Week 5 Musculoskeletal
Alan, age 46, presents with a tender, red, swollen knee. You rule out septic arthritis and diagnose gout by confirming: 1.An elevated white blood cell (WBC) count. 2.Hyperuricemia. 3.A significant response to a dose of ceftriaxone (Rocephin). 4.A positive antinuclear antibody test.
Hyperuricemia. rationale: To diagnose gout, there should be hyperuricemia and a negative joint culture.
Alexander, age 12, sprained his ankle playing ice hockey. He is confused as to whether he should apply heat or cold. What should the nurse practitioner tell him? 1."Use continuous heat for the first 12 hours and then use heat or cold to your own preference." 2."Use continuous cold for the first 12 hours and then use heat or cold to your own preference." 3."Apply cold for 20 minutes, then remove it for 30 to 45 minutes; repeat this for the first 24 to 48 hours while awake." 4."Alternate between cold and heat for 20 minutes each for the first 24 to 48 hours."
"Apply cold for 20 minutes, then remove it for 30 to 45 minutes; repeat this for the first 24 to 48 hours while awake." rationale: Tell a client who has sprained his ankle to apply cold for 20 minutes, then remove it for 30 to 45 minutes, and repeat that procedure for the first 24 to 48 hours while awake. Cold will cause vasoconstriction and decrease edema, preventing any further bleeding into the tissues. After any sprain, use the principles of RICE: rest, ice, compression, and elevation.
John, age 16, works as a stock boy at the local supermarket. He is in the office for a routine visit. You notice that he had an episode of low back pain 6 months ago after lifting heavy boxes improperly. In discussing with him proper body mechanics to prevent future injuries, you tell him: 1."Bend your knees and face the object straight on." 2."Hold boxes away from your body at arm's length." 3."Bend and twist simultaneously as you lift." 4."Keep your feet firmly together."
"Bend your knees and face the object straight on." rationale: In discussing with John proper body mechanics to prevent future injuries, you tell him to bend his knees and face the object straight on, to hold boxes close to his body and not at arm's length, and to spread his feet about shoulder width apart. Using legs and arms, facing objects straight on, and keeping a wide stance will provide a broad base of support and allow for use of supporting muscles, relieving stress on the back muscles.
For an adult patient with a knee injury, the nurse practitioner orders a nonsteroidal anti-inflammatory drug (NSAID) to be taken on a routine basis for the next 2 weeks. Patient teaching should include which of the following? 1."You may take this medication on an empty stomach as long as you eat within two to three hours of taking it." 2."If one pill does not seem to help, you can double the dose for subsequent doses." 3."If you notice nausea, vomiting, or black or bloody stools, take the next dose with a glass of milk or a full meal." 4."If you have additional pain, an occasional acetaminophen (Tylenol) is permitted in between the usual doses of the NSAID."
"If you have additional pain, an occasional acetaminophen (Tylenol) is permitted in between the usual doses of the NSAID." rationale: If the client is having additional pain, acetaminophen (Tylenol) may be taken in conjunction with an NSAID because it is not an NSAID and will not potentiate gastric bleeding.
James, age 17, has been complaining of a painful knob below his right knee that has prevented him from actively participating in sports. He has recently been given a diagnosis of Osgood-Schlatter disease and asks you about his treatment options. The nurse practitioner should tell him that the initial treatment is: 1.Relative rest; he could benefit from hamstring, heel cord, and quadriceps stretching exercises. 2.Immobilization; a long-leg knee immobilizer is recommended. 3.Surgical intervention; removal of the bony fragments is necessary. 4.Bed rest for 1 week.
.Relative rest; he could benefit from hamstring, heel cord, and quadriceps stretching exercises. rationale: Osgood-Schlatter disease is an overuse injury that results from the excessive tension and pull of the patellar tendon on the tibial tuberosity. Treating the client conservatively while an adolescent will prevent potential problems as an active adult. Initially, relative rest should be used with hamstring, heel cord, and quadriceps stretching exercises.
A 55-year-old patient is able to complete range of motion (ROM) against gravity with some resistance. The nurse practitioner would assign which of the following numerical grades to this manual muscle testing description? 1.5. 2.4. 3.3. 4.2.
4. rationale: Complete ROM against gravity with some resistance is given a numerical grade of 4 and described as good muscle strength.
Paul has a malignant fibrosarcoma of the femur. He recently had surgery and is now on radiation therapy. You want to order a test to determine the extent of the tumor invasion of the surrounding tissues and the response of the bone tumor to the radiation. Which of the following tests should you order? 1.An x-ray. 2.A magnetic resonance imaging (MRI) scan. 3.A computed tomography (CT) scan. 4.A needle biopsy.
A magnetic resonance imaging (MRI) scan. rationale: For Paul, who has a malignant fibrosarcoma of the femur, an MRI scan will determine the extent of the tumor invasion of the surrounding tissues and the response of the bone tumor to the radiation. It will also determine response to chemotherapy and detect recurrent disease.
During assessment of a client's foot, the nurse practitioner notes that the foot is in alignment with the long axis of the lower leg and that weight-bearing falls on the middle of the foot from the heel, along the midfoot, to between the second and third toes. These findings best describe: 1.A normal foot. 2.Hallux valgus. 3.Talipes equinovarus. 4.Hammertoes.
A normal foot. rationale: If you note during your assessment of your client's foot that the foot is in alignment with the long axis of the lower leg and that weight-bearing falls on the middle of the foot from the heel, along the midfoot, to between the second and third toes, you would diagnose a normal foot.
The nurse practitioner (NP) is assessing Maya, a 69-year-old Asian woman, for the first time. When trying to differentiate between scoliosis and kyphosis, the NP recalls that kyphosis involves: 1.Asymmetry of the shoulders, scapulae, and waist creases. 2.A lateral curvature and vertebral rotation on posteroanterior x-rays. 3.One leg appearing shorter than the other. 4.A posterior rounding at the thoracic level.
A posterior rounding at the thoracic level. rationale: Kyphosis involves a posterior rounding at the thoracic level and a kyphotic curve of more than 45 degrees on an x-ray. There may be moderate pain with kyphosis.
A 13-year-old obese (body mass index [BMI] above the 95th percentile) boy reports low-grade left knee pain for the past 2 months. He denies antecedent trauma but admits to frequent "horseplay" with his friends. The pain has progressively worsened, and he is now unable to bear weight at all on his left leg. His current complaints include left groin, thigh, and medial knee pain and tenderness. His examination demonstrates negative drawer, Lachman, and McMurray tests; left hip with decreased internal rotation and abduction; and external hip rotation with knee flexion. Based on the above scenario, the nurse practitioner should suspect: 1.A left meniscal tear. 2.A left anterior cruciate ligament (ACL) tear. 3.A slipped capital femoral epiphysis (SCFE). 4.Osgood-Schlatter disease.
A slipped capital femoral epiphysis (SCFE). rationale: SCFE is a displacement of the femoral head relative to the femoral neck that occurs through the physis (growth plate) of the femur. The vast majority of clients with this condition are obese, as the added weight increases shear stress across the physis. The mean age at diagnosis is 12 years for females and 13.5 years for males. Surgery is often required via in situ pin fixation (single screw) to stabilize the growth plate to prevent further slippage and avoid complications.
Janine, age 69, has class III rheumatoid arthritis. According to the American Rheumatism Association, which of the following describes her ability to function? 1.Adequate for normal activities despite a handicap of discomfort or limited motion of one or more joints. 2.Largely or wholly incapacitated, bedridden, or confined to a wheelchair, permitting little or no self-care. 3.Completely able to carry out all usual duties without handicap. 4.Adequate to perform only a few or none of the duties of usual occupation or self-care.
Adequate to perform only a few or none of the duties of usual occupation or self-care. rationale: The American Rheumatism Association has established functional classes I to IV to describe a client's ability to accomplish activities of daily living. Because Janine is class III, her function would be adequate to perform only a few or none of the duties of usual occupation or self-care.
When teaching Alice, age 77, to use a cane because of osteoarthritis of her left knee, an important point to stress is: 1.Carrying the cane in the ipsilateral hand. 2.Advancing the cane with the ipsilateral leg. 3.Making sure the cane length equals the height of the iliac crest. 4.Using the cane to aid in joint protection and safety.
Advancing the cane with the ipsilateral leg. rationale: When teaching clients about using a cane, tell them to advance the cane with the ipsilateral (affected) leg.
Jessie, age 49, states she thinks she has rheumatoid arthritis. Before any diagnostic tests are ordered, the nurse practitioner completes a physical examination and makes a diagnosis of osteoarthritis rather than rheumatoid arthritis. Which clinical manifestation ruled out rheumatoid arthritis? 1.Fatigue. 2.Affected joints are swollen, cool, and bony hard on palpation. 3.Decreased range of motion. 4.Joint stiffness.
Affected joints are swollen, cool, and bony hard on palpation. rationale: In osteoarthritis, the affected joints are swollen, cool, and bony hard on palpation. With rheumatoid arthritis, the affected joints are red, hot, and swollen and boggy and tender on palpation.
Jeffrey, age 16, was involved in a motor vehicle accident. He walks in to the office with an obvious facial fracture and then collapses. What should the first action of the nurse practitioner be? 1.Calling his parents for permission to treat. 2.Assessing for an adequate airway. 3.Obtaining a head and maxillofacial computed tomography (CT). 4.Assessing for a septal hematoma.
Assessing for an adequate airway. rationale: The primary concern in the management of facial fractures is ensuring an adequate and stable airway. Displaced soft tissues, blood, secretions, or other foreign material may obstruct the airway and cause asphyxia.
Lois, age 52, who has just been given a diagnosis of sarcoidosis, has joint symptoms, including arthralgias and arthritis. Your next plan of action would be to: 1.Order a bone scan. 2.Obtain a tissue biopsy. 3.Begin a course of glucocorticoids. 4.Order daily doses of vitamin B.
Begin a course of glucocorticoids. rationale: Sarcoidosis is the result of an exaggerated immune system response to a class of antigens or self-antigens. Fifty percent of clients experience joint symptoms, including myopathy and polyarthritis; glucocorticoids are prescribed to suppress the immune process, thus relieving symptoms.
Mike, age 42, a golf pro, has had chronic back pain for many years. His workup reveals that it is not the result of a degenerative disk problem. His back "goes out" about twice per year, and he is out of work for about a week each time. Which of the following should the nurse practitioner advise him to do? 1.Consider changing careers to something less physical. 2.Begin a planned exercise program to strengthen back muscles. 3.Make an appointment with a neurosurgeon for a surgical consultation. 4.Start on a daily low-dose narcotic to take away the pain.
Begin a planned exercise program to strengthen back muscles. rationale: In this case, Mike may benefit from a regular planned exercise program to strengthen his back muscles and attempt to reduce the probability of future episodes of back pain.
Jim, age 22, a stock boy, has an acute episode of low back pain. The nurse practitioner orders a nonsteroidal anti-inflammatory drug (NSAID) and should educate him in which of the following? 1.Maintaining moderate bed rest for 3 to 4 days. 2.Calling the office for narcotic medication if there is no relief with the NSAID after 24 to 48 hours. 3.Beginning lower back strengthening exercises depending on pain tolerance. 4.Wearing a Boston brace at night.
Beginning lower back strengthening exercises depending on pain tolerance. rationale: Years ago, muscle relaxants and bed rest were the treatments of choice for low back pain. Studies have now shown that resuming normal activity within the limits imposed by the pain has an effect as good as, if not better than, 2 days of bed rest. The key here is letting pain be your guide. Exercise should begin as soon as possible after the acute injury and be directed at building endurance and stamina, with consideration given to one's pain tolerance.
Sam, age 50, presents with Paget disease that has been stable for several years. Recently, his serum alkaline phosphatase level has been steadily rising. The nurse practitioner determines that it is time to start him on pharmacologic management. Which of the following should she initially prescribe? 1.Nonsteroidal anti-inflammatory drugs (NSAIDs). 2.Corticosteroids. 3.Bisphosphonates. 4.Calcitonin.
Bisphosphonates. rationale: When the serum alkaline phosphatase level rises—which indicates the disease has progressed—bisphosphonates, which decrease bone resorption by inhibiting osteoclast activity, are the treatment of choice.
Mr. McKinsey, age 69, was recently given a diagnosis of degenerative joint disease. Which assessment should the nurse practitioner use to check for effusion of the patient's knee? 1.Thomas test. 2.Tinel test. 3.Bulge test. 4.Phalen test.
Bulge test. rationale: The bulge test assesses for an effusion of the knee. If effusion is present, a bulge will appear at the sides of or below the patella when the practitioner compresses the area above the patella.
A 55-year-old patient presents with complaints of paresthesias in the lower lateral arm, thumb, and middle finger. The nerve roots most commonly related to these symptoms are C6 and C7. The most likely diagnosis would be: 1.Brachial plexus neuritis. 2.Cervical radiculopathy. 3.Peripheral polyneuropathy. 4.Thoracic outlet syndrome.
Cervical radiculopathy. rationale: Cervical nerve root compression of C6 and C7 causes cervical radiculopathy.
Joyce, age 87, broke her wrist after falling off a curb. She just had a plaster cast applied to her wrist. In instructing Joyce and her family on allowing the cast to dry properly, tell them to: 1.Continuously elevate Joyce's arm on a pillow. 2.Change the position of Joyce's arm every hour. 3.Position a fan near Joyce during the night to ensure even drying of the cast. 4.Put a blanket over the cast to absorb the dampness.
Change the position of Joyce's arm every hour. rationale: Instructions to the client and family on how to allow a cast to dry properly should include advising them to change the position of the casted extremity every hour. In this case, Joyce's arm should be repositioned frequently to prevent indentations in the cast itself (caused by continuous placement on a pillow) and to ensure drying of all surfaces of the cast.
You are assessing Jamal, age 16, after a football injury to his right knee. You elicit a positive anterior/posterior drawer sign. This test indicates an injury to the: 1.Lateral meniscus. 2.Cruciate ligament. 3.Medial meniscus. 4.Collateral ligament.
Cruciate ligament. rationale: Positive anterior and posterior drawer signs indicate injury to the anterior cruciate ligament and posterior cruciate ligament, respectively. The drawer and Lachman tests are utilized to assess for cruciate ligament injury.
Beth, age 49, comes in with low back pain. An x-ray of the lumbosacral spine is within normal limits. Which of the following diagnoses do you explore further? 1.Scoliosis. 2.Osteoarthritis. 3.Spinal stenosis. 4.Herniated nucleus pulposus.
Herniated nucleus pulposus. rationale: A plain x-ray will not show a herniated nucleus pulposus or a muscle strain. It will show spondylolisthesis, scoliosis, osteoarthritis, and spinal stenosis. Note that x-rays of the spine are not indicated in low back pain unless the cause of the pain is thought to be bony in origin or traumatic in nature or there is a need to rule out systemic disease.
Lillian, age 70, was told that she has osteoporosis. When she asks you what this is, you respond that osteoporosis: 1.Develops when loss of bone occurs more rapidly than new bone growth. 2.Is a degenerative joint disease characterized by loss of cartilage in certain joints. 3.Is a chronic inflammatory disorder that affects multiple joints. 4.Is a bone disorder that has to do with inadequate mineralization of the bones.
Develops when loss of bone occurs more rapidly than new bone growth. rationale: Osteoporosis develops when bone resorption occurs more rapidly than bone deposition.
Mrs. Kelly, age 80, has a curvature of the spine. This is likely to indicate which age-related change? 1.Lordosis. 2.Dorsal kyphosis. 3.Scoliosis. 4.Kyphoscoliosis.
Dorsal kyphosis. rationale: Dorsal kyphosis, an exaggerated convexity of the thoracic curvature, typically accompanies the aging process.
Mickey, age 18, is on a chemotherapeutic antibiotic for a musculoskeletal neoplasm. Which drug do you think he is taking? 1.Cyclophosphamide (Cytoxan). 2.Doxorubicin (Adriamycin). 3.Methotrexate (Rheumatrex). 4.Cisplatin (Platinol).
Doxorubicin (Adriamycin). rationale: The only antineoplastic antibiotic listed is doxorubicin (Adriamycin). All of the other medications are chemotherapeutic agents of other classifications that may be used for musculoskeletal neoplasms.
Daniel, age 45, is of Northern European ancestry and has a dysfunctional and disfiguring condition affecting the palmar tissue under the skin of the distal palm and fourth and fifth fingers. What do you suspect? 1.Hallux valgus. 2.De Quervain tenosynovitis. 3.Dupuytren contracture. 4.Hallux rigidus.
Dupuytren contracture. rationale: Dupuytren contracture affects the palmar tissue under the skin of the distal palm and fingers—most often the fourth and fifth fingers, but also the thumb-index finger web space. It is progressive and results in a flexion contracture, though it does not affect the flexor tendons. Occurring most frequently in males between the ages of 40 and 60, it is common among people of Northern European ancestry. It is dysfunctional and disfiguring. Although it is not actually painful, it may be tender. Surgery is recommended when the inability to straighten the fingers limits the client's hand function.
A nurse practitioner is driving home from work and stops at the scene of a motorcycle accident that must have just occurred, as there are no rescue vehicles present. The driver is lying unconscious at the side of the road with an obvious open fracture of his femur. Which of the following actions should take priority? 1.Stopping the bleeding from the wound. 2.Determining if there has been a cervical fracture. 3.Establishing an airway. 4.Palpating the peripheral pulses.
Establishing an airway. rationale: Follow the ABCs of first aid: airway, breathing, and circulation. Establishing an airway is the first priority, followed by breathing, and then circulation. Stopping the bleeding from the wound, assessing if there has been a cervical fracture, and palpating the peripheral pulses are all important actions, but if the client is not breathing, the other actions will not be necessary.
Cass, age 67, tells the nurse practitioner (NP) that she has been diagnosed with a condition that causes sudden flares of pain, swelling, and redness of the joints in her toes. She cannot remember the name of the diagnosis, but she knows it is caused by urate crystals that "get stuck in the joint and cause pain." She is on hydrochlorothiazide (HCTZ) for management of her hypertension. The NP should suspect a diagnosis of: 1.Septic arthritis. 2.Gout. 3.Rheumatoid arthritis. 4.Charcot neuro-osteoarthropathy.
Gout. rationale: Gout is a disorder that involves abnormal metabolism of uric acid and results in hyperuricemia. High concentrations of urate precipitate into crystals that collect in tissue and joint spaces and can cause pain and inflammation. The patient's symptoms may be aggravated by the use of HCTZ.
Steve, age 32, fell off a roof while shingling it. He is complaining of pain in his left hip and leg area. Other than an x-ray, what would make you suspect a fractured pelvis? 1.A clicking sensation when moving the hips. 2.A positive pelvic tilt test. 3.Hematuria. 4.Absence of distal reflexes.
Hematuria rationale: If a client has a fractured pelvis, a test for hematuria will usually prove positive. A fracture of the pelvis usually results in hypovolemia due to a generally significant associated blood loss. Surrounding blood vessels rupture, which results in a large retroperitoneal hematoma and shock. Pelvic fractures also commonly injure the urinary bladder or urethra. A client with a fracture in several locations of the pelvis may need a pneumatic antishock garment to control the blood loss and stabilize the pelvis. Only x-ray studies will confirm the diagnosis.
Greg, age 26, runs marathons and frequently complains of painful contractions of his calf muscles after running. You attribute this to: 1.Hypercalcemia. 2.Hyponatremia. 3.Heat exhaustion. 4.Dehydration.
Hyponatremia. rationale: Painful contractions of muscles after exertion, such as heat cramps, may be related to hyponatremia or other electrolyte imbalances. Usually the gastrocnemius and hamstring muscles are involved. Treatment of heat cramps includes passive muscle stretching, cessation of activities, transfer to a cooler environment, and drinking cool liquids. Sports drinks that contain electrolytes, such as Gatorade, may be beneficial.
Jill, age 49, has recently begun a rigorous weightlifting regimen. She presents to the primary care office with a shoulder dislocation. Which of the following clinical manifestations leads the nurse practitioner to suspect an anterior shoulder dislocation over a posterior dislocation? 1.Inability to shrug the shoulder. 2.Absence of pain. 3.Inability to rotate the shoulder externally. 4.Shortening of the arm.
Inability to shrug the shoulder. rationale: Clinical manifestations of an anterior shoulder dislocation, which is far more common than a posterior dislocation, include the inability to shrug the shoulder, pain, and lengthening of the arm.
The valgus stress test, varus stress test, Lachman test, and thumb sign are all considered standard tests to check the integrity of the ligaments of the knee. Which test would the nurse practitioner choose to assess the anterior cruciate ligament (ACL), which is the most commonly involved structure in severe knee injury? 1.Valgus stress test. 2.Varus stress test. 3.Lachman test. 4.Thumb sign.
Lachman test rationale: The Lachman test assesses the ACL.
Upon assessment, the nurse practitioner notes unilateral back pain of acute onset that increases when standing and bending. A straight leg raise test is negative. The most likely diagnosis is: 1.Herniated nucleus pulposus. 2.Muscle strain. 3.Osteoarthritis. 4.Spondylolisthesis.
Muscle strain. rationale: Muscle strain is usually located in the low back and is unilateral in location. The onset is acute, and pain increases with standing and bending and decreases with sitting. The straight leg raise test and plain x-ray are both negative.
Marsha, age 34, presents with symptoms resembling both fibromyalgia and chronic fatigue syndrome, which have many similarities. Which of the following is more characteristic of fibromyalgia than of chronic fatigue syndrome? 1.Musculoskeletal pain. 2.Difficulty sleeping. 3.Depression. 4.Fatigue.
Musculoskeletal pain. rationale: Musculoskeletal pain is not characteristic of chronic fatigue syndrome; rather, it is characteristic of fibromyalgia. The musculoskeletal pain, usually an achy muscle pain that may be localized or involve the entire body, is usually gradual in onset, although the onset may occasionally be sudden, such as after a viral illness.
June, age 67, presents with back pain with no precipitating event. The pain is located over her lower back muscles and spine, without sciatica, and it is aggravated by sitting, standing, and certain movements. It is alleviated with rest. Palpation localizes the pain, and muscle spasms are felt. There was an insidious onset with progressive improvement. What is the most likely diagnosis? 1.Ankylosing spondylitis. 2.Musculoskeletal strain. 3.Spondylolisthesis. 4.Herniated disk.
Musculoskeletal strain. rationale:Pain over the lower back muscles and spine, without sciatica, is caused by musculoskeletal strain. Often there is no precipitating event, and there is an insidious onset. It is aggravated by sitting, standing, and certain movements. Palpation localizes the pain, and muscle spasms may be felt. It is alleviated by rest, and there is progressive improvement.
You are caring for a patient who has a history of psoriasis and is now showing signs of joint involvement. Seropositivity provides a definitive diagnosis of psoriatic arthritis (PsA). The initial treatment choice for management of the patient is: 1.Disease-modifying antirheumatic drugs (DMARDs). 2.Nonsteroidal anti-inflammatory drugs (NSAIDs). 3.Tumor necrosis factor-alpha (TNF-α) inhibitors. 4.Uricosuric medications.
Nonsteroidal anti-inflammatory drugs (NSAIDs). rationale: NSAIDs are the first-line treatment for musculoskeletal signs and symptoms with joint involvement.
A nurse practitioner is trying to distinguish between an articular and a nonarticular musculoskeletal complaint in a 26-year-old patient complaining of pain in the elbow area. Which of the following would characterize nonarticular bursitis? 1.Deep or diffuse pain. 2.Limited range of motion (ROM) on active and passive movement. 3.Point or focal tenderness. 4.Swelling and instability.
Point or focal tenderness. rationale: Articular disorders are characterized by deep or diffuse pain, limited range of motion (ROM) on both active and passive movement, swelling, crepitation, instability, and deformity. Nonarticular disorders are characterized by painful active but not passive movement and point or focal tenderness in regions far from articular surfaces.
Sandy, age 49, presents with loss of anal sphincter tone, impaired micturition, incontinence, and progressive loss of strength in the legs. You suspect cauda equina syndrome. What is your next action? 1.Ordering physical therapy. 2.Ordering a lumbosacral x-ray. 3.Ordering extensive lab work. 4.Referring to a neurosurgeon.
Referring to a neurosurgeon. rationale: A prompt referral to a neurosurgeon is required when a diagnosis of cauda equina syndrome is suspected. Cauda equina syndrome is a widespread neurologic disorder in which there is loss of anal sphincter tone; impaired micturition; incontinence; saddle anesthesia (ie, loss of sensation in the anus, perineum, genitals, and inner thighs); and motor weakness or sensory loss in both legs.
The nurse practitioner suspects adolescent idiopathic scoliosis in Victoria, age 15, who is in her "growth spurt." An Adams forward bend test is performed, and it is noted that the patient has a right-sided rib hump. What is this indicative of? 1.Right lumbar shifting. 2.Right thoracic curvature. 3.Right truncal shift. 4.Spondylolysis.
Right thoracic curvature. rationale: When you have a client bend forward to assess the spine (ie, the Adams forward bend test) and you note a right-sided rib hump, this is indicative of a right thoracic curve. Adolescent idiopathic scoliosis is defined as a lateral spinal curvature of greater than 10 degrees with no determined pathologic cause. Management consists of the 3 Os: observation, orthosis, and operation.
Ethan, age 10, jumped off a 2-foot wall, twisting his foot and ankle upon landing. His ankle x-ray demonstrates a fracture of the distal tibia, over the articular surface, through the epiphysis and physis. Based on the Salter-Harris classification of growth plate injuries, you know this is a: 1.Salter-Harris II fracture. 2.Salter-Harris III fracture. 3.Salter-Harris IV fracture. 4.Salter-Harris V fracture.
Salter-Harris III fracture. rationale: The Salter-Harris classification system of growth plate injuries divides most growth plate injuries into 5 categories based on the damage: A Salter-Harris III fracture travels through the epiphysis and physis. A Salter-Harris I fracture travels through the physis.
Margaret, age 55, presents to you for evaluation of left hand and wrist pain and swelling after a slip and fall on the ice yesterday. On examination, you note tenderness at her "anatomical snuffbox." You know this probably indicates a(n): 1.Ulnar styloid fracture. 2.Scaphoid fracture. 3.Hamate fracture. 4.Radial head fracture.
Scaphoid fracture. rationale: There is tenderness over the "anatomical snuffbox" in a scaphoid (aka navicular) fracture, the most common injury of the carpal bones. Poor blood supply puts the scaphoid bone at risk of avascular necrosis; therefore, wrist pain and tenderness in the anatomical snuffbox, even without history of antecedent trauma, warrant a wrist x-ray.
Anne Marie states she has a maternal history of rheumatoid disease, but she has never been affected. Today she presents with complaints of dryness of the eyes and mouth. What is the most likely diagnosis? 1.Rheumatoid arthritis (RA). 2.Systemic lupus erythematosus (SLE). 3.Sjögren syndrome. 4.Rosacea.
Sjögren syndrome. rationale: Sjögren syndrome, which affects the salivary and lacrimal glands, causes clients to have dry eyes and mouths. It is an inflammatory disease of the exocrine glands and may be an isolated entity or may be associated with other rheumatic diseases, such as rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE).
Hilda, age 73, presents with a complaint of low back pain. Red flags in her history of a minor fall, osteopenia, and prolonged steroid use for systemic lupus erythematosus suggest the possibility of which of the following serious underlying conditions as the cause of her low back pain? 1.Cancer. 2.Cauda equina syndrome. 3.Neurologic compromise. 4.Spinal fracture.
Spinal fracture. rationale: The red flags for spinal fracture include major trauma or direct blow to the back in an adult, a minor fall or heavy lifting in a potentially osteoporotic or elderly person, prolonged steroid use, and age greater than 70.
The nurse practitioner (NP) suspects a herniated disk in a 72-year-old patient. The NP elevates the patient's affected leg when she is in the supine position, and it elicits back and sciatic nerve pain, which indicates a positive test. This is known as which test or sign? 1.Femoral stretch test. 2.Crossed straight leg raise test. 3.Doorbell sign. 4.Straight leg raise test.
Straight leg raise test. rationale: All of the tests listed are tests done to assess for a herniated disk. In the straight leg raise test, you elevate the affected leg when the client is in the supine position; back pain and sciatic nerve pain (ie, radiating leg pain) indicate a herniated disk.
In assessing the skeletal muscles, the nurse practitioner turns the patient's forearm so that the palm is up. This is called: 1.Supination. 2.Pronation. 3.Abduction. 4.Eversion.
Supination. rationale: Turning the forearm so that the palm is up is called supination.
The nurse practitioner is considering a diagnosis of calcium pyrophosphate deposition disease (CPPD), or pseudogout, in a 72-year-old man who presents with complaints of pain and stiffness in his wrists and knees. The most useful diagnostic tests to assist in confirming this diagnosis would be: 1.Synovial fluid analysis and x-ray. 2.Bacterial cultures. 3.Bone scan and magnetic resonance imaging (MRI). 4.Anticitrullinated protein antibodies (ACPA) and rheumatoid factor (RF).
Synovial fluid analysis and x-ray. rationale: CPPD (pseudogout) may appear clinically similar to gouty arthritis; however, in CPPD crystals form in the cartilage and lead to inflammation. The typical age of onset is later than that of gout, initially presenting in the sixth decade of life or later. Diagnosis is made through synovial fluid analysis and will reveal positive calcium pyrophosphate dihydrate crystals. An x-ray will show radiographic evidence of chondrocalcinosis or calcification in the hyaline cartilage and/or fibrocartilage of the affected joint.
In assessing a patient, you place the tips of your first 2 fingers in front of each ear and ask the patient to open and close his mouth. Then you drop your fingers into the depressed area over the joint and assess for smooth motion of the mandible. With this action, you are checking for: 1.Maxillomandibular integrity. 2.Well-positioned permanent teeth or well-fitting dentures. 3.Temporomandibular joint syndrome. 4.Mastoid inflammation.
Temporomandibular joint syndrome. ratonale: In assessing your client, place the tips of your first 2 fingers in front of each ear and ask him to open and close his mouth. Then drop your fingers into the depressed area over the temporomandibular joint (TMJ) and check for smooth motion of the mandible. With this action, you are assessing for TMJ syndrome. Clicking or popping noises, decreased range of motion, pain, or swelling may indicate TMJ syndrome. However, an audible and palpable snap or click does occur in many normal people as they open their mouths. In rare cases, this may indicate osteoarthritis.
Christian, age 22, is a carpenter who is right hand dominant. He comes to the clinic for follow-up from the emergency department, where he was seen for right forearm pain. He states he was diagnosed with right forearm tendinitis and wants the provider to explain this diagnosis to him. Patient teaching should explain that he has inflammation of one or more tendons, which are: 1.The ropelike bundles of collagen fibrils that connect bone to bone. 2.The collagen fibers that connect muscle to bone. 3.The pouches of synovial fluid that cushion bone and other joint structures. 4.The fibrocartilaginous disks that separate bony surfaces.
The collagen fibers that connect muscle to bone. rationale: Tendons are the collagen fibers that connect muscle to bone.
Anne, age 67, sustained a fall on an outstretched hand. She presents holding her arm against her chest with her elbow flexed. Based on the specific location of her pain, you suspect a radial head fracture. The best initial strategy to assess for a radial head fracture would be: 1.To palpate for tenderness, swelling, and crepitus just distal to the lateral epicondyle. 2.To palpate for tenderness, swelling, and crepitus along the radial wrist. 3.To palpate for tenderness in the "anatomical snuffbox." 4.To order an x-ray of the wrist.
To palpate for tenderness, swelling, and crepitus just distal to the lateral epicondyle. rationale: The radial head is the proximal aspect of the radius, located in the elbow joint. Falling on an outstretched hand transfers a significant amount of force to the radial head. Often a fracture line cannot be seen on an x-ray, but the presence of an anterior or posterior fat pad sign (or sail sign) indicates an occult radial head fracture.
Sean, a factory line worker, has osteoarthritis (OA) of the right hand. According to the American College of Rheumatology (ACR), the guidelines for pharmacologic treatment include: 1.Acetaminophen, tramadol, and intra-articular corticosteroid injections. 2.Oral nonsteroidal anti-inflammatory drugs (NSAIDs), tramadol, and articular corticosteroid injections. 3.Acetaminophen, topical capsaicin, and topical nonsteroidal anti-inflammatory drugs (NSAIDs). 4.Topical capsaicin, topical nonsteroidal anti-inflammatory drugs (NSAIDs), and oral NSAIDs.
Topical capsaicin, topical nonsteroidal anti-inflammatory drugs (NSAIDs), and oral NSAIDs. rationale: Topical capsaicin, topical NSAIDs, oral NSAIDs, and tramadol are recommended by the ACR for the treatment of OA of the hand.
Sandra, a computer programmer, has just been given a new diagnosis of carpal tunnel syndrome. The nurse practitioner's next step is to: 1.Refer her to a hand surgeon. 2.Take a more complete history. 3.Try neutral position wrist splinting and order an oral nonsteroidal anti-inflammatory drug (NSAID). 4.Order nerve conduction studies and electromyography (EMG).
Try neutral position wrist splinting and order an oral nonsteroidal anti-inflammatory drug (NSAID). rationale: For the client who has just been given a diagnosis of carpal tunnel syndrome, your next step is to try neutral position wrist splinting and order an oral NSAID. For symptoms of less than 10 months' duration, conservative treatment should be tried first.
Karen, who is postmenopausal, is taking 1200 mg of calcium daily but does not understand why she also needs to take vitamin D. You tell her that: 1.A deficiency of vitamin D results in inadequate mineralization of bone matrix. 2.All vitamins need to be supplemented. 3.Vitamin D increases intestinal absorption of dietary calcium and mobilizes calcium from the bone. 4.Vitamin D binds with calcium to allow active transport into the cells.
Vitamin D increases intestinal absorption of dietary calcium and mobilizes calcium from the bone. rationale: Advise clients taking calcium supplements that they also need to take vitamin D because vitamin D raises serum calcium levels by increasing the intestinal absorption of dietary calcium and mobilizing calcium from the bone.
Karen, who is postmenopausal, is taking 1200 mg of calcium daily but does not understand why she also needs to take vitamin D. You tell her that: 1. A deficiency of vitamin D results in inadequate mineralization of bone matrix. 2. All vitamins need to be supplemented. 3. Vitamin D increases intestinal absorption of dietary calcium and mobilizes calcium from the bone. 4. Vitamin D binds with calcium to allow active transport into the cells.
Vitamin D increases intestinal absorption of dietary calcium and mobilizes calcium from the bone. rationale: Advise clients taking calcium supplements that they also need to take vitamin D because vitamin D raises serum calcium levels by increasing the intestinal absorption of dietary calcium and mobilizing calcium from the bone.
Matthew, age 52, is a chef who just severed 2 of his fingers with a meat cutter. You would recommend that he: 1.Wrap the severed fingers tightly in a dry towel for transport to the emergency department with him. 2.Leave the severed fingers at the scene because fingers cannot be reattached. 3.Immediately freeze the severed fingers for reattachment in the near future. 4.Wrap the fingers in a clean, damp cloth; seal them in a plastic bag; and place the bag in an ice water bath.
Wrap the fingers in a clean, damp cloth; seal them in a plastic bag; and place the bag in an ice water bath. rationale: If a client has severed his fingers, the fingers should be wrapped in a clean, damp cloth; sealed in a plastic bag; placed in an ice water bath; and transported to the emergency room along with the client.
