Ch. 35 Med-Surg: Assessment of Musculoskeletal Function

A nurse is providing care for a client whose pattern of laboratory testing reveals long-standing hypocalcemia. Which other laboratory result is most consistent with this finding? A. An elevated parathyroid hormone level B. An increased calcitonin level C. An elevated potassium level D. A decreased vitamin D level

A. An elevated parathyroid hormone level Rationale: In the response to low calcium levels in the blood, increased levels of parathyroid hormone prompt the mobilization of calcium and the demineralization of bone. Increased calcitonin levels would exacerbate hypocalcemia. Vitamin D levels do not increase in response to low calcium levels. Potassium levels would likely be unaffected. P 1111

A client has symptoms of osteoporosis and is being assessed during an annual physical examination. The assessment shows that the client will require further testing related to a possible exacerbation of osteoporosis. The nurse should anticipate which diagnostic test? A. Bone densitometry B. Hip bone radiography C. Computed tomography (CT) D. Magnetic resonance imaging (MRI)

A. Bone densitometry Rationale: Bone densitometry is considered the most accurate test for osteoporosis and for predicting a fracture. As such, it is more likely to be used than CT, MRI, or x-rays. P 1110

A client has been experiencing an unexplained decline in knee function and has consequently been scheduled for arthrography. The nurse should teach the client about what process? A. Injection of a contrast agent into the knee joint prior to ROM exercises B. Aspiration of synovial fluid for serologic testing C. Injection of corticosteroids into the client's knee joint to facilitate ROM D. Replacement of the client's synovial fluid with a synthetic substitute

A. Injection of a contrast agent into the knee joint prior to ROM exercises Rationale: During arthrography, a radiopaque contrast agent or air is injected into the joint cavity to visualize the joint structures such as the ligaments, cartilage, tendons, and joint capsule. The joint is put through its range of motion to distribute the contrast agent while a series of x-rays are obtained. Synovial fluid is not aspirated or replaced and corticosteroids are not given. P 1108

A nurse on the orthopedic unit is assessing a client's peroneal nerve. The nurse should perform this assessment by doing what action? A. Pricking the skin between the great and second toe B. Stroking the skin on the sole of the client's foot C. Pinching the skin between the thumb and index finger D. Stroking the distal fat pad of the small finger

A. Pricking the skin between the great and second toe Rationale: The nurse will evaluate the sensation of the peroneal nerve by pricking the skin centered between the great and second toe. None of the other listed actions elicits the function of one of the peripheral nerves. P 1109

A client is receiving ongoing nursing care for the treatment of Parkinson disease. When assessing this client's gait, which finding is most closely associated with this health problem? A. Spastic hemiparesis gait B. Shuffling gait C. Rapid gait D. Steppage gait

B. Shuffling gait Rationale: A variety of neurologic conditions are associated with abnormal gaits, such as a spastic hemiparesis gait (stroke), steppage gait (lower motor neuron disease), and shuffling gait (Parkinson disease). A rapid gait is not associated with Parkinson disease. P 1106

A nurse is caring for a client with a diagnosis of cancer that has metastasized to the bone. Which laboratory value would the nurse expect to be elevated in this client? A. Bilirubin B. Potassium C. Alkaline phosphatase D. Creatinine

C. Alkaline phosphatase Rationale: Alkaline phosphatase is elevated during early fracture healing and in diseases with increased osteoblastic activity (e.g., metastatic bone tumors). Elevated bilirubin, potassium, and creatinine would not be expected in a client with metastatic bone tumors. P 1111

A client has been experiencing progressive increases in knee pain and diagnostic imaging reveals a worsening effusion in the synovial capsule. The nurse should anticipate what diagnostic procedure? A. Arthrography B. Knee biopsy C. Arthrocentesis D. Electromyography

C. Arthrocentesis Rationale: Arthrocentesis (joint aspiration) is carried out to obtain synovial fluid for purposes of examination or to relieve pain due to effusion. Arthrography, biopsy, and electromyography would not remove fluid and relieve pressure. P 1111

The results of a nurse's musculoskeletal examination show an increase in the lumbar curvature of the spine. The nurse should recognize the presence of what health problem? A. Osteoporosis B. Kyphosis C. Lordosis D. Scoliosis

C. Lordosis Rationale: The nurse documents the spinal abnormality as lordosis. Lordosis is an increase in lumbar curvature of the spine. Kyphosis is an increase in the convex curvature of the spine. Scoliosis is a lateral curvature of the spine. Osteoporosis is the significant loss of bone mass and strength with an increased risk for fracture. P 1105

A client has come to the clinic for a regular check-up. The nurse's initial inspection reveals an increased thoracic curvature of the client's spine. The nurse should document the presence of which condition? A. Scoliosis B. Epiphyses C. Lordosis D. Kyphosis

D. Kyphosis Rationale: Kyphosis is the increase in thoracic curvature of the spine. Scoliosis is a deviation in the lateral curvature of the spine. Epiphyses are the ends of the long bones. Lordosis is the exaggerated curvature of the lumbar spine. P 1105

The nurse is performing an assessment of a client's musculoskeletal system and is appraising the client's bone integrity. Which action should the nurse perform during this phase of assessment? A. Compare parts of the body symmetrically. B. Assess extremities when in motion rather than at rest. C. Percuss as many joints as are accessible. D. Administer analgesia 30 to 60 minutes before assessment.

A. Compare parts of the body symmetrically. Rationale: When assessing bone integrity, symmetric parts of the body, such as extremities, are compared. Analgesia should not be necessary, and percussion is not clinically useful for assessing bone integrity. Bone integrity is best assessed when the client is not moving. P 1106

A nurse is assessing a client who is experiencing peripheral neurovascular dysfunction. Which assessment findings are most consistent with this diagnosis? A. Hot skin and a capillary refill of 1 to 2 seconds B. Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin C. Pain, diaphoresis, and erythema D. Jaundiced skin, weakness, and capillary refill of 3 seconds

B. Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin Rationale: Indicators of peripheral neurovascular dysfunction include pale, cyanotic, or mottled skin with a cool temperature; capillary refill greater than 3 seconds; weakness or paralysis with motion; and paresthesia, unrelenting pain, pain on passive stretch, or absence of feeling. Jaundice, diaphoresis, and warmth are inconsistent with peripheral neurovascular dysfunction. P 1109

A nurse is performing a nursing assessment of a client suspected of having a musculoskeletal disorder. Which assessment should the nurse prioritize for a client who has a musculoskeletal disorder? A. Range of motion B. Activities of daily living C. Gait D. Strength

B. Activities of daily living Rationale: The nursing assessment is primarily a functional evaluation, focusing on the client's ability to perform activities of daily living. The nurse also assesses strength, gait, and range of motion, but these are assessed to identify their effect on functional status rather than to identify a medical diagnosis. P 1104

A client is undergoing diagnostic testing for suspected Paget disease. What assessment finding is most consistent with this diagnosis? A. Altered serum magnesium levels B. Altered serum calcium levels C. Altered serum potassium levels D. Altered serum sodium levels

B. Altered serum calcium levels Rationale: Serum calcium levels are altered in clients with osteomalacia, parathyroid dysfunction, Paget's disease, metastatic bone tumors, or prolonged immobilization. Paget's disease is not directly associated with altered magnesium, potassium, or sodium levels. P 1111

A public health nurse is organizing a campaign that will address the leading cause of musculoskeletal-related disability. The nurse should focus on what health problem? A. Osteoporosis B. Arthritis C. Hip fractures D. Lower back pain

B. Arthritis Rationale: The leading cause of musculoskeletal-related disability is arthritis. P 1097

A client's fracture is healing and compact bone is replacing spongy bone around the periphery of the fracture. This process characterizes what phase of the bone healing process? A. Hematoma formation B. Fibrocartilaginous callus formation C. Remodeling D. Bony callus formation

C. Remodeling Rationale: Remodeling occurs as necrotic bone is removed by the osteoclasts. In this phase, compact bone replaces spongy bone around the periphery of the fracture. Each of the other listed phases precedes this stage. P 1098

During assessment, a client reports experiencing rhythmic muscle contractions when the nurse performs passive extension of the wrist. The nurse should recognize the presence of which condition? A. Fasciculations B. Contractures C. Effusion D. Clonus

D. Clonus Rationale: Clonus may occur when the ankle is dorsiflexed or the wrist is extended. It is characterized as rhythmic contractions of the muscle. Fasciculation is involuntary twitching of muscle fiber groups. Contractures are prolonged tightening of muscle groups, and an effusion is the pathologic escape of body fluid. P 1108

A nurse is assessing a child who has a diagnosis of muscular dystrophy. Assessment reveals that the child's muscles have greater-than-normal tone. The nurse should document the presence of: A. tonus. B. flaccidity. C. atony. D. spasticity.

D. spasticity. Rationale: A muscle with greater-than-normal tone is described as spastic. Soft and flabby muscle tone is defined as atony. A muscle that is limp and without tone is described as being flaccid. The state of readiness known as muscle tone (tonus) is produced by the maintenance of some of the muscle fibers in a contracted state. P 1101

A nurse is caring for a client who has an MRI scheduled. What is the priority safety action prior to this diagnostic procedure? A. Assessing the client for signs and symptoms of active infection B. Ensuring that the client can remain immobile for up to 3 hours C. Assessing the client for a history of nut allergies D. Ensuring that there are no metal objects on or in the client

D. Ensuring that there are no metal objects on or in the client Rationale: Absolutely no metal objects can be present during MRI—their presence constitutes a serious safety risk. The procedure takes up to 90 minutes. Nut allergies and infection are not contraindications to MRI. P 1109

When assessing a client's peripheral nerve function, the nurse uses an instrument to prick the fat pad at the top of the client's small finger. This action will assess what nerve? A. Radial B. Ulnar C. Median D. Tibial

B. Ulnar Rationale: The ulnar nerve is assessed for sensation by pricking the fat pad at the top of the small finger. The radial, median, and tibial nerves are not assessed in this manner. P. 1109

A clinic nurse is caring for a client with a history of osteoporosis. What diagnostic test will best allow the care team to assess the client's risk of fracture? A. Arthrography B. Bone scan C. Bone densitometry D. Arthroscopy

C. Bone densitometry Rationale: Bone densitometry is used to detect bone density and can be used to assess the risk of fracture in osteoporosis. Arthrography is used to detect acute or chronic tears of joint capsule or supporting ligaments. Bone scans can be used to detect metastatic and primary bone tumors, osteomyelitis, certain fractures, and aseptic necrosis. Arthroscopy is used to visualize a joint. P 1110

A client has just had an arthroscopy performed to assess a knee injury. What nursing intervention should the nurse perform following this procedure? A. Wrap the joint in a compression dressing. B. Perform passive range of motion exercises. C. Maintain the knee in flexion for up to 30 minutes. D. Apply heat to the knee.

A. Wrap the joint in a compression dressing. Rationale: Interventions to perform following an arthroscopy include wrapping the joint in a compression dressing, extending and elevating the joint, and applying ice or cold packs. Passive ROM exercises, static flexion, and heat are not indicated. P 1111

. Diagnostic tests show that a client's bone density has decreased over the past several years. The client asks the nurse which factors contribute to bone density decreasing. Which response by the nurse would be best? A. "For many people, a lack of proper nutrition can cause a loss of bone density." B. "Progressive loss of bone density is mostly related to your genes." C. "Stress is known to have many unhealthy effects, including reduced bone density." D. "Bone density decreases with age, but scientists are not exactly sure why this is the case."

A. "For many people, a lack of proper nutrition can cause a loss of bone density." Rationale: Nutrition has a profound effect on bone density, especially later life. Genetics are also an important factor, but nutrition has a more pronounced effect. The pathophysiology of bone density is well understood and psychosocial stress has a minimal effect. P 1098

A nurse is caring for a client whose cancer metastasis has resulted in bone pain. What should the nurse expect the client to describe? A. A dull, deep ache that is "boring" in nature B. Soreness or aching that may include cramping C. Sharp, piercing pain that is relieved by immobilization D. Spastic or sharp pain that radiates

A. A dull, deep ache that is "boring" in nature Rationale: Bone pain is characteristically described as a dull, deep ache that is "boring" in nature, whereas muscular pain is described as soreness or aching and is referred to as "muscle cramps." Fracture pain is sharp and piercing and is relieved by immobilization. Sharp pain may also result from bone infection with muscle spasm or pressure on a sensory nerve. P 1104

A nurse is taking a health history on a client with musculoskeletal dysfunction. What should the nurse prioritize during this phase of the assessment? A. Evaluating the effects of the musculoskeletal disorder on the client's function B. Evaluating the client's adherence to the existing treatment regimen C. Evaluating the presence of genetic risk factors for further musculoskeletal disorders D. Evaluating the client's active and passive range of motion

A. Evaluating the effects of the musculoskeletal disorder on the client's function Rationale: The nursing assessment of the client with musculoskeletal dysfunction includes an evaluation of the effects of the musculoskeletal disorder on the client. This is a vital focus of the health history and supersedes the assessment of genetic risk factors and adherence to treatment, though these are both valid inclusions to the interview. Assessment of ROM occurs during the physical assessment, not the interview. P 1101

A nurse is caring for a client who has just had an arthroscopy as an outpatient and is getting ready to go home. The nurse should teach the client to monitor closely for what postprocedure complication? A. Fever B. Crepitus C. Fasciculations D. Synovial fluid leakage

A. Fever Rationale: Following arthroscopy, the client and family are informed of complications to watch for, including fever. Synovial fluid leakage is unlikely and crepitus would not develop as a postprocedure complication. Fasciculations are muscle twitches and do not involve joint integrity or function. P 1110

A 10-year-old client is growing at a rate appropriate for the client's age. Which cells are responsible for the secretion of bone matrix, which eventually results in bone growth? A. Osteoblasts B. Osteocytes C. Osteoclasts D. Lamellae

A. Osteoblasts Rationale: Osteoblasts function in bone formation by secreting bone matrix. Osteocytes are mature bone cells, and osteoclasts are multinuclear cells involved in dissolving and resorbing bone. Lamellae are circles of mineralized bone matrix. P 1115

A nurse is explaining a client's decreasing bone density in terms of the balance between bone resorption and formation. What dietary nutrients and hormones play a role in the resorption and formation of adult bones? Select all that apply. A. Thyroid hormone B. Growth hormone C. Estrogen D. Vitamin B12 E. Luteinizing hormone

A. Thyroid hormone B. Growth hormone C. Estrogen Rationale: The balance between bone resorption and formation is influenced by the following factors: physical activity; dietary intake of certain nutrients, especially calcium; and several hormones, including calcitriol (i.e., activated vitamin D), parathyroid hormone (PTH), calcitonin, thyroid hormone, cortisol, growth hormone, and the sex hormones estrogen and testosterone. Luteinizing hormone and vitamin B12 do not play a role in bone formation or resorption. P 1098

A nurse is caring for an older adult who has been diagnosed with geriatric failure to thrive. The nurse should perform interventions to prevent what complication? A. Muscle clonus B. Muscle atrophy C. Rheumatoid arthritis D. Muscle fasciculations

B. Muscle atrophy Rationale: If a muscle is in disuse for an extended period of time, it is at risk of developing atrophy, which is the decrease in size. Clonus is a pattern of rhythmic muscle contractions and fasciculation is the involuntary twitch of muscle fibers; neither results from immobility. Lack of exercise is a risk factor for rheumatoid arthritis. P 1101

A client is scheduled for a bone scan to rule out osteosarcoma of the pelvic bones. Which client status would be most important for the nurse to verify before the client's scan? A. Completion of the bowel cleansing regimen B. Empty bladder C. No allergy to penicillins D. Fast for at least 8 hours

B. Empty bladder Rationale: Before the scan, the nurse asks the client to empty the bladder, because a full bladder interferes with accurate scanning of the pelvic bones. Bowel cleansing and fasting are not indicated for a bone scan, and an allergy to penicillins is not a contraindication. P 1110

A bone biopsy has just been completed on a client with suspected bone metastases. The nurse should prioritize assessments for which common complication of bone biopsy? A. Dehiscence at the biopsy site B. Pain C. Hematoma formation D. Infection

B. Pain Rationale: Bone biopsy can be painful, and the nurse should prioritize relevant assessments. Dehiscence is not a possibility, because the incision is not linear. Signs and symptoms of infection would not be evident in the immediate recovery period, and hematoma formation is not a common complication. P 1111

While performing an assessment, the nurse notes that a client has soft subcutaneous nodules along the extensor tendons of the fingers. Which disorder does this client most likely have? A. Osteoarthritis B. Rheumatoid arthritis C. Gout D. Paget disease

B. Rheumatoid arthritis Rationale: Soft nodules that occur within or along tendons that provide extensor function to joints are characteristic of rheumatoid arthritis. The nodules of osteoarthritis are hard and painless and consist of bony overgrowth. The nodules of gout are hard and lie within and immediately adjacent to the joint capsule. Nodules are not characteristic of gout. P 1108

A nurse is caring for a client who has been scheduled for a bone scan. Which statement should the nurse include when educating the client about this diagnostic test? A. "The test is brief and requires that you drink a calcium solution 2 hours before the test." B. "You will not be allowed fluid for 2 hours before and 3 hours after the test." C. "You will be encouraged to drink water after the administration of the radioisotope injection." D. "This is a common test that can be safely performed on anyone."

C. "You will be encouraged to drink water after the administration of the radioisotope injection." Rationale: It is important to encourage the client to drink plenty of fluids to help distribute and eliminate the isotope after it is injected. There are important contraindications to the procedure, including pregnancy or an allergy to the radioisotope. The test requires the injection of an intravenous radioisotope, and the scan is performed 2 to 3 hours after the isotope is injected. A calcium solution is not used. P 1110

A client injured in a motor vehicle accident has sustained a fracture to the diaphysis of the right femur. Of which tissue is the diaphysis of the femur mainly constructed? A. Epiphyses B. Cartilage C. Cortical bone D. Cancellous bone

C. Cortical bone Rationale: The long bone shaft, which is referred to as the diaphysis, is constructed primarily of cortical bone. P 1097

A client has sustained traumatic injuries that involve several bone fractures. A fracture of what type of bone may interfere with the protection of the client's vital organs? A. Long bones B. Short bones C. Flat bones D. Irregular bones

C. Flat bones Rationale: Flat bones, such as the sternum, provide vital organ protection. Fractures of the flat bones may lead to puncturing of the vital organs or may interfere with the protection of the vital organs. Long, short, and irregular bones do not usually have this physiologic function. P 1097

A nurse is taking a health history on a new client who has been experiencing unexplained paresthesia. What question should guide the nurse's assessment of the client's altered sensations? A. How does the strength in the affected extremity compare to the strength in the unaffected extremity? B. Does the color in the affected extremity match the color in the unaffected extremity? C. How does the feeling in the affected extremity compare with the feeling in the unaffected extremity? D. Does the client have a family history of paresthesia or other forms of altered sensation?

C. How does the feeling in the affected extremity compare with the feeling in the unaffected extremity? Rationale: Questions that the nurse should ask regarding altered sensations include "How does this feeling compare to sensation in the unaffected extremity?" Asking questions about strength and color is not relevant and a family history is unlikely. P 1103

The nurse's comprehensive assessment of an older adult involves the assessment of the client's gait. How should the nurse best perform this assessment? A. Instruct the client to walk heel-to-toe for 15 to 20 steps. B. Instruct the client to walk in a straight line while not looking at the floor. C. Instruct the client to walk away from the nurse for a short distance and then toward the nurse. D. Instruct the client to balance on one foot for as long as possible and then walk in a circle around the room.

C. Instruct the client to walk away from the nurse for a short distance and then toward the nurse. Rationale: Gait is assessed by having the client walk away from the examiner for a short distance. The examiner observes the client's gait for smoothness and rhythm. Looking at the floor is not disallowed and gait is not assessed by observing balance on one leg. Heel-to-toe walking ability is not gauged during an assessment of normal gait. P 1105

A nurse's assessment reveals that a client has shoulders that are not level and one prominent scapula that is accentuated by bending forward. The nurse should expect to read about which health problem in the client's electronic health record? A. Lordosis B. Kyphosis C. Scoliosis D. Muscular dystrophy

C. Scoliosis Rationale: Scoliosis is evidenced by an abnormal lateral curve in the spine, shoulders that are not level, an asymmetric waistline, and a prominent scapula, accentuated by bending forward. Lordosis is the curvature in the lower back; kyphosis is an exaggerated curvature of the upper back. This finding is not suggestive of muscular dystrophy. P 1106

A client has had a cast placed for the treatment of a humeral fracture. The nurse's most recent assessment shows signs and symptoms of compartment syndrome. What is the nurse's most appropriate action? A. Arrange for a STAT assessment of the client's serum calcium levels. B. Perform active range of motion exercises. C. Assess the client's joint function symmetrically. D. Contact the primary provider immediately.

D. Contact the primary provider immediately. Rationale: This major neurovascular problem is caused by pressure within a muscle compartment that increases to such an extent that microcirculation diminishes, leading to nerve and muscle anoxia and necrosis. Function can be permanently lost if the anoxic situation continues for longer than 6 hours. Therefore, immediate medical care is a priority over further nursing assessment. Assessment of calcium levels is unnecessary. P 1108

A nurse is performing a musculoskeletal assessment of a client with arthritis. During passive range-of-motion exercises, the nurse hears an audible grating sound. The nurse should document the presence of what assessment finding? A. Fasciculations B. Clonus C. Effusion D. Crepitus

D. Crepitus Rationale: Crepitus is a grating, crackling sound or sensation that occurs as the irregular joint surfaces move across one another, as in arthritic conditions. Fasciculations are involuntary twitching of muscle fiber groups. Clonus is the rhythmic contractions of a muscle. Effusion is the collection of excessive fluid within the capsule of a joint. P 1106

The nurse's musculoskeletal assessment of a client reveals involuntary twitching of muscle groups. How would the nurse document this observation in the client's chart? A. Tetany B. Atony C. Clonus D. Fasciculations

D. Fasciculations Rationale: Fasciculation is involuntary twitching of muscle fiber groups. Clonus is a series of involuntary, rhythmic, muscular contractions and tetany is involuntary muscle contraction, but neither is characterized as "twitching." Atony is a loss of muscle strength. P 1106