Chapter 21 PrepU

An adult client tells the nurse that he eats sardines every day. The nurse should instruct the client that a diet hight in purines can contribute to...

gouty arthritis

The nurse is performing an assessment of client's musculoskeletal system. What would the nurse examine first?

the client's gait

A nurse wants to assess the prevertebral muscles of a client who reports neck stiffness. In order to effectively conduct the physical examination of this area, the nurse should give which instruction to the client?

"Bring your chin to your chest"

What is an appropriate question by the nurse to ask a client about the presence of temporomandibular joint dysfunction?

"Have you noticed a popping or grating sound when you chew?"

When assessing a client's foot, how would the nurse document an exaggerated arch height?

"Patient has pes cavus"

During the health history of the musculoskeletal system, the client reports having low back pain that radiates into the leg with numbness and tingling. The nurse should further assess for spinal stenosis when the client makes which of the following statements?

"The pain improves when I am leaning over a shopping cart"

A client is brought to the health care facility with a sudden loss of movement on the right side of the body. Upon assessment, the nurse finds that the client has a slight flicker of contraction in the muscles on the right side. What should the nurse document as a muscle strength rating?

1

How would the nurse document normal muscle strength?

5/5

Which joint movement is a nurse testing when asking a client to move an extremity towards the body?

Adduction

A nurse inspects a flattened lumbar curvature in a client. Which of the following conditions should the nurse most suspect in this client?

Ankylosing spondylitits

While assessing the elbow of an adult client, the client complains of pain and swelling. The nurse should assess the client for

Arthritis

A nurse is caring for a client who is recovering from a stroke. The nurse assesses the muscle strength of the client's arm and finds that the joint exhibits active motion against gravity. Which of the following should the nurse document to classify the muscle strength based on this finding?

Average weakness

The nurse asks the client to perform the action shown. What is the nurse assessing?

Carpal tunnel syndrome

A nurse is working with a client who has cervical disc degenerative disease with resulting impaired range of motion and pain that radiates to the back. The nurse understands that joints between the vertebrae are which type of joint?

Cartilaginous

A client complains of chronic pain and fatigue. The nurse suspects fibromyalgia. What is a diagnosis of this condition based on?

Client's symptoms

A client is being discharged home from the hospital. This client has a history of falling at home. A caregiver is not able to stay with the client all the time. What can be done to decrease the risk for falling at the client's home?

Correct environmental hazards in the home Install grab bars in the bathroom Make sure house hallways are well lit

Durning the nursing history of a newly admitted client, the nurse is reviewing a client's current medication regimen. What medication category creates a risk for decreased bone density?

Corticosteroids

When assessing the gait pattern of a client diagnosed with Alzheimer disease, the nurse should expect to observe which finding?

Difficulty initiating a slow, shuffling gait

The nurse is examining an older adult client. During the physical assessment, the client appears to be getting fatigued. What can the nurse do to help the client finish the assessment?

Divide the assessment into portions

The nurse performs the maneuver shown with the client. What is the nurse assessing?

Elbow extension

Risk factors in which of the following areas are most readily changed to reduce the potential risk for falls?

Environmental

When assessing the client's upper extremities, the nurse instructs the client to put the hands behind the neck with the elbows pointed laterally. This positioning facilitates assessment of which of the following functions?

External rotation of the shoulder

A new client is admitted to a long term care facility. The nurse assesses the client with an unsteady gait and incontinence. Which problem should the nurse address when planning care for this client?

Falls

What range of motion is the nurse testing by asking the client to stoop to pick up an object off the floor?

Flexion

Upon examination of an elderly client, the nurse finds hard, painless nodules over the distal interphalangeal joints. What is the appropriate term the nurse should use to document this finding in the client's medical records?

Heberden's nodes

A nurse is clustering data after performing a comprehensive assessment on an older adult client. The nurse notes the following findings: bilateral joint pain and stiffness that is worse in the morning and after sitting for long periods of time. Pain and stiffness improve with movement. What is the best action of the nurse?

Further assess the client for other signs and symptoms of rheumatoid arthritis

A nurse inspects a child's legs while standing and notices that the knees turn inward. How should this finding be documented in the medical record?

Genu valgum

Which of these medications should a nurse ask whether a client is taking when assessing the risk for osteoporosis?

Glucocorticoids

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?

Goniometer

A client presents at the clinic with an enlarged, swollen, hot, and red metatarsophalangeal joint and bursa of the great toe. What medical diagnosis would the nurse expect?

Gout

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?

Impaired Physical Mobility

A community health nurse is providing education to help reduce musculoskeletal injuries in adults. What should the nurse include in these instructions?

Importance or regular exercise Maintaining a body weight appropriate to height and frame Using proper body mechanics with lifting objects Maintaining a safe home environment

Which finding in an elderly client requires additional assessment by a nurse when inspecting the musculoskeletal system?

Inability to button the jacket due to swollen finger joints

Which characteristic should a nurse assess during inspection of the musculoskeletal system?

Massess Color Contour Swelling

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

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

arthritis

A nurse notices that a client's flexibility of the right elbow is less than the left elbow. What is an appropriate action by the nurse in regard to this finding?

Measure movement with a goniometer

The client is complaining that his lower joints are increasingly painful as the day progresses. The nurse suspects the client is experiencing what musculoskeletal disorder?

Osteoarthritis

Louise is a 60-year-old woman who complains of left knee pain associated with tenderness throughout, redness, and warmth over the joint. Which of the following is least helpful in determining if a joint problem is inflammatory?

Pain

The client presents at the clinic with a history of cerebral palsy. When examining the client the nurse notes increased resistance that is rate dependent and increases with rapid movement. What would the nurse chart about this client?

Patient demonstrates spasticity

Which action by a nurse is a correct method for performing Tinel's test to determine the presence of carpel tunnel syndrome?

Percuss lightly on the inner aspect of the wrist

When inspecting a client's feet, the nurse observes that the toes point inward. The nurse documents this finding as which of the following?

Pes varus

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?

Pronation

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?

Protraction

A client visits the health care facility with reports of lumbar back pain that radiates down the back. The nurse performs Lasegue's test to determine the origin of the pain. Which techniques should the nurse use to perform Lasegue's test?

Raise the leg to the point of pain and dorsiflex the foot

After teaching a group of students about the bones and their functions, the instructor determines that the teaching was successful when the students state that blood cells are produced in which of the following?

Red marrow

What finding should a nurse expect when performing the Phalen's test on a client with suspected carpal tunnel syndrome?

Reports of tingling, numbness, and pain in the involved wrist

Into which of the following positions should the client be placed for the nurse to effectively examine the tibiofemoral joint of the knee?

Sitting with knees in flexion

A 38-year-old woman presents with multiple small joints that are symmetrically involved with pain, swelling, and stiffness. Which of the following is the most likely explanation?

Rheumatoid arthritis

The nurse is planning the care of a 77-year-old woman who has recently been diagnosed with osteoporosis. What nursing diagnoses should the nurse address in the client's plan of care?

Risk for injury related to osteoporosis Activity intolerance related to osteoporosis Impaired physical mobility related to osteoporosis

A client has uneven height of the shoulders and hips. What should the nurse suspect this client is demonstrating?

Scoliosis

The school nurse notes that the client carries her left shoulder higher than her right shoulder. You should recognize the likely presence of what health problem?

Scoliosis

A nurse is conducting a physical examination of the musculoskeletal system of a client who reports having joint pain. Which signs indicate there is inflammation in the joints?

Swelling Warmth Redness Tenderness

Assessment of a client's ankle joint includes palpation along the Achilles tendon to look for which of the following?

Tenderness and nodules

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 had a total hip replacement 2 years ago

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 midline and aligned with the spine

A 50-year-old woman presents with "left hip pain" of several weeks duration. She is exquisitely tender when the nurse presses over her proximal lateral thigh. What is her most likely health problem?

Trochanteric bursitis

When assessing muscle tone and strength, the nurse would document expected findings as...

Upper and lower extremity muscle strength is 5/5 bilaterally

The nurse is performing the bulge test during the assessment of the client's knee. This test will allow the nurse to make what determination?

Whether the client's swollen knee is caused by tissue swelling or by fluid accumulation

A nurse is assessing a group of clients. The nurse identifies which of the following clients as being at the highest risk for developing osteoporosis?

a 63-year-old female who began menarche late and had an early menopause

Joints may be classified as cartilaginous, synovial, or...

fibrous

While reviewing a client's chart before seeing the client for the first time, the nurse notes that the client has a diagnosis of Dupuytren contracture. The nurse anticipates that the client will exhibit...

inability to extend the ring and little finger

While sitting a client raises both legs while the nurse holds the lower legs below the knee. What does this finding indicate?

normal quadriceps muscle strength

The nurse is going to test range of motion in a client. To test extension of the triceps muscle, the nurse would instruct the client to

straighten the elbow