NUR 201 PrepU ch. 21
A previously healthy 64-year-old man has been recently diagnosed with osteoarthritis. The client is motivated to maintain his quality of life and slow the progression of his new health problem. What advice can the nurse provide for the client in his efforts to minimize the effects and progression of osteoarthritis?
"It is important for you to maintain a healthy body weight" explanation: Maintaining a healthy body weight can slow the progression of OA. The disease is not significantly affected by calcium and vitamin D intake. While it is a common accompaniment to aging, there are still tangible actions that clients can take to slow the progression.
When assessing a patient's foot, how would the nurse document an exaggerated arch height?
"Patient has pes cavus." explanation: Pes cavus is an exaggerated arch height.
During the health history of the musculoskeletal system, the client reports having low back pain that radiates into the leg with numbness and tingling. The nurse should further assess for spinal stenosis when the client makes which of the following statements?
"The pain improves when I am leaning over a shopping cart" explanation: Radiating leg pain with numbness and tingling are common low back pain symptoms. Pain due to spinal stenosis is relieved when the client is in a flexed position, such as when leaning over a shopping cart. Leg pain that resolves with forward flexion suggests spinal stenosis. Because pain from spinal stenosis is due to spinal compression, exercise may actually exacerbate pain caused by this condition. Coughing, sneezing and bearing down, such as when the client is sitting to have a bowel movement would also serve to increase pain associated with spinal stenosis.
The nurse is preparing to perform a musculoskeletal examination on an adult client. The nurse has explained the examination procedure to the client. The nurse determines that the client needs further instructions when the client says
"You'll continue with range of motion even if I have discomfort." explanation: Do not force the part beyond its normal range. Stop passive motion if the client expresses discomfort or pain. Be especially cautious with the older client when testing ROM. When comparing bilateral strength, keep in mind that the client's dominant side will tend to be the stronger side.
How many vertebrae make up the spinal column?
33 explanation: The spine is a column of 33 vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3 to 4 coccygeal.
Assessment reveals that a client has slight weakness with active range of motion against some resistance. The nurse would document this as which of the following?
4/5 explanation: 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.
After completing the musculoskeletal health history, the nurse determines that a client is at risk for osteoporosis. Which of the following risk factors were most likely identified in this client?(Select all that apply.)
Age 65 Current smoker Sedentary lifestyle Alcohol intake four drinks per day explanation: Risk factors for the development of osteoporosis include age over 50 years, current smoker, sedentary lifestyle, and higher than the daily recommended allowance of alcohol intake. Body weight less than 70 kg or 154 pounds increases the client's risk for osteoporosis.
A nurse is working with a client who has cervical disc degenerative disease with resulting impaired range of motion and pain that radiates to the back. The nurse understands that joints between the vertebrae are which type of joint?
Cartilaginous explanation: Fibrous joints (e.g., sutures between skull bones) are joined by fibrous connective tissue and are immovable. Cartilaginous joints (e.g., joints between vertebrae) are joined by cartilage. Synovial joints (e.g., shoulders, wrists, hips, knees, ankles) contain a space between the bones that is filled with synovial fluid, a lubricant that promotes a sliding movement of the ends of the bones. Compact is a type of bone, not a type of joint.
A client is being discharged home from the hospital. This client has a history of falling at home. A caregiver is not able to stay with the client all the time. What can be done to decrease the risk for falling at the client's home? Select all that apply.
Correct environmental hazards in the home Install grab bars in the bathroom Make sure house hallways are well lit explanation: Clients should correct environmental hazards such as slippery surfaces, uneven floors, poor lighting on stairs, loose rugs, unstable furniture, and objects on floors. The nurse can recommend installation of grab bars in restrooms for clients with poor balance. Participation in physical therapy might help clients with gait and balance problems, but the nurse cannot implement this intervention independently.
Upon examination of an elderly client, the nurse finds hard, painless nodules over the distal interphalangeal joints. What is the appropriate term the nurse should use to document this finding in the client's medical records?
Herberden's nodes
A community health nurse is providing education to help reduce musculoskeletal injuries in adults. What should the nurse include in these instructions? (Select all that apply.)
Importance of regular exercise Maintaining a body weight appropriate to height and frame Using proper body mechanics with lifting objects Maintaining a safe home environment explanation: Health promotion topics to prevent musculoskeletal injuries include engaging in regular exercise, maintaining a body weight appropriate to height and frame, using proper body mechanics with lifting or moving objects, and maintaining a safe home environment. Clients should not be told to limit dairy intake because this is a source of dietary calcium. Having the recommended daily intake of calcium can prevent risk factors for osteoporosis, therefore, musculoskeletal injuries.
Which finding in an elderly client requires additional assessment by a nurse when inspecting the musculoskeletal system?
Inability to button the jacket due to swollen finger joints explanation: With aging, the joints and muscles lose their flexibility and bones loose their density. Therefore, the elderly client is at risk for joint stiffening, muscle atrophy, and fractures. Swelling of the joints may indicate an inflammatory process is occurring and this needs to be further assessed by the nurse. When muscle loss is symmetrical it is generally due to the normal aging process. A slow and steady gait assists the elderly client to maintain balance. Kyphosis is a normal finding in the elderly client.
A client expresses to the nurse that he has a "giving in" or "locking" sensation in the knee. Which test should the nurse perform to elicit related findings of a possible tear in the meniscus of the client's knee?
McMurray's explanation: The nurse should perform McMurray's test to confirm meniscal tear. Pain or clicking during the test is indicative of a torn meniscus of the knee. The Ballottement test and the Bulge test are done to detect the presence of fluid in the knee joint. Phalen's test is done to test carpal tunnel syndrome.
Pain, swelling, loss of both active and passive motion, locking, and deformity would be consistent with which of the following?
articular joint pain explanation: These features are consistent with articular joint pain, whereas the other problems are associated with nonarticular structures.
When testing muscle strength, a client has difficulty moving her right arm against resistance. What would the nurse to do next?
ask the client to move the part against gravity explanation: 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.
A nurse performs a nudge test to assess the gait of a client with Parkinson's disease. Which action by the nurse demonstrates the correct technique for performing this test? The nurse should stand:
at the back of the client and nudge the sternum
While assessing the elbow of an adult client, the client complains of pain and swelling. The nurse should further assess the client for
arthritis explanation: Redness, heat, and swelling may be seen with bursitis of the olecranon process due to trauma or arthritis.
A nurse is caring for a client who is recovering from a stroke. The nurse assesses the muscle strength of the client's arm and finds that the joint exhibits active motion against gravity. Which of the following should the nurse document to classify muscle strength based on this finding?
average weakness explanation: The nurse should document the finding as average weakness of the arm muscles. In passive range of motion (ROM), gravity is removed and the client performs ROM with assistance; in this case, the strength is classified as poor ROM. When the client is able to perform the active motion against some resistance, it is classified as slight weakness. If the client has only a slight flicker of contraction, muscle strength is classified as severe weakness.
A client complains of chronic pain and fatigue. The nurse suspects fibromyalgia. What is a diagnosis of this condition based on?
client symptoms explanation: Fibromyalgia, manifested by chronic pain and fatigue, affects about 5 million Americans. Diagnosis is made based on a person's symptoms as no there are no objective findings on X-rays or lab tests or range of motion tests. Persistent pain and fatigue interferes with the client's activities of daily living.
The nurse is assessing an adolescent client and notes 45-degree flexion of the cervical spine. What is the nurse's most appropriate action?
continue the exam because the curve is normal explanation: Normal flexion of the cervical spine is 45 degrees. Since the finding is normal, further assessment or referral would be unnecessary.
When assessing the gait pattern of a client diagnosed with Alzheimer disease, the nurse should expect to observe which finding?
difficulty initiating a slow, shuffling gait explanation: Apraxic gait occurs when the client has difficulty initiating walking, then exhibits a slow, shuffling gait. It is often seen in clients with Alzheimer disease. Footdrop or steppage, raising the leg high when walking, occurs with nerve injuries or damage to spinal nerve roots. Limping is indicative of short leg gait. A waddling gait is often seen with hip dysplasia or muscular dystrophy.
The nurse is examining an older adult client. During the physical assessment, the client appears to be getting fatigued. What can the nurse do to help the client finish the assessment?
divide the assessment into portions explanation:
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?
external rotation explanation: 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.
Bones in synovial joints are joined together by
ligaments explanation: Bones in synovial joints are joined by ligaments, which are strong, dense bands of fibrous connective tissue.
When inspecting a client's feet, the nurse observes that the toes point inward. The nurse documents this finding as which of the following?
pes varus explanation: 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 is conducting a physical examination of the musculoskeletal system of a client who reports having joint pain. Which signs indicate there is inflammation in the joints? Select all that apply.
swelling warmth redness tenderness explanation: Swelling is palpable and involves the synovial membrane of the joints. The nurse should assess to note if the area surrounding the joints feels boggy and doughy. Nearby tissues of joints may feel warm to touch; heat is always generated as a result of the inflammation process. Redness is less common, but if present it is also a sign of inflammation around a joint. Due to pressure from swelling of the tissues surrounding affected joints, inflammation causes tenderness and is painful to touch. Subcutaneous nodules are extra-articular lesions associated with rheumatoid arthritis and is not one of the four signs of inflammation commonly seen in the tissues surrounding joints.
Skeletal muscles are attached to bones by
tendons explanation: Skeletal muscles attach to bones by way of strong, fibrous cords called tendons.
The nurse suspects carpal tunnel syndrome after examining a patient in the clinic. A test result that would suggest this diagnosis would be
weak opposition of the thumb explanation: If the client cannot raise the thumb up from the plane and stretch the thumb pad to the little finger pad, this indicates thumb weakness in carpal tunnel syndrome.
During the history, a young adult woman tells the nurse, "My mother has osteoporosis. What can I do to help reduce my risk?" Which response by the nurse would be most appropriate?
"Try to avoid drinking too much coffee or other caffeinated fluids. explanation: To reduce the risk of osteoporosis, the nurse would instruct the client to avoid excessive caffeine or alcohol consumption; increase physical exercise or activity, especially weight-bearing activities; increase calcium intake to approximately 1000 to 1500 mg daily; and get adequate vitamin D to absorb calcium such as with sun exposure.
The nurse is assessing an older adult with new onset dementia. The nurse is using the Morse Fall Scale; the client's score is 63. What does this tell the nurse?
the client is at high risk for falling explanation: A score of 63 on the Morse Fall Scale represents a high risk for falling. Restraints are used only as a last possible resort in cases where the client poses a risk of violent harm to self or others. Restraints usually have serious legal ramifications and would not be appropriate for consideration in this situation.
Sarah presents with left lateral knee pain and has some locking in full extension. There is tenderness over the medial joint line. When the knee is extended with the foot externally rotated and some valgus stress is applied, a click is noted. What is the most likely diagnosis?
torn medial meniscus explanation: This maneuvre is called McMurray's test. Along with the medial joint line tenderness, the nurse should suspect a medial meniscus injury. Cruciate ligament tears should cause an anterior or posterior "drawer sign." Although we can't rule out a lateral meniscus tear, the tenderness along the medial joint line makes this the more likely site of injury.
A nurse is providing health education about osteoporosis to a community group. What ethnicity is considered to be an independent risk factor for osteoporosis?
Caucasian explanation: Caucasian ethnicity is a risk factor for osteoporosis. This is not true of the other listed ethnicities.
A nurse is caring for a client who is recovering from a stroke. The nurse assesses the muscle strength of the client's arm and finds that the joint exhibits active motion against gravity. Which of the following should the nurse document to classify the muscle strength based on this finding?
average weakness explanation: The nurse should document the finding as average weakness of the arm muscles. When there is passive range of motion (ROM), the gravity is removed, and the client performs ROM with assistance, the strength is classified as poor ROM. When the client is able to perform the active motion against some resistance, it is classified as slight weakness. If the client has a slight flicker of contraction, the muscle strength is classified as having severe weakness.
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?
ballotment test explanation: The ballottement test is used to detect large amounts of fluid in the knee. Phalen's test and Tinel's test would be used to assess for carpal tunnel syndrome. Lasegue's test is used to detect low back pain.
When assessing the client's upper extremities, the nurse instructs the client to put the hands behind the neck with the elbows pointed laterally. This positioning facilitates assessment of which of the following functions?
external rotation of the shoulder explanation: Pointing the elbows laterally tests the shoulder's ability to rotate externally and abduct.
While reviewing a client's chart before seeing the client for the first time, the nurse notes that the client has a diagnosis of Dupuytren contracture. The nurse anticipates that the client will exhibit
inability to extend ring and little finger explanation: Inability to extend the ring and little fingers is seen in Dupuytren's contracture.
A client visits the clinic and tells the nurse that after playing softball yesterday, he thinks his knee is "locking up." The nurse should perform the McMurray test by asking the client to
flex the knee and hip while in supine position explanation: If the client complains of a "giving in" or "locking" of the knee, perform McMurray's test. With the client in the supine position, ask the client to flex one knee and hip. Then place your thumb and index finger of one hand on either side of the knee. Use your other hand to hold the heel of the foot up. Rotate the lower leg and foot laterally. Slowly extend the knee, noting pain or clicking. Repeat, rotating lower leg and foot medially. Again, note pain or clicking.
The nurse asks the client to perform the action shown. What is the nurse assessing?
flexion explanation: Bending forward to touch the toes assesses for spinal flexion. Twisting the spine from side to side assesses for spinal rotation. Bending the back as far as possible assesses spinal extension. Bending to the side from the waist assesses for lateral flexion.
A nurse inspects a child's legs with the child standing and notices that the knees turn inward. How should this finding be documented in the medical record?
genu valgum explanation: The inward turning of the knees is called knock knees or genu valgum. Genu varum is the outward turning or the knees or bowed legs. Ballottement is a knee test used to assess for the presence of large amounts of fluid in the knee.
When the client performs straight leg flexion, the client complains of pain that radiates down his leg. The nurse understands that this may indicate what?
herniated disc explanation: Straight leg flexion that produces back and leg pain radiating down the leg may indicate a herniated disc. One leg longer than the other may indicate a hip fracture. Arthritis is accompanied by pain and stiffness. Asymmetry, discomfort when touched, or crepitus during movement may occur with degenerative joint disease.
A nurse is preparing a program on osteoporosis for a local women's group. What would the nurse cite as a risk factor?
history of smoking explanation: Smoking is a risk factor for osteoporosis. Obesity, multiparity, and African-American ethnicity are not noted risk factors for this disease.
Mary started a job 2 weeks ago that requires carrying heavy buckets. She presents with elbow pain worse on the right. On examination, it hurts her elbows to dorsiflex her hands against resistance when her palms face the floor. What condition does she have?
lateral epicondylitis (tennis elbow) explanation: Mary's injury probably occurred by lifting heavy buckets with her palms down (toward the bucket). This caused her chronic overuse injury at the lateral epicondyle. Medial epicondylitis has reproducible pain when palmar flexion against resistance is performed and also features tenderness over the involved epicondyle. Olecranon bursitis produces erythema and swelling over the olecranon process. A supracondylar fracture of the humerus is a major injury and would present more acutely.
A nurse notices that a client's flexibility of the right elbow is less than the left elbow. What is an appropriate action by the nurse in regard to this finding?
measure movement with a goniometer explanation: If the nurse identifies a limitation in the range of motion for a joint, a goniometer should be used to measure the exact angle of movement present. The goniometer is placed at the joint and then moved to match the angle of the joint being assessed. It is not necessary to notify the health care provider until all information is collected. The hand grips test strength not range of motion. The dominant side of the body is stronger but does not necessarily have greater range of motion.
The nurse notes limitation in active range of motion of a client's right shoulder. What would the nurse to do next?
measure the range of motion with a goniometer explanation: 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.
The nurse is planning a presentation on osteoporosis to a group of high school students. Which of the following should the nurse plan to include in the presentation?
moderate strenuous exercise tends to increase bone density explanation: Regular exercise promotes flexibility, bone density, and muscle tone and strength. It can also help to slow the usual musculoskeletal changes (progressive loss of total bone mass and degeneration of skeletal muscle fibers) that occur with aging.
Put the following scale in order from 0 to 6 for grading muscle strength.
no muscular contraction detected barely detectable flicker or trace of contraction active movement of body part with gravity eliminated active movement against gravity active movement against gravity and some resistance active movement against gravity with full resistance and no evident fatigue
While sitting a client raises both legs while the nurse holds the lower legs below the knee. What does this finding indicate?
normal quadriceps muscle strength explanation: An active movement against full resistance without evidence of fatigue is considered normal muscle strength. If the client is unable to keep the opposite leg extended, when one leg is flexed, it suggests a flexion deformity of the opposite leg's hip. Symmetric weakness of the proximal muscles suggests a myopathy or muscle disorder. Symmetric weakness of distal muscles suggests a polyneuropathy, or disorder of peripheral nerves.
A nurse has just performed the test for Allis' sign on a newborn; the result is positive. What did the nurse observe while performing this test?
one knee is lower than the other explanation: The examiner tests for Allis' sign by placing the infant supine with flexed hips and knees and both feet flat on the table. A negative Allis' sign is when the knees are at equal heights. A positive Allis' sign is when one knee is lower than the other, indicating hip dysplasia. In the Barlow-Ortolani maneuver, the infant is supine with flexed knees and hips so that the heels touch the buttocks. The examiner places his or her fingers on the baby's greater trochanter of the humerus and adducts the legs, moving the knees down and laterally. This maneuver is negative when the movement is smooth, with no clicking sound. If a clicking sound is audible, the maneuver is considered a positive indication of hip dislocation.
The client is complaining that his lower joints are increasingly painful as the day progresses. The nurse suspects the client is experiencing what musculoskeletal disorder?
osteoarthritis explanation: Osteoarthritis is characterized by pain with motion that increases throughout the day. Rheumatoid arthritis discomfort decreases with motion. A bone fraction causes a sharp, knife-lie pain. Chronic pain and fatigue is a symptom of fibromyalgia.
The client presents at the clinic with a history of cerebral palsy. When examining the patient the nurse notes increased resistance that is rate dependent and increases with rapid movement. What would the nurse chart about this patient?
patient demonstrates spasticity explanation: Spasticity is increased resistance that worsens at the extremes of range. Spasticity, seen in central corticospinal tract diseases, is rate dependent, increasing with rapid movement.
A patient has been admitted to a medical unit. The nurse notes that the patient has irregular, uncoordinated movements. How would the nurse document this finding?
patient shows signs of ataxia explanation: Ataxia (irregular uncoordinated movements) or loss of balance may be due to cerebellar disorders, Parkinson disease, multiple sclerosis, strokes, brain tumors, inner ear problems, or medications.
Which action by a nurse is a correct method for performing the Tinel's test to determine the presence of carpel tunnel syndrome?
percuss lightly on the inner aspects of the wrists explanation: The nurse should tap at the inner aspect of the wrist to percuss the median nerve because the median nerve is located at the inner aspect of the wrist where it enters the carpal canal. Palpation of the hollow area on the back of the wrist is done to examine the anatomic snuffbox. Asking the client to bend the wrist down and back and performing wrist movements against resistance are done to assess range of motion and muscle strength.
A client receives physical therapy for carpal tunnel syndrome. Which action by the nurse is appropriate to assess the efficacy of the treatment?
place the backs of both hands against each other explanation: The nurse should ask the client to place the backs of both hands against each other while flexing the wrist 90 degrees downwards for 60 seconds for the Phalen's test. If therapy for carpal tunnel syndrome has not been successful, the client may report tingling, numbness, and pain after holding the position for 60 seconds. The client need not flex the wrists 90 degrees upward for 90 seconds. The nurse asks the client to bend the wrists down and back to test the client's range of motion for the wrist.
A 55-year-old woman with a history of type 2 diabetes went through menarche at age 19 and menopause 2 years ago. Which of the preceding is a risk factor for osteoporosis?
postmenopausal status explanation: Diabetes, late menopause, and late menarche are not associated with osteoporosis. Postmenopausal status is the only choice that is a known risk factor for osteoporosis.
A client visits the health care facility with reports of lumbar back pain that radiates down the back. The nurse performs Lasègue's test to determine the origin of the pain. Which techniques should the nurse use to perform Lasègue's test?
raise the leg to the point of pain and dorsiflextion of the foot explanation: To perform the Lasègue's test, the nurse should raise the client's leg to the point of pain and dorsiflex the foot to check for a herniated nucleus pulposus(vertebral disk). Asking the client to bend forward and touch the toes facilitates assessment of range of motion of the lumbar spine. Asking the client to touch the chin to the chest evaluates range of motion of the cervical spine. The spinous processes and the paravertebral muscles on both sides of the spine are palpated for tenderness and pain and are not a part of Lasègue's test.
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?
red marrow explanation: 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 centers of the bone.
A client is unable to externally rotate the left shoulder. What health problem should the nurse suspect is occurring with this client?
rotator cuff explanation: In a complete tear of the supraspinatus tendon, or a rotator cuff tear, active abduction and forward flexion at the glenohumeral joint are severely impaired, producing a characteristic shrugging of the shoulder and a positive "drop arm" test. Rotator cuff tendonitis is characterized by acute, recurrent, or chronic pain of the supraspinatus tendon. Carpal tunnel syndrome effects the wrist and not the shoulder. Anterior dislocation of the humerus is characterized by the shoulder seeming to slip out of the joint.
Into which of the following positions should the client be placed for the nurse to effectively examine the tibiofemoral joint of the knee?
sitting with knees in flexion explanation: To examine the tibiofemoral joint of the knee, the nurse should ask the client to sit on the edge of the examining table with the knees flexed. The supine position is used to assess muscle strength. The prone position with soles facing up is not the correct position for assessing this joint. The standing position is used to assess knee alignment and contours but should be used with the client standing up straight.
The nurse is going to test range of motion in a patient. To test extension of the triceps muscle, the nurse would instruct the patient to
straighten the elbow explanation: The client should have full range of motion.
The nurse is assessing a client with joint pain and is trying to decide whether it is inflammatory or non-inflammatory. Which of the following symptoms is consistent with an inflammatory process?
tenderness explanation: Tenderness implies an inflammatory process along with increased temperature. Nodules and ecchymosis are not typically associated with inflammatory processes.
Assessment of a client's ankle joint includes palpation along the Achilles tendon to look for which of the following?
tenderness and nodules explanation: Palpation of the Achilles tendon involves assessing for tenderness or nodules. Strength and flexibility are not assessed during palpation, and calluses and bogginess are not typically associated with the Achilles tendon.