Chapter 39: Assessment of Musculoskeletal Function - ML4
The nurse is admitting an older adult to a skilled nursing facility. What assessment parameters will the nurse expect to find with the musculoskeletal assessment? Select all that apply. 1. decreased range of motion 2. increase in height 3. joint stiffness 4. increased muscle strength 5. decreased endurance
1, 3, 5. Explanation: Significant assessment findings of the musculoskeletal system in the older adult would include joint stiffness and decreased height, range of motion, muscle strength, and endurance. Older adults may have decreased height from osteoporosis and decreased muscle strength from atrophy. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1103
Which term refers to moving away from midline? Inversion Adduction Abduction Eversion
Abduction Explanation: Abduction is moving away from the midline. Adduction is moving toward the midline. Inversion is turning inward. Eversion is turning outward. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1102
The primary functions of cartilage are to reduce friction between articular surfaces, absorb shocks, and reduce stress on joint surfaces. Where in the human body is cartilage found? between the vertebrae between the ribs All options are correct. covering elbow joints
All options are correct. Explanation: Types of cartilage include costal cartilage, which connects the ribs and sternum; semilunar cartilage, which is one of the cartilages of the knee joint; fibrous cartilage, found between the vertebrae (intervertebral disks); and elastic cartilage, found in the larynx, epiglottis, and outer ear. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1097
A client has had an electromyography. What is an appropriate nursing intervention following this diagnostic procedure? Apply a compression dressing. Apply warm compresses. Monitor the client for anaphylaxis. Monitor the client for infection.
Apply warm compresses. Explanation: Electromyography involves the insertion of needles into select muscles. The nurse applies warm compresses to the insertion sites to relieve discomfort following the procedure. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1111
A patient is scheduled for a procedure that will allow the physician to visualize the knee joint in order to diagnose the patient's pain. What procedure will the nurse prepare the patient for? Arthroscopy Electromyography Bone scan Arthrocentesis
Arthroscopy Explanation: Arthroscopy is a procedure that allows direct visualization of a joint through the use of a fiberoptic endoscope. Thus, it is a useful adjunct to diagnosing joint disorders. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1110
The nurse is performing a neurological assessment. What will this assessment include? Observe for capillary refill of the great toe. Inspect the foot for edema. Palpate the dorsalis pedis pulse. Ask the client to plantar flex the toes.
Ask the client to plantar flex the toes. Explanation: A neurological assessment evaluates sensation and motion. Assessing plantar flexion of the toes would be included in a neurological assessment. Capillary refill, palpation of pulses, and inspecting for edema would be included in a vascular assessment. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1104
The nurse is discussing an older adult's risk for skeletal fractures with a group of students assigned to the clinical area. Which of the following would the nurse most likely explain as the underlying reason for the increased risk? Bone resorption is more rapid than bone formation. Aging leads to a deficiency of calcium. No bone reformation occurs in the older adult. Collagen formation decreases.
Bone resorption is more rapid than bone formation. Explanation: Older adults are more prone to skeletal fractures because bone resorption is more rapid than bone formation. Collagen formation increases resulting in fibrosis and loss of strength and flexibility. Increased risk for skeletal fractures is not always due to a calcium deficiency. The process of bone reformation does not stop with age. Age-related declines of estrogen and testosterone production cause bone loss. After age 35 years, people generally experience a loss of bone mass. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1101
Which hormone inhibits bone reabsorption and increases calcium deposit in the bone? Calcitonin Sex hormones Growth hormone Vitamin D
Calcitonin Explanation: Calcitonin, secreted by the thyroid gland in response to elevated blood calcium concentration, inhibits bone reabsorption and increases the deposit of calcium in the bone. The other answers do not apply. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1098
What is the term for a rhythmic contraction of a muscle? Clonus Crepitus Hypertrophy Atrophy
Clonus Explanation: Clonus is a rhythmic contraction of the muscle. Atrophy is a shrinkage-like decrease in the size of a muscle. Hypertrophy is an increase in the size of a muscle. Crepitus is a grating or crackling sound or sensation that may occur with movement of ends of a broken bone or irregular joint surface. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1108
The nurse is performing a neurovascular assessment of a client's injured extremity. Which would the nurse report? Positive distal pulses Dusky or mottled skin color Skin warm to touch Capillary refill of 3 seconds
Dusky or mottled skin color Explanation: Normally, skin color would be similar to the color in other body areas. Pale or dusky skin color indicates an abnormality that needs to be reported. Presence of pulses, capillary refill of 3 seconds, and warm skin are normal findings. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1107
Which diagnostic test would the nurse expect to be ordered for a client with lower extremity muscle weakness? Bone scan Biopsy Arthrocentesis Electromyograph (EMG)
Electromyograph (EMG) Explanation: The EMG provides information about the electrical potential of the muscles and the nerves leading to them. The test is performed to evaluate muscle weakness, pain, and disability. An arthrocentesis, bone scan, and biopsy does not measure muscle weakness. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1111
The nurse is performing an assessment on an older adult patient and observes the patient has an increased forward curvature of the thoracic spine. What does the nurse understand this common finding is known as? Osteoporosis Lordosis Kyphosis Scoliosis
Kyphosis Explanation: Common deformities of the spine include kyphosis, which is an increased forward curvature of the thoracic spine that causes a bowing or rounding of the back, leading to a hunchback or slouching posture. The second deformity of the spine is referred to as lordosis, or swayback, an exaggerated curvature of the lumbar spine. A third deformity is scoliosis, which is a lateral curving deviation of the spine (Fig. 40-4). Osteoporosis is abnormal excessive bone loss. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1101
A nurse is caring for a client with an undiagnosed bone disease. When instructing on the normal process to maintain bone tissue, which process transforms osteoblasts into mature bone cells? Ossification and calcification Resorption Epiphyses and diaphysis formation Remodeling
Ossification and calcification Explanation: Ossification and calcifications the body's process to transform osteoblasts into mature bone cells called osteocytes. Osteocytes are involved in maintaining bone tissue. Resorption and remodeling are involved in bone destruction. Epiphyses and diaphyses are bone tissues that provide strength and support to the human skeleton. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1099
An instructor is describing the process of bone development. Which of the following would the instructor describe as being responsible for the process of ossification? Cortical bone Osteoclasts Osteoblasts Cancellous bone
Osteoblasts Explanation: Osteoblasts secrete bone matrix (mostly collagen), in which inorganic minerals, such as calcium salts, are deposited. This process of ossification and calcification transforms the blast cells into mature bone cells, called osteocytes, which are involved in maintaining bone tissue. Cortical bone is dense hard bone found in the long shafts; cancellous bone is spongy bone found in the irregular rounded edges of bone. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1098
After a fracture, during which stage or phase of bone healing is devitalized tissue removed and new bone reorganized into its former structural arrangement? Revascularization Reparative Remodeling Inflammation
Remodeling Explanation: Remodeling is the final stage of fracture repair. During inflammation, macrophages invade and debride the fracture area. Revascularization occurs within about 5 days after a fracture. Callus forms during the reparative stage but is disrupted by excessive motion at the fracture site. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1099
A client has a fracture that is being treated with open rigid compression plate fixation devices. What teaching will the nurse reinforce to the client about how the progress of bone healing will be monitored? An arthroscopy will be performed. The bone will heal on its own without intervention. The plate will be removed to determine if the bone is growing back. Serial x-rays will be taken.
Serial x-rays will be taken. Explanation: Serial x-rays are used to monitor the progress of bone healing. The plate need not be disturbed. An arthroscopy is used to visualize joints. While the bone will heal without interference, monitoring of bone healing is needed to ensure further adjustments are not necessary. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1099
The nurse is reviewing the client's admission assessment and notes that crepitus of the right knee joint was documented. What assessment will the nurse find as described by crepitus? a grating sound when a joint is put through range of motion excessive fluid within the capsule of a joint characterized by limited range of motion of a joint characterized by involuntary muscle twitching of the knee
a grating sound when a joint is put through range of motion Explanation: Crepitus is a grating sound or sensation when a joint is put through range of motion. Limited range of motion can be a contracture and is not part of crepitus. Excessive fluid is an effusion. An involuntary muscle twitching is clonus. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1106
The nurse working in the emergency department receives a call from the x-ray department communicating that the client the nurse is caring for has a fracture in the shaft of the tibia. The nurse tells the physician that the client's fracture is in the diaphysis. lordosis. scoliosis. epiphysis.
diaphysis. Explanation: The diaphysis is primarily cortical bone. An epiphysis is an end of a long bone. Lordosis refers to an increase in lumbar curvature of spine. Scoliosis refers to lateral curving of the spine. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1097
A client is recovering from a fractured hip. The nurse would suggest that the client increase intake of which of the following to facilitate calcium absorption from food and supplements? Vitamin B6 Vitamin D Amino acids Dairy products
Vitamin D Explanation: The nurse must advise a client recovering from a fractured hip to increase the intake of vitamin D because it protects against bone loss and decreases the risk of recurring fracture by facilitating calcium absorption from food and supplements. Amino acids and vitamin B6, although important, do not facilitate the absorption of calcium. Dairy products also do not facilitate the absorption of calcium; however, the exception to this is vitamin D-fortified milk. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1098
Which medication taken by the client in the previous 24 hours would be of greatest concern to the nurse caring for a client undergoing a bone biopsy? furosemide aspirin NPH insulin digoxin
aspirin Explanation: Aspirin has anti-clotting properties, and bone is a very vascular tissue. The client taking aspirin in close proximity to a bone biopsy is at increased risk for excessive bleeding. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1111
The nurse is conducting a medication reconciliation with a client admitted with a fracture. What medication predisposes a client for a risk for fractures? digoxin prednisone furosemide metoprolol
prednisone Explanation: Prednisone, a corticosteroid, causes increased bone resorption and decreased bone formation, resulting in increased risk for fractures. Furosemide, digoxin, and metoprolol do not interfere with bone resorption or predispose clients to fractures. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1104
A patient has a fracture of the right femur sustained in an automobile accident. What process of fracture healing does the nurse understand will occur with this patient? Primary phase, secondary phase, third phase First intention, secondary intention, third intention Reactive phase, reparative phase, remodeling phase Active phase, dormant phase, restructure phase
Reactive phase, reparative phase, remodeling phase Explanation: The process of fracture healing occurs over three phases. These include the following: Phase I: Reactive phase; Phase II: Reparative phase; and Phase III: Remodeling phase. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1099
A client has just undergone arthrography. What is the most important instruction for the nurse to include in the teaching plan? Avoid intake of dairy products. Gently massage joints with any crackling or clicking joint noises. Report joint crackling or clicking noises occurring after the second day. Avoid sunlight or harsh, dry climate.
Report joint crackling or clicking noises occurring after the second day. Explanation: After undergoing arthrography, the client must be informed that he or she may hear crackling or clicking noises in the joints for up to 2 days, but if noises occur beyond this time, they should be reported. These noises may indicate the presence of a complication, and therefore should not be ignored or treated by the client. Massage is not indicated. The client need not be asked to avoid sunlight or dairy products. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1110
Which is an indicator of neurovascular compromise? Diminished pain Warm skin temperature Capillary refill of more than 3 seconds Pain upon active stretch
Capillary refill of more than 3 seconds Explanation: Capillary refill of more than 3 seconds is an indicator of neurovascular compromise. Other indicators include cool skin temperature, pale or cyanotic color, weakness, paralysis, paresthesia, unrelenting pain, pain upon passive stretch, and absence of feeling. Cool skin temperature is an indicator of neurovascular compromise. Unrelenting pain is an indicator of neurovascular compromise. Pain upon passive stretch is an indicator of neurovascular compromise. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1107
A client is exhibiting diminished range of motion, loss of flexibility, stiffness, and loss of height. The history and physical findings are associated with age-related changes of which area? Joints Muscles Ligaments Bones
Joints Explanation: History and physical findings associated with age-related changes of the joints include diminished range of motion, loss of flexibility, stiffness, and loss of height. History and physical findings associated with age-related changes of bones include loss of height, posture changes, kyphosis, flexion of hips and knees, back pain, osteoporosis, and fracture. History and physical findings associated with age-related changes of muscles include loss of strength, diminished agility, decreased endurance, prolonged response time (diminished reaction time), diminished tone, a broad base of support, and a history of falls. History and physical findings associated with age-related changes of ligaments include joint pain on motion that resolves with rest, crepitus, joint swelling/enlargement, and degenerative joint disease (osteoarthritis). Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1103
A nurse practitioner assesses a patient's movement in his left hand after a cast is removed. The nurse asks the patient to turn his wrist so the palm of his hand is facing up. This movement is known as: Pronation. Supination. Eversion. Extension.
Supination. Explanation: Refer to Figure 40-3 in the text for an illustration of body movements produced by muscle contraction. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1102
Red bone marrow produces which of the following? Select all that apply. Estrogen White blood cells (WBCs) Platelets Red blood cells (RBCs) Corticosteroids
White blood cells (WBCs) Platelets Red blood cells (RBCs) Explanation: The red bone marrow located within the bone cavities produces RBC, WBCs, and platelets through the process of hematopoiesis. The red bone marrow does not produce estrogen or corticosteroids. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1098
Which is a neurovascular problem caused by pressure within a muscle area that increases to such an extent that microcirculation diminishes? Hypertrophy Fasciculation Compartment syndrome Remodeling
Compartment syndrome Explanation: Compartment syndrome is caused by pressure within a muscle area that increases to such an extent that microcirculation diminishes. Remodeling is a process that ensures bone maintenance through simultaneous bone resorption and formation. Hypertrophy is an increase in muscle size. Fasciculation is the involuntary twitch of muscle fibers. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1108
The nurse is evaluating a client's peripheral neurovascular status. Which would the nurse report to the health care provider as a circulatory indicator of peripheral neurovascular dysfunction? Cool skin Weakness Paralysis Paresthesia
Cool skin Explanation: Indicators of peripheral neurovascular dysfunction related to circulation include pale, cyanotic, or mottled skin with a cool temperature. The capillary refill is more than 3 seconds. Weakness and paralysis are related to motion. Paresthesia is related to sensation. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1109
The homecare nurse is evaluating the musculoskeletal system of a geriatric client whose previous assessment was within normal limits. The nurse initiates a call to the health care provider and/or emergency services when which change is found? Decreased agility Increased joint stiffness Decreased flexibility Decreased right-sided muscle strength
Decreased right-sided muscle strength Explanation: Although symmetrical decreases in muscle strength can be a part of the aging process, asymmetrical decreases are not. The nurse should contact the health care provider when decreased right-sided muscle strength is found, as this could indicate a stroke or transient ischemic attack. Decreased flexibility, decreased agility, and increased joint stiffness are all part of the aging process and therefore do not require the nurse to contact the health care provider. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1105
A client comes to the emergency department with reports of pain in the left ankle. The client states, "I missed a step coming down the stairs, and landed funny." The ankle is swollen and tender to the touch. What will the nurse do to help control the swelling? Apply heat to the ankle. Tell the client to flex the left foot frequently. Raise the left leg above the level of the heart. Have the client dangle the left leg over the side of the bed.
Raise the left leg above the level of the heart. Explanation: To help relieve swelling and promote tissue perfusion, the nurse would have the client elevate the swollen body part above the level of the heart to promote venous circulation. If appropriate, the nurse would consult with the health care provider about applying ice to the area to help relieve edema. Telling the client to flex the foot would have no effect on edema and would most likely increase the pain and possibly the injury. Dangling the leg over the side of the bed would cause venous stasis, possibly increasing the edema due to the effect of gravity. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1107
The nurse is assessing the client for scoliosis. What will the nurse have the client do to perform the assessment? Stand in front of the client and ask the client to bend forward at the waist. Stand to the side of the client and observe the client's spinal curvatures. Stand behind the client and ask the client to walk a short distance away. Stand behind the client and ask the client to bend forward at the waist.
Stand behind the client and ask the client to bend forward at the waist. Explanation: Scoliosis is characterized by a lateral curvature of the spine. The nurse stands behind the client and asks the client to bend forward at the waist for the nurse to examine the spine curvature. The nurse cannot see the spine by standing beside the client or in front of the client. The spinal curve cannot be seen by watching the client walk. Reference: Chapter 35: Assessment of Musculoskeletal Function - Page 1105
