Ch 21: Musculoskeletal
GALS locomotor screen what 4 things
gait, arms, legs, spine
Risk factors for osteoporosis
age, skinny, smoking, alcoholics, steroids, menopause, malnutrition, family hx, Asians/whites
When assessing muscle tone and strength, the nurse would document expected findings as A. upper extremities strength 5/5 bilaterally B. extremity muscle strength 5/5 bilaterally C. upper and lower strength 5/5 bilaterally D. upper and lower extremity muscle strength 5/5
C. upper and lower strength 5/5 bilaterally
An 86 year old patient admitted for a fracture in his left ankle. What is the priority for a nursing assessment: A. Capillary refill distal to injury of the left ankle B. Pulse proximal to injury of right ankle C. Capillary refill proximal to injury of left ankle D. Capillary refill distal to injury on right ankle
A. Capillary refill distal to injury of the left ankle
A patient experiencing bilateral pain in his joints, he asks what rheumatoid arthritis is? A. Chronic inflammatory disease of the joints & surrounding connective tissue B. Dry crackling sound caused due to granting damaged bone C. Inability to perform coordinated movements D. Congenital deformity of the foot with plantar flexed and inverted
A. Chronic inflammatory disease of the joints & surrounding connective tissue
Which description of pain from the patient makes a nurse suspect the patient's pain is originating from a muscle? A. Crampy & sore B. Dull & sharp C. Borning & intense D. General & sharp
A. Crampy & sore
During a history, the patient reports having gout. Based on this info what findings does the nurse anticipate during a focused assessment? A. Edema, warmth, & redness of one great toe and pea-like nodules in the ear lobes B. Warm, tender, & deformed wrists & peripheral interphalangeal (PIP) joints bilaterally C. Tenderness with pronation & supination of elbow & point tenderness on the lateral epicondyle D. Contraction of cervical neck muscles
A. Edema, warmth, & redness of one great toe and pea-like nodules in the ear lobes
Risk factors in which of the following areas are most readily changed to reduce the potential risk for falls? A. Environmental B. Physiological C. Cognitive D. SOcial
A. Environmental (page 657)
What range of motion is the nurse testing by asking a client to stoop to pick an object off the floor? A. Flexion B. Rotation C. Abduction D. Extension
A. Flexion
Which involves both the musculoskeletal and neurological system? A. Gait, coordination, and balance B. Skin temperature and edema C. Tone, color, and moist D. Smell, tension and symmetry
A. Gait, coordination, and balance
Which of the following assessments can a registered nurse delegate to an unlicensed care provider? A. Height, weight, vitals B. Active and passive ROM C. Palpation and percussion of the knees D. Blood draw for calcium and vitamin D
A. Height, weight, vitals
Your patient was playing softball with their daughters and felt a pop in the left knee. It appears swollen and they have difficulty moving sideways, what is the first assessment you should make? A. Inspect both knees for swelling & deformities B. Palpate left and right knee C. Assess active ROM of knee D. Twist both knees to determine pain difference
A. Inspect both knees for swelling & deformities
A 70 year old woman has come for a health exam. Which of the following is a common age related change in the curvature of the spinal column? A. Kyphosis B. Lordosis C. Scoliosis D. Lateral scoliosis
A. Kyphosis
The nurse is assessing a client's ability to shrug her shoulders against resistance. The nurse is assessing which cranial nerve? A. XI B. III C. VII D. V
A. XI (page 647)
During the history, a young adult woman asks the nurse, "My mother has osteoporosis. What can I do to help reduce my risk?" Which response by the nurse would be most appropriate? A. avoid smoking and alcohol B. keep calcium intake at 800 mg a day C. increase amount o non weight bearing physical activity D. avoid being out in sun for longer periods of time
A. avoid smoking and alcohol
During the assessment of the spine, the patient would be asked for: A. Flex, extend, abduct, and rotate B. Abduct and extend C. Supinate, evert, and retract D. Extend, adduct, invert, & rotate
A. flex, extend, abduct, and rotate
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? A. head is straight up and down in accordance with spine B. head is centered in line with backbone C. head is equally distributed on neck D. head is midline & aligned with spine
A. head is straight up and down in accordance with spine
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 the Phalen's test and Tinel's tests 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? A. impaired physical mobility B. risk for trauma C. disturbed body image D. activity intolerance
A. impaired physical mobility (page 641)
After assessing a client's musculoskeletal system, the nurse is preparing to document the data gathered. Which of the following would the nurse document as objective data? A. neck rotation limited to 50 degrees B. complains of burning in the lower back C. denies pain in hips or legs D. history of osteoporosis
A. neck rotation limited to 50 degrees
Loss of bone density that occurs with greatest frequency in postmenopausal women is called? A. osteoporosis B. kyphosis C. lordosis D. scoliosis
A. osteoporosis
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? A. tenderness B. ecchymosis C. nodules D. cool temperature
A. tenderness (page 644)
Skeletal muscles are attached to bones by A. tendons B. fibrous connective tissue C. cartilage D. ligaments
A. tendons
Which of the following patients is at the highest risk for osteoporosis? A. white middle aged female of lower socioeconomic status who is sedentary, a heavy smoker, and drinks alcohol 6x a week B. African american young male with stable job preparing for a bodybuilding contest, who is using anabolic steriods C. Hispanic female who works as an executive, drinks vodka 3x a week, and is a recreational marathoner D. Retired Asian american male, nonsmoker, who drinks alcohol socially and goes dancing 3x a week
A.white middle-aged female of lower socioeconomic status who is sedentary, a heavy smoker, and drinks alcohol 6x a week
In assessing a client's temporomandibular joint (TMJ), the nurse asks the client to move the jaw forward. This movement is known as which of the following? A. Pronation B. Protraction C. Supination D. Retraction
B. Protraction (page 626-627)
Which nutrient deficiency should a nurse recognize as placing a client at risk for osteoporosis? A. vitamin c B. calcium C. vitamin d D. protein
B. calcium
While assessing the range of motion in an adult client's shoulders, the client expresses pain and exhibits limited abduction and muscle weakness. The nurse plans to refer the client to a physician for possible A. cervical disc degeneration B. rotator cuff tear C. nerve damage D. tendonitis
B. rotator cuff tear
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? A. leg length test B. straight leg raise test C. phelans test D. tinels test
B. straight leg raise test
The nurse is assessing an elderly client and finds an exaggerated thoracic curve. This would be documented as what? A. lordosis B. scoliosis C. kyphosis D. ankylosing spondylitis
C. Kyphosis (page 629)
When providing teaching to clients in the community, a nurse is accurate in stating that the musculoskeletal system is most closely aligned with which other body system? A. GI system B. Integumentary system C. Neurological system D. Renal system
C. Neurological system (page 638)
Which joint movement is a nurse testing when asking a client to move an extremity towards the body? A. abduction B. extension C. adduction D. flexion
C. adduction
A client visits the clinic and tells the nurse that she has joint pain in her hands, especially in the morning. The nurse should assess the client further for signs and symptoms of A. neurologic disorder B. osteoporosis C. arthritis D. carpal tunnel
C. arthritis (page 634)
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: A. mastastases B. osteoporosis C. herniated intervertebral disc D. rheumatoid arthritis
C. herniated intervertebral disc (page 644)
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. 49 year old african american woman who is obese B. 71 year old man with type 2 diabetes C. 37 year old woman taking oral contraceptives D. 69 year old woman with no major risk factors to osteoporosis
D. 69 year old woman with no major risk factors to osteoporosis
While assessing the elbow of an adult client, the client complains of pain and swelling. The nurse should further assess the client for A. nerve damage B. ganglion cust C. carpal tunnel D. arthritis
D. arthritis
A 70-year-old woman has come to the clinic to follow up her bone density testing. The results suggest that she has osteoporosis. What is a medication that might be ordered for this client? A. testosterone B. thyroid hormone C. vitamin c supplements D. calcitonin
D. calcitonin (page 633)
An adult client tells the nurse that he eats sardines every day. The nurse should instruct the client that a diet high in purines can contribute to A. osteomyelitis B. bone fracture C. osteomalacia D. gouty arthritis
D. gouty arthritis (page 666)
A client has rheumatoid arthritis most prominent in the hands, where the client has decreased range of motion (ROM), pain, and tenderness. What is an appropriate nursing diagnosis for this client? A. risk for falls related to degenerative joint disease B. risk for infection related to pain and inflammation C. risk for depression related to immobility D. impaired physical mobility related to reduced strength and ROM
D. impaired physical mobility related to reduced strength and ROM (page 650)
The client is facing the nurse with his forearm turned so that his palm is up. What movement is the client exhibiting? A. Eversion B. Inversion C. Pronation D. Supination
D. supination
Passive ROM present, what should the nurse NOT perform?
Do not force joints beyond resistance development
loss of bone density indicates
osteoporosis
