evaluate the movements of the shoulder; the patient is asked to move the arm in circles from the shoulder joint.
A patient reports muscle weakness in the lower extremities. What factors are important for the nurse to assess to promote safety? Select all that apply.
Risk for fall and injury Abnormality in gait Need for ambulatory devices A patient with a muscle weakness in the lower extremities is at increased risk for fall and injury, abnormality in gait, and may need ambulatory devices. The patient is unable to bear weight and maintain balance so the risk for fall and injury is increased. Painful legs or weak muscles in the buttocks or leg cause abnormality in gait; the patient finds it difficult to walk without assistance and often needs ambulatory devices. Patients with weakness in the upper extremities have difficulty in performing ADLs. The patient with spinal deformities has difficulty in maintaining good posture.
The nurse assessing a patient for spinal alignment observes a lateral curve of the spine. How does the nurse document this finding?
Scoliosis Scoliosis is a lateral curve of the spine; this deformity is assessed when the patient flexes forward from the hips. Lurch is an abnormal gait that occurs in the swing phase of walking; this develops when the muscles in the buttocks or legs are too weak to allow the change of weight from one foot to another. Lordosis is seen in patients with abdominal obesity. A patient with kyphotic posture has a widened gait and a shift in the center of gravity; this is often observed in older patients.
Which aspect of a musculoskeletal assessment will the physical therapist and the nurse plan to collaborate on?
The need for ambulatory devices The nurse and the physical therapist assess and collaborate on the need for ambulatory devices. It is the nurse's responsibility to assess which medications the patient is currently taking. Nutritional assessment is performed by the nurse, but this might also involve a dietitian if special needs exist. The nurse assesses the patient for all present medical conditions.
Which statement about the blood supply and nerve fibers of bone is accurate?
Very few nerve fibers are connected to the bone. Very few nerve fibers are connected to bone. Each bone has a main nutrient artery which enters near the middle of the shaft. It branches into ascending and descending vessels that supply the cortex, marrow, and the haversian system. Sympathetic nerve fibers in the bone control the dilation of blood vessels.
What does the nurse teach a patient with osteomalacia to include in the daily diet?
Vitamin D Osteomalacia causes softening of the bone due to the decrease in vitamin D in the body. The patient with osteomalacia should include vitamin D in the diet because it promotes the absorption of calcium and phosphorus from the small intestine. The bone accounts for 99% of the calcium and 90% of the phosphorus in the body. As the serum calcium levels rise, the serum phosphorus levels decrease. Calcitonin produced by the thyroid gland decreases the serum calcium concentration if it increases above its normal level; it inhibits the bone resorption and increases the renal excretion of calcium and phosphorus. It is not necessary for the nurse to instruct the patient to include vitamin A in the diet.
The nurse is completing an admission assessment on a patient 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 Swelling, heat, and redness may indicate infection in the knee joint, which would indicate a need to cancel the procedure. Having knee pain before surgery is not unexpected but will not affect whether the patient will have surgery. Allergy to shellfish and iodine will need to be reported, but also will not affect whether the patient will have surgery. Having previous surgery on the other knee does not preclude the patient from having this surgery.
