NUR 3065 CH 18 PrepU
When assessing muscle tone and strength, the nurse would document expected findings as "upper extremity muscle strength is 5/5 bilaterally" "extremity muscle strength is 5/5 bilaterally" "upper and lower extremity muscle strength is 5/5" "upper and lower extremity muscle strength is 5/5 bilaterally"
"upper and lower extremity muscle strength is 5/5 bilaterally"
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 3/5 5/5 2/5
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.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.
How would the nurse document normal muscle strength? 2 & 2 4+ 5/5 1:1
5/5 Explanation: Scale for grading muscle strength: muscle strength is graded on a 0 to 5 scale: 0: No muscular contraction detected 1: A barely detectable flicker or trace of contraction 2: Active movement of the body part with gravity eliminated 3: Active movement against gravity 4: Active movement against gravity and some resistance 5: Active movement against full resistance without evident fatigue. This is normal muscle strength.
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 69-year-old woman with no major risk factors for osteoporosis A 37-year-old woman who takes oral contraceptives A 71-year-old man who has type 2 diabetes A 49-year-old African-American woman who is obese
A 69-year-old woman with no major risk factors for osteoporosis
Pain, swelling, loss of both active and passive motion, locking, and deformity would be consistent with which of the following? Muscular injury Bursitis Nerve damage Articular joint pain
Articular joint pain Explanation: These features are consistent with articular joint pain, whereas the other problems are associated with nonarticular structures.
A client visits the health care facility with reports of lumbar back pain that radiates down the back. The nurse performs the straight leg test to determine the origin of the pain. Which techniques should the nurse use to perform this test? Instruct the client to bend forward and touch the toes Palpate the spinous processes and the paravertebral muscles Instruct the client to touch the chin to the chest Ask the client to raise the leg to the point of pain and then dorsiflex the foot
Ask the client to raise the leg to the point of pain and then dorsiflex the foot Explanation: To perform the straight leg test, the nurse should ask the client to raise the client's leg to the point of pain and then dorsiflex the foot to check for a herniated nucleus pulposus. 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 the straight leg test.
The nurse is assessing a client who presents with shoulder pain. No signs of inflammation are present. What is the nurse's priority action? Administer prescribed pain medication. Notify the healthcare provider immediately. Check for passive range of motion. Assess for shortness of breath.
Assess for shortness of breath. Explanation: Suspect a cardiac origin for reports of shoulder pain without tenderness or inflammation. Assess for shortness of breath, nausea, and diaphoresis. If these symptoms are present, the client needs to be sent to an emergency department for assessment of cardiac ischemia. Cardiac ischemia is an emergency; therefore assessing for shortness of breath is priority. If present, then the nurse should notify the healthcare provider. Passive range of motion is not as relevant as shortness of breath. Pain medication cannot be administered without a prescription.
The nurse is preparing to palpate the anatomic snuffbox. At which location would the nurse palpate? At the anterior area of the sternoclavicular joint At the posterior temporomandibular joint At the olecranon process of the elbow At the back of the wrist and extended thumb
At the back of the wrist and extended thumb Explanation: 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.
Which nutrient deficiency should a nurse recognize as placing a client at risk for osteoporosis? Protein Vitamin D Calcium Vitamin C
Calcium Explanation: A calcium deficiency increases the risk osteoporosis. This causes the bones to become softer in nature because the rate at which bone is destroyed is occurring at a faster rate than new bone is made. Protein functions in muscle tone and growth. Vitamin C promotes healing of tissues and bones. Vitamin D deficiency causes osteomalacia, softening of the bones due to defective bone mineralization. Osteomalacia in children is known as rickets.
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? Gouty arthritis Carpal tunnel syndrome Diabetic neuropathy Osteoarthritis
Carpal tunnel syndrome Explanation: The nurse has performed Phalen's test, which assesses for carpal tunnel syndrome. A positive result is not suggestive of neuropathy, osteoarthritis, or gouty arthritis.
The nurse asks the client to perform the action shown. What is the nurse assessing? **pic of a man facing forward and put his hands together (like upside down prayer) but with the back of the hands touching each other** Elbow range of motion Shoulder strength Carpal tunnel syndrome Hand grasp strength
Carpal tunnel syndrome Explanation: This maneuver is the Phalen test which assesses for carpal tunnel syndrome. The client flexes the wrists 90 degrees and holds the backs of the hands together for 60 seconds. Positive signs include numbness, burning, or pain. This maneuver is not done to test for shoulder or hand grasp strength or to assess for elbow range of motion
A nurse is providing health education about osteoporosis to a community group. What ethnicity is considered to be an independent risk factor for osteoporosis? African American Caucasian South Asian Native American
Caucasian Explanation: Caucasian ethnicity is a risk factor for osteoporosis. This is not true of the other listed ethnicities.
A 50-year-old realtor comes to the office for evaluation of neck pain. She was in a motor vehicle collision 2 days ago and was assessed by the emergency medical technicians on site, but she didn't think that she needed to go to the emergency room at that time. Now, she has severe pain and stiffness in her neck. On physical examination, the nurse notes pain and spasm over the paraspinous muscles on the left side of the neck, and pain when the client does active range of motion of the cervical spine. What is the most likely cause of this neck pain? Simple stiff neck Cervical herniated disc Cervical sprain Aching neck
Cervical sprain Explanation: The client most likely has an acute whiplash injury secondary to the collision. The features of the physical examination, local tenderness and pain on movement, are consistent with cervical sprain.
A client presents to the health care clinic with reports of onset of neck pain three (3) days ago. The nurse recognizes that the most common cause of neck pain is what condition? Compression fractures Cervical spinal cord compression Cervical strain Cervical disc degenerative disease
Cervical strain Explanation: The most common cause of neck pain is cervical strain. This can occur from sleeping in the wrong position, carrying a heavy load, or being in an automobile accident. Cervical disc degenerative disease is associated with impaired range of motion and pain that radiates to the back, shoulders, or arms. Cervical spinal cord compression causes neck pain with loss of sensation in the legs. Compression fractures of the neck may also cause loss of sensation in the legs if the spinal cord becomes compressed.
A client complains of chronic pain and fatigue. The nurse suspects fibromyalgia. What is a diagnosis of this condition based on? Client's symptoms Range of motion tests X-rays Lab tests
Client's 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.
A nurse notices that a client has decreased range of motion with lateral bending of the cervical spine to the left side. What should the nurse do next in relation to this finding? Finish with the assessment of the cervical spine before documenting Ask the client about previous injuries to the head and neck Notify the health care provider for further orders Compare this finding to the range of motion to the right side
Compare this finding to the range of motion to the right side Explanation: It is always important to compare both sides of the body for symmetry before making a judgment that data is abnormal. The nurse should then ask the client about previous injuries to the head and neck. All data must be properly documented in the client's record. If this finding is abnormal, the nurse should alert the health care provider for further orders.
A client comes to the clinic and reports a sore knee. The nurse notes popping and cracking noises when the client attempts to bend the knee. The client exhibits signs of pain by facial expression. The nurse knows that the popping and cracking noises should be charted as what? Tactile emphysema Grating noise Popping and cracking noises Crepitus
Crepitus Explanation: Crepitus may be heard as a popping sound and may be felt as grating in the joint as it moves. The other options are incorrect since they are not considered medical terms that describe the assessment findings.
A nurse asks a client to bring his hands together behind his head with his elbows flexed. What is the nurse testing? Internal rotation Abduction External rotation Adduction
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.
What would the nurse expect to find when examining a client with a herniated lumbar disc? Rounded thoracic convexity Flattened lumbar curve Lateral curvature of the spine Lumbar lordosis
Flattened lumbar curve Explanation: 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.
What range of motion is the nurse testing by asking a client to stoop to pick an object off the floor? Flexion Rotation Extension Abduction
Flexion Explanation: Stooping is another term for bending. The client must be able to flex the thoracic and lumbar spines and flex the knees. Extension is straightening the extremity at the joint and increasing the angle of the joint. Abduction is moving away from the midline of the body. Rotation is turning the head to the right and then the left.
Which movement should the nurse instruct the client to perform to assess range of motion for the knee? Flexion Abduction Circumduction Rotation
Flexion Explanation: The nurse should instruct the client to perform flexion to assess the range of motion for the client's knee. Circumduction, rotation, and abduction movements are not possible in the knees. Circumduction is the circular motion of the joint. Rotation involves turning the head to the right shoulder then back to midline and then turning the head to the left shoulder then back to midline. Abduction refers to moving away from the midline of the body. The knees are capable of performing only flexion and extension.
An 85-year-old retired housewife comes with her daughter to establish care. Her daughter is concerned because the client has experienced frequent falls in recent months. As part of the physical examination, the nurse asks the client to walk across the examination room. Which of the following is not part of the stance phase of gait? Foot arched Heel strike Mid-stance Push-off
Foot arched Explanation: The foot when it is flat is part of the stance phase of gait, not the foot when it is arched. The heel-strike, mid-stance and push-off are components of the stance phase of the client's gait.
The nurse is assessing the range of motion (ROM) of a client's joints. What would the nurse use to assess flexion and extension of a joint if the client complains of pain on examination? Calibrator Goniometer Angulator Scoliometer
Goniometer Explanation: If ROM is limited, use a goniometer to measure the angle of the joint at its maximum flexion and extension.
Assessment of the musculoskeletal system usually proceeds from general to specific and from? Right to left Head to toe Anterior to posterior Bottom to top
Head to toe Explanation: As with other systems, assessment of the musculoskeletal system usually proceeds from general to specific and from head to toe. Focused assessments may be more appropriate when the client reports an injury to a specific area or joint.
The nurse notes that a client has limited range of motion of the spine and the lumbar curvature is flattened. On which health problem should the nurse focus during the remainder of this assessment? Select all that apply. Pregnancy Ankylosing spondylitis Scoliosis Herniated lumbar disc Obesity
Herniated lumbar disc Ankylosing spondylitis Explanation: A flattened lumbar curvature may be seen with a herniated lumbar disc or ankylosing spondylitis. An exaggerated lumbar curve is often seen in pregnancy or obesity. Lateral curvature of the thoracic spine is seen in scoliosis.
A client presents to the health care clinic with reports of pain in the hands and right wrist. Additional history reveals that the client is a factory worker who spends all day performing the same repetitive task. The nurse performs Phalen's test and Tinel's test with positive results. The hand grips are unequal, with the right weaker than the left. What nursing diagnosis can the nurse confirm from this data? Risk for Trauma Activity Intolerance Impaired Physical Mobility Disturbed Body Image
Impaired Physical Mobility Explanation: This client is likely experiencing carpal tunnel syndrome because of the repetitive hand movements that inflame the median nerve as it passes through the wrist. Impaired Physical Mobility related to decreased muscle strength as evidenced by a weak right hand grip meets the major criteria to confirm this nursing diagnosis. Risk for Trauma cannot be confirmed because the client already has carpal tunnel syndrome so he is not at risk. Disturbed Body Image and Activity Intolerance do not meet any major defining characteristics to confirm these nursing diagnoses.
A school age client has been diagnosed with genu valgum. What is the other name for this disease? Clubfoot Knock kneed Flatfeet Bowlegs
Knock kneed Explanation: Many children have a temporary period of genu valgum, but persistent knock knee may be genetic or the result of metabolic bone disease. The client may need to swing each leg outward while walking to prevent striking the planted limb with the moving limb. The strain on the knee frequently causes anterior and medial knee pain. Physical therapy and surgical intervention may be required. Bowlegs, also known as genu varum, the knees do not touch when the child stands with the feet together. Bowlegs is consider normal up to the age of 2 to 3 years, but may persist until age 6. Clubfoot, also known as congenital talipes equinovarus (CTEV), is a congenital deformity that rotates the foot internally at the ankle. Flatfeet, a deformity of the foot where the arch collapses or never properly forms.
The nurse is assessing an elderly client and finds an exaggerated thoracic curve. This would be documented as what? Scoliosis Lordosis Ankylosing spondylitis Kyphosis
Kyphosis Explanation: Kyphosis is an exaggerated thoracic curve and is common with aging. Scoliosis is lateral curvature of the thoracic spine with an increase in the convexity on the curved side. An exaggerated lumbar curve is lordosis. Ankylosing spondylitis is associated with a flattening of the lumbar curvature.
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? Olecranon bursitis Supracondylar fracture Lateral epicondylitis (tennis elbow) Medial epicondylitis (golfer's elbow)
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 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 Bulge Phalen's Ballottement
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 for carpal tunnel syndrome.
A nurse obtains an order to measure a client's leg length. How should a nurse correctly implement this order? Assess from the umbilicus to the knee then from the knee to the heel Place the tape on the iliac crest and measure down to the heel Ask the client to stand up straight and measure from the iliac crest to the floor Measure from the anterior superior iliac spine to the medial malleolus
Measure from the anterior superior iliac spine to the medial malleolus Explanation: To correctly measure leg length, ask the client to lie with legs extended. With a tape measure, measure the distance between the anterior superior iliac spine and the medial malleolus, crossing the tape on the medial side of the knee.
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? Bone density in the Asian population is higher than in the white population. Moderate strenuous exercise tends to increase bone density. Bone density rises to a peak at age 50 for both sexes. Approximately 5 million fractures in the United States are due to osteoporosis.
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.
The nurse asks the client to "raise the arm out to the side" in the position shown. What is the nurse assessing? **Picture of a man with his arm out to the side and moving it upward** Elbow adduction Shoulder adduction Shoulder abduction Elbow abduction
Shoulder abduction Explanation: Raising the arms out to the side tests for should abduction. Moving the arm towards the midline assesses for shoulder adduction. The elbow is assessed for flexion, extension, pronation, and supination.
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? Supination Rotation Flexion Pronation
Pronation Explanation: 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 finding should a nurse expect when performing Phalen's test on a client with suspected carpal tunnel syndrome? Inability to perform active range of motion with the involved wrist Stiffness in the hands and fingers after holding and releasing a tight fist Reports of tingling, numbness, and pain in the involved wrist A change in the color of the fingers from red to white (pale)
Reports of tingling, numbness, and pain in the involved wrist Explanation: Phalen's test is performed by asking the client to place the backs of both hands against each other while flexing the wrists 90 degrees downward. The client holds this position for 60 seconds. A positive test would be the report of tingling, numbness, and pain in the involved wrist by the client. Inability to perform active range of motion with the involved wrist and stiffness in the hands and fingers after holding and releasing a tight fist may be seen in clients with arthritis in the joints. A change in color of the fingers from red to white (pale) is seen in clients with Raynaud's disease.
A client is unable to perform abduction with the right arm and reports pain when attempting to do so. The nurse notices that the muscles surrounding the right shoulder are smaller than those on the left shoulder. The nurse recognizes this finding as the possibility of what condition? Tendinitis Fracture Rotator cuff tear Degenerative joint disease
Rotator cuff tear Explanation: Painful and limited abduction accompanied by muscle weakness and atrophy are seen with rotator cuff tears. Rotator cuff tendinitis causes the client to report sharp catches of pain when bringing the hands overhead. A bone fracture presents with acute, severe pain, and often weakness of the entire extremity. Degenerative joint disease may cause limited range of motion for all of the shoulder movements and most likely occurs symmetrically.
A 32-year-old warehouse worker presents for evaluation of low back pain. He notes a sudden onset of pain after lifting a heavier-than-usual set of boxes. He also states that he has numbness and tingling in the left leg. What test should the nurse perform to assess for a herniated disc? Tinel's test Straight leg raise test Phelan's test Leg length test
Straight leg raise test Explanation: The straight leg raise test involves having the client lie supine with the examiner raising the leg. If the client experiences a sharp pain radiating from the back down the leg in an L5 or S1 distribution, that suggests a herniated disc. Leg strength test, Tinel's test, and Phelan's test do not assess for a herniated disc.
The client is facing the nurse with his forearm turned so that his palm is up. What movement is the client exhibiting? Supination Pronation Inversion Eversion
Supination Explanation: Supination occurs when the forearm is turned so that the palm is up. Pronation is turning the forearm so the palm is down. Inversion sis turning the sole of the foot inward. Turning the sole of the foot outward is eversion.
Mrs. Fletcher presents to the office with chronic unilateral pain when chewing. She does not have facial or scalp tenderness. Which of the following is the most likely cause of her pain? Tumor of the mandible Trigeminal neuralgia Temporomandibular joint syndrome Temporal arteritis
Temporomandibular joint syndrome Explanation: Temporomandibular joint syndrome is a very common cause of pain with chewing. Ischemic pain with chewing, or jaw claudication, can occur with temporal arteritis, but the lack of tenderness of the scalp overlying the artery makes this less likely. Trigeminal neuralgia can be associated with extreme tenderness over the branches of the trigeminal nerve. While a tumor of the mandible is possible, it is much less likely than the other choices.
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? The client suffered a fractured humerus 1 year earlier. The client had a total hip replacement 2 years ago. The client has a diagnosis of type 1 diabetes. The client takes medications to treat hypertension.
The client had a total hip replacement 2 years ago. Explanation: 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.
After assessing the client for posture and body alignment, how would the nurse document head position in relation to the spine if alignment is normal with noticeable defect? The head is straight up and down in accordance with the spine The head is equally distributed on the neck The head is centered and in line with the backbone The head is midline and aligned with the spine
The head is midline and aligned with the spine Explanation: The correct documentation would be "the trunk and head are erect with weight distributed equally on both feet. The head is midline and aligned with the spine."
While assessing the elbow of an adult client, the client complains of pain and swelling. The nurse should further assess the client for arthritis. nerve damage. carpal tunnel syndrome. ganglion cyst.
arthritis. Explanation: Redness, heat, and swelling may be seen with bursitis of the olecranon process due to trauma or arthritis.
An older adult client visits the clinic and tells the nurse that she has had shooting pain in both of her legs. The nurse should assess the client for signs and symptoms of rheumatoid arthritis. herniated intervertebral disc. metastases. osteoporosis.
herniated intervertebral disc. Explanation: Thirty-three bones: 7 concave-shaped cervical (C); 12 convex shaped thoracic (T); 5 concave-shaped lumbar (L); 5 sacral (S); and 3-4 coccygeal, connected in a vertical column. Bones are cushioned by elastic fibrocartilaginous plates (intervertebral discs) that provide flexibility and posture to the spine. Paravertebral muscles are positioned on both sides of vertebrae.
A client is unable to externally rotate the left shoulder. What health problem should the nurse suspect is occurring with this client? carpal tunnel syndrome rotator cuff tear anterior dislocation of the humerus rotator cuff tendinitis
rotator cuff tear 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.
The subacromial bursae are contained in the wrist joint. temporomandibular joint. shoulder joint. elbow joint.
shoulder joint. Explanation: Articulation of the head of the humerus in the glenoid cavity of the scapula. The acromioclavicular joint includes the clavicle and acromion process of the scapula. It contains the subacromial and subscapular bursae.