Chapter 22 (musculoskeletal)-Jarvis

A patient states, "I can hear a crunching or grating sound when I kneel." She also states that "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem?

ANS: Crepitation Crepitation is an audible and palpable crunching or grating that accompanies movement and occurs when articular surfaces in the joints are roughened, as with rheumatoid arthritis. The other options are not correct.

To palpate the temporomandibular joint, the nurse's fingers should be placed in the depression _____ of the ear.

ANS: anterior to the tragus The temporomandibular joint can be felt in the depression anterior to the tragus of the ear. The other locations are not correct.

The functional units of the musculoskeletal system are the:

ANS: joints. Joints are the functional units of the musculoskeletal system because they permit the mobility needed for the activities of daily living. The skeleton (bones) is the framework of the body.

A teenage girl has arrived complaining of pain in her left wrist. She was playing basketball when she fell and landed on her left hand. The nurse examines her hand and would expect a fracture if the girl complains:

ANS: of sharp pain that increases with movement A fracture causes sharp pain that increases with movement. The other pains do not occur with a fracture.

The nurse notices that a woman in an exercise class is unable to jump rope. The nurse knows that to jump rope, one's shoulder has to be capable of:

ANS: circumduction. Circumduction is defined as moving the arm in a circle around the shoulder.

An imaginary line connecting the highest point on each iliac crest would cross the _____ vertebra.

ANS: fourth lumbar An imaginary line connecting the highest point on each iliac crest crosses the fourth lumbar vertebra.

The nurse has completed the musculoskeletal examination of a patient's knee and has found a positive bulge sign. The nurse interprets this finding to indicate:

ANS: swelling from fluid in the suprapatellar pouch. For swelling in the suprapatellar pouch, the bulge sign confirms the presence of fluid. The other options are not correct.

A 14-year-old boy who has been diagnosed with Osgood-Schlatter disease reports painful swelling just below the knee for the past 5 months. Which response by the nurse is appropriate?

ANS: "Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest." Osgood-Schlatter disease is painful swelling of the tibial tubercle just below the knee. It is most likely due to repeated stress on the patellar tendon. It is usually self-limited, occurring during rapid growth and most often in males. The symptoms resolve with rest. The other responses are not appropriate.

When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale?

ANS: 5 Complete range of motion against gravity is normal muscle strength and is recorded as Grade 5 muscle strength.

Of the 33 vertebrae in the spinal column, there are:

ANS: 5 lumbar. There are 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3 to 4 coccygeal vertebrae.

The nurse is assessing the joints of a woman who has stated, "I have a long family history of arthritis, and my joints hurt." The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? Select all that apply.

ANS: Asymmetric joint involvement Pain with motion of affected joints Affected joints are swollen with hard, bony protuberances In osteoarthritis, asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness, swelling with hard bony protuberances, pain with motion, and limitation of motion. The other options reflect signs of rheumatoid arthritis.

The nurse is explaining the mechanism of the growth of long bones to a mother of a toddler. Where does lengthening of the bones occur?

ANS: Epiphyses Lengthening occurs at the epiphyses, or growth plates. The other options are not correct.

The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)?

ANS: Flexion and extension The knee is a hinge joint, permitting flexion and extension of the lower leg on a single plane. The knee is not capable of the other movements listed.

The nurse is examining a 2-month-old infant and notices asymmetry of the infant's gluteal folds. The nurse should assess for other signs of what disorder?

ANS: Hip dislocation Unequal gluteal folds may accompany hip dislocation after 2 to 3 months of age, but some asymmetry may occur in healthy children. Further assessment is needed. The other responses are not correct.

A patient is complaining of pain in his joints that is worse in the morning, is better after he has moved around for awhile, and then gets worse again if he sits for long periods of time. The nurse should assess for other signs of what problem?

ANS: Rheumatoid arthritis Rheumatoid arthritis is worse in the morning when arising. Movement increases most joint pain, except in rheumatoid arthritis, in which movement decreases pain. The other options are not correct.

A patient who has had rheumatoid arthritis for years comes to the clinic to ask about changes in her fingers. The nurse will assess for signs of what problems?

ANS: Swan neck deformities Changes in the fingers caused by chronic rheumatoid arthritis include swan neck and boutonniere deformities. Heberden's nodes and Bouchard's nodules are associated with osteoarthritis. Dupuytren's contractures occur because of chronic hyperplasia of the palmar fascia and causes contractures of the digits (see Table 22-4).

The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal women. Which of these actions is the best way to prevent or delay bone loss in this group?

ANS: Taking calcium and vitamin D supplements Physical activity, such as fast walking, delays or prevents bone loss in perimenopausal women. The faster the pace of walking, the higher the preventive effect on the risk of hip fracture. The other options are not correct.

The nurse is examining a 6-month-old infant and places the infant's feet flat on the table and flexes his knees up. The nurse notes that the right knee is significantly lower than the left. Which of these statements is true of this finding?

ANS: This is a positive Allis sign and suggests hip dislocation. Finding one knee significantly lower than the other is a positive Allis sign and suggests hip dislocation. Normally the tops of the knees are at the same elevation. The other statements are not correct.

A patient has been diagnosed with a ganglion cyst over the dorsum of his left wrist. He asks the nurse, "What is this thing?" The nurse's best answer would be, "It is:

ANS: a common benign tumor." A ganglionic cyst is a common benign tumor; it does not become malignant, and it does not need to be drained. It is not caused by chronic repetitive motion injury.

An 80-year-old woman is visiting the clinic for a checkup. She states, "I can't walk as much as I used to." The nurse is observing for motor dysfunction in her hip and should have her:

ANS: abduct her hip while she is lying on her back. Limitation of abduction of the hip while supine is the most common motion dysfunction found in hip disease. The other options are not correct.

A 40-year-old man has come into the clinic with complaints of "extreme tenderness in my toes." The nurse notices that his toes are slightly swollen, reddened, and warm to the touch. His complaints would suggest:

ANS: acute gout. Acute gout occurs primarily in men over 40 years of age. Clinical findings consist of redness, swelling, heat, and extreme tenderness. Gout is a metabolic disorder of disturbed purine metabolism, associated with elevated serum uric acid. See Table 22-1 for descriptions of the other terms.

A patient is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called:

ANS: adduction. Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body. Flexion is bending a limb at a joint; extension is straightening a limb at a joint.

A young swimmer comes to the sports clinic complaining of a very sore shoulder. He was running at the pool, slipped on some wet concrete, and tried to catch himself with his outstretched hand. He landed on his outstretched hand and has not been able to move his shoulder since then. The nurse suspects:

ANS: adhesive capsulitis. Dislocated shoulder occurs with trauma involving abduction, extension, and external rotation (e.g., falling on an outstretched arm or diving into a pool). See Table 22-2 for a description of the other conditions.

When reviewing the musculoskeletal system, the nurse recalls that hematopoiesis takes place in the:

ANS: bone marrow. The musculoskeletal system functions to encase and protect inner vital organs, support the body, produce red blood cells in the bone marrow, and store minerals.

The nurse is assessing a patient's ischial tuberosity. To palpate the ischial tuberosity, the nurse knows that it is best to have the patient:

ANS: flex the hip. The ischial tuberosity lies under the gluteus maximus muscle and is palpable when the hip is flexed.

A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement?

ANS: flexion. Flexion, or bending a limb at a joint, would be required to move the hand to the mouth. Extension is straightening a limb at a joint. Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body.

A patient's annual physical examination reveals a lateral curvature of the thoracic and lumbar segments of his spine; however, this curvature disappears with forward bending. The nurse knows that this abnormality of the spine is called:

ANS: functional scoliosis. Functional scoliosis is flexible; it is apparent with standing and disappears with forward bending. Structural scoliosis is fixed; the curvature shows both when standing and when bending forward. See Table 22-7 for description of herniated nucleus pulposus. These findings are not indicative of a dislocated hip.

A patient tells the nurse that "all my life I've been called 'knock knees.'" The nurse knows that another term for "knock knees" is:

ANS: genu valgum. Genu valgum is also known as "knock knees" and is present when there is more than 2.5 cm between the medial malleoli when the knees are together.

The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. The nurse knows that a rotator cuff injury involves the:

ANS: glenohumeral joint. A rotator cuff injury involves the glenohumeral joint, which is enclosed by a group of four powerful muscles and tendons that support and stabilize it. The nucleus pulposus is located in the center of each intervertebral disk. The medial epicondyle is located at the elbow.

The nurse is examining the hip area of a patient and palpates a flat depression on the upper, lateral side of the thigh when the patient is standing. The nurse interprets this finding as the:

ANS: greater trochanter. The greater trochanter of the femur is palpated when the person is standing, and it appears as a flat depression on the upper lateral side of the thigh. The iliac crest is the upper part of the hip bone; the ischial tuberosity lies under the gluteus maximus muscle and is palpable when the hip is flexed. The gluteus muscle is part of the buttocks.

During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, he complains of a pain going down his buttock into his leg. The nurse suspects:

ANS: herniated nucleus pulposus. Lateral tilting and sciatic pain with straight leg raising are findings that occur with a herniated nucleus pulposus. The other options are not correct.

The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen's test. To perform this test, the nurse should instruct the patient to:

ANS: hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. For the Phalen's test, the nurse should ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. The Phalen's test reproduces numbness and burning in a person with carpal tunnel syndrome. The other actions are not correct for testing for carpal tunnel syndrome.

The nurse is explaining to a patient that there are "shock absorbers" in his back to cushion the spine and to help it move. The nurse is referring to his:

ANS: intervertebral disks. Intervertebral disks are elastic fibrocartilaginous plates that cushion the spine like shock absorbers and help it move. The vertebral column is the spinal column itself. The nucleus pulposus is located in the center of each disk. The vertebral foramen is the channel, or opening, for the spinal cord in the vertebrae.

Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called:

ANS: ligaments. Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called ligaments.

A mother brings her newborn baby boy in for a checkup; she tells the nurse that he doesn't seem to be moving his right arm as much as his left and that he seems to have pain when she lifts him up under the arms. The nurse suspects a fractured clavicle and would observe for:

ANS: limited range of motion during the Moro's reflex. For a fractured clavicle, the nurse should observe for limited arm range of motion and unilateral response to the Moro's reflex. The other tests are not appropriate for this problem.

A woman who is 8 months pregnant comments that she has noticed a change in posture and is having lower back pain. The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus. This shift in posture is known as:

ANS: lordosis. Lordosis compensates for the enlarging fetus, which would shift the center of balance forward. This shift in balance in turn creates strain on the low back muscles, felt as low back pain during late pregnancy by some women. Scoliosis is lateral curvature of portions of the spine; ankylosis is extreme flexion of the wrist, as seen with severe rheumatoid arthritis; and kyphosis is an enhanced thoracic curvature of the spine.

A patient has been diagnosed with osteoporosis and asks the nurse, "What is osteoporosis?" The nurse explains to the patient that osteoporosis is defined as:

ANS: loss of bone density. After age 40, loss of bone matrix (resorption) occurs more rapidly than new bone formation. The net effect is a gradual loss of bone density, or osteoporosis. The other options are not correct.

A professional tennis player comes into the clinic complaining of a sore elbow. The nurse will assess for tenderness at the:

ANS: medial and lateral epicondyle. The epicondyles, the head of radius, and tendons are common sites of inflammation and local tenderness, or "tennis elbow." The other locations are not affected.

A patient is visiting the clinic for an evaluation of a swollen, painful knuckle. The nurse notices that the knuckle above his ring on the left hand is swollen and that he is unable to remove his wedding ring. This joint is called the _____ joint.

ANS: metacarpophalangeal The joint located just above the ring on the finger is the metacarpophalangeal joint. The interphalangeal joint is located distal to the metacarpophalangeal joint. The tarsometatarsal and tibiotalar joints are found in the foot and ankle. See Figure 22-10 for a diagram of the bones and joints of the hand and fingers.

The nurse is examining a 3-month-old infant. While holding the thumbs on the infant's inner mid thighs and the fingers outside on the hips, touching the greater trochanter, the nurse adducts the legs until the nurse's thumbs touch and then abducts the legs until the infant's knees touch the table. The nurse does not notice any "clunking" sounds and is confident to record a:

ANS: negative Ortolani's sign. Normally this maneuver feels smooth and has no sound. With a positive Ortolani's sign, the nurse will feel and hear a "clunk" as the head of the femur pops back into place. A positive Ortolani's sign reflects hip instability. The Allis test also tests for hip dislocation, but is done by comparing leg lengths.

An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because:

ANS: of the shortening of the vertebral column. Postural changes are evident with aging; decreased height is most noticeable and is due to shortening of the vertebral column. Long bones do not shorten with age. Intervertebral disks actually get thinner with age. Subcutaneous fat is not lost but is redistributed to the abdomen and hips.

A 68-year-old woman has come in for an assessment of her rheumatoid arthritis, and the nurse notices raised, firm, nontender nodules at the olecranon bursa and along the ulna. These nodules are most commonly diagnosed as:

ANS: olecranon bursitis. Subcutaneous nodules are raised, firm, and nontender and occur with rheumatoid arthritis in the olecranon bursa and along the extensor surface of the ulna. See Table 22-3 for a description of the other conditions.

During a neonatal examination, the nurse notices that the newborn infant has six toes. This finding is documented as:

ANS: polydactyly. Polydactyly is the presence of extra fingers or toes. Syndactyly is webbing between adjacent fingers or toes. The other terms are not correct.

When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be:

ANS: proximal to distal. The musculoskeletal assessment should be done in an orderly approach, head to toe, proximal to distal, from the midline outward. The other options are not correct.

A patient is able to flex his right arm forward without difficulty or pain but is unable to abduct his arm because of pain and muscle spasms; the nurse should suspect:

ANS: rotator cuff lesions. Rotator cuff lesions may cause limited range of motion and pain and muscle spasm during abduction, whereas forward flexion stays fairly normal. The other options are not correct.

The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal woman. A participant shows that she needs more instruction when she states, "I will:

ANS: start swimming to increase my weight-bearing exercise." Weight-bearing exercises include walking, low-impact aerobics, dancing, or stationary cycling. Swimming is not considered a weight-bearing exercise. The other responses are correct.

The nurse is assessing a 1-week-old infant and is testing his muscle strength. The nurse lifts the infant with hands under the axillae and notices that the infant starts to "slip" between the hands. The nurse should:

ANS: suspect that the infant may have weakness of the shoulder muscles. An infant who starts to "slip" between the nurse's hands shows weakness of the shoulder muscles. An infant with normal muscle strength wedges securely between the nurse's hands. The other responses are not correct.

The ankle joint is the articulation of the tibia, the fibula, and the:

ANS: talus. The ankle or tibiotalar joint is the articulation of the tibia, fibula, and talus. The other bones listed are foot bones, but not part of the ankle joint.

The articulation of the mandible and the temporal bone is known as the:

ANS: temporomandibular joint. The articulation of the mandible and the temporal bone is the temporomandibular joint. The other responses are not correct.

A man who has had gout for several years comes to the clinic with a problem with his toe. On examination, the nurse notices the presence of hard, painless nodules over the great toe; one has burst open with a chalky discharge. This finding is known as:

ANS: tophi. Tophi are collections of sodium urate crystals resulting from chronic gout in and around the joint that cause extreme swelling and joint deformity. They appear as hard, painless nodules (tophi) over the metatarsophalangeal joint of the first toe and they sometimes burst with a chalky discharge (See Table 22-6). See Table 22-6 for descriptions of the other conditions.

A woman who has had rheumatoid arthritis for years is starting to notice that her fingers are drifting to the side. The nurse knows that this condition is commonly referred to as:

ANS: ulnar deviation. Fingers drift to the ulnar side because of stretching of the articular capsule and muscle imbalance caused by chronic rheumatoid arthritis. Radial drift is not seen. See Table 22-4 for descriptions of swan neck deformity and Dupuytren's contracture.

During an interview the patient states, "I can feel this bump on the top of both of my shoulders—it doesn't hurt but I am curious about what it might be." The nurse should tell the patient, "That is:

ANS: your acromion process." The bump of the scapula's acromion process is felt at the very top of the shoulder. The other options are not correct.