Chapter 39 Assessment of musculoskeletal function: Prep-U
Which nursing action is most important in caring for the client following an arthrogram? Assist the client with passive range of motion. Keep the joint below the level of the heart. Administer morphine sulfate. Apply ice to the joint.
Apply ice to the joint. Explanation: Ice is applied to minimize edema and provide analgesia to the joint. The joint is elevated to minimize edema. Mild analgesics are sufficient to control pain. The joint is usually rested for 12 hours post-procedure.
The nurse is reporting on the results of client blood work to the oncoming nurse. Upon reviewing the data, it is noted that the client has an elevated uric acid level. Which inflammatory process would the nurse screen for on shift rounds? Lupus erythematosus Rheumatoid arthritis Osteoporosis Gout
Gout Explanation: Gout is a medical condition with symptoms of acute inflammatory arthritis that is caused by high levels of uric acid in the blood. The client has uric acid crystal deposits in the joint. The nurse would assess joint areas for pain, redness, and swelling. Rheumatoid arthritis is a chronic disease of joint inflammation and pain. Lupus erythematous is a chronic tissue disorder of the connective tissue and is known to have an elevated antinuclear antibody level. Osteoporosis has a deficiency in the serum calcium level.
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? NPH insulin furosemide aspirin digoxin
aspirin Explanation: Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 39: Assessment of Musculoskeletal Function, Biopsy, p. 1129.
A nursing student asks the nurse why older adults are at risk for falls. The best response by the nurse is: "Cartilage deteriorates with age." "Bones become more fragile." "Muscles atrophy with aging." "Ligaments become lax with age."
"Muscles atrophy with aging." Explanation: Muscle atrophy results in weakness and decreased flexibility, which increases the risk for stumbling and falls.
Which of the following is an example of a hinge joint? Hip Joint at base of thumb Carpal bones in the wrist Knee
Knee Explanation: Hinge joints permit bending in one direction only and include the knee and elbow. The hip is a ball-and-socket joint. The joint at the base of the thumb is a saddle joint. Gliding joints allow for limited movement in all directions and are represented by the joints of the carpal bones in the wrist.
The client presents with an exaggeration of the lumbar spine curve. How does the nurse interpret this finding? Dowager's hump Kyphosis Scoliosis Lordosis
Lordosis Explanation: Lordosis is an exaggeration of the lumbar spine curve.
A nurse knows that a person with a 3-week-old femur fracture is at the stage where angiogenesis is occurring. What are the characteristics of this stage? New capillaries producing a bridge between the fractured bones. Inflammation and the stimulation of osteoblasts and osteoclasts. The formation of a hematoma and fibrin. Cartilage cells forming matrix villa that regulate calcification of the cartilage.
New capillaries producing a bridge between the fractured bones. Explanation: Angiogenesis and cartilage formation begin when fibroblasts from the periosteum produce a bridge between the fractured bones. This is known as a callus.
The older client asks the nurse how best to maintain strong muscles. What is the nurse's best response? "Cardio-training is the best way to build muscle." "Weight-resistance exercises can strengthen muscles." "Range of motion exercises build muscle mass." "Getting a lot of rest can strengthen muscles."
"Weight-resistance exercises can strengthen muscles." Explanation: Weight-resistance exercises maintain and strengthen muscles. Cardio-training is important for heart health and weight maintenance/reduction. Rest is good if you get exercise but doesn't build muscle on its own. Range of motion exercises are essential for joint mobility.
Which is an indicator of neurovascular compromise? Capillary refill of more than 3 seconds Warm skin temperature Pain upon active stretch Diminished pain
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.
Choose the correct statement about the endosteum, a significant component of the skeletal system: Covers the marrow cavity of long bones Facilitates bone growth Contains blood vessels and lymphatics Supports the attachment of tendons to bones
Covers the marrow cavity of long bones Explanation: The endosteum is a thin vascular membrane that covers the marrow cavity of long bones and the spaces in cancellous bone. Osteoclasts are located near the endosteum.
A client is diagnosed with a fracture of a diarthrosis joint. What is an example of this type of joint? Symphysis pubis Elbow Skull Fifth thoracic vertebrae
Elbow Explanation: A diarthrosis joint, like the elbow, is freely movable. The skull is an example of an immovable joint. The vertebral joints and symphysis pubis are amphiarthrosis joints that have limited motion.
Which diagnostic test would the nurse expect to be ordered for a client with lower extremity muscle weakness? Arthrocentesis Electromyograph (EMG) Biopsy Bone scan
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.
A group of students are reviewing information about bones in preparation for a quiz. Which of the following indicates that the students have understood the material? The yellow marrow is responsible for manufacturing red blood cells. Osteoclasts are involved in the destruction and remodeling of bone. Osteocytes are transformed into osteoblasts or mature bone cells. Long bones typically contain more red bone marrow than yellow.
Osteoclasts are involved in the destruction and remodeling of bone. Explanation: Osteoclasts are the cells involved in the destruction, resorption, and remodeling of bone. Red bone marrow is responsible for manufacturing red blood cells. Long bones contain yellow bone marrow; the sternum, ileum, vertebrae, and ribs contain red bone marrow. Osteoblasts are transformed into osteocytes, mature bone cells.
Which nerve is being assessed when the nurses asks the client to dorsiflex the ankle and extend the toes? Median Radial Peroneal Ulnar
Peroneal Explanation: The motor function of the peroneal nerve is assessed by asking the client to dorsiflex the ankle and to extend the toes, while pricking the skin between the great toe and center toe assesses sensory function. The radial nerve is assessed by asking the client to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. The median nerve is assessed by asking the client to touch the thumb to the little finger. Asking the client to spread all fingers allows the nurse to assess motor function affected by ulnar innervation.
Which nerve is assessed when the nurse asks the client to spread all fingers? Median Peroneal Radial Ulnar
Ulnar Explanation: Asking the client to spread all fingers allows the nurse to assess motor function affected by ulnar innervation, while pricking the fat pad at the top of the small finger allows assessment of the sensory function affected by the ulnar nerve. The peroneal nerve is assessed by asking the client to dorsiflex the ankle and to extend the toes. The radial nerve is assessed by asking the client to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. The median nerve is assessed by asking the client to touch the thumb to the little finger.
A patient tells the nurse, "I was working out and lifting weights and now that I have stopped, I am flabby and my muscles have gone!" What is the best response by the nurse? "Your muscles were in a state of hypertrophy from the weight lifting but it will persist only if the exercise is continued." "The muscle mass has decreased from the lack of calcium in the cells." "While you are lifting weights, endorphins are released, creating increase in muscle mass, but if the muscles are not used they will atrophy." "Once you stop exercising, the contraction of the muscle does not regain its strength."
"Your muscles were in a state of hypertrophy from the weight lifting but it will persist only if the exercise is continued." Explanation: Muscles need to exercise to maintain function and strength. When a muscle repeatedly develops maximum or close to maximum tension over a long time, as in regular exercise with weights, the cross-sectional area of the muscle increases. This enlargement, known as hypertrophy, results from an increase in the size of individual muscle fibers without an increase in their number. Hypertrophy persists only if the exercise is continued.
A client is experiencing muscle weakness in the upper extremities. The client raises an arm above the head but then loses the ability to maintain the position. Muscular dystrophy is suspected. Which diagnostic test would evaluate muscle weakness or deterioration? An arthroscopy A serum calcium test An electromyography A magnetic resonance imaging (MRI)
An electromyography Explanation: An electromyography tests the electrical potential of muscles and nerves leading to the muscles. It is done to evaluate muscle weakness or deterioration. A serum calcium test evaluates the calcium in the blood. An arthroscopy assesses changes in the joint. An MRI identifies abnormalities in the targeted area.
The nurse is taking an initial history of a new client with a musculoskeletal problem. Which factor is most important for the nurse to keep in mind for this assessment? Client's lifestyle Client's age Duration and location of discomfort or pain Any chronic disorder or recent injury
Any chronic disorder or recent injury Explanation: The focus of the initial history depends on the nature of the musculoskeletal problem, whether the client has a chronic disorder or a recent injury. If the disorder is long-standing, the nurse obtains a thorough medical, drug, and allergy history. If the client is injured, the nurse finds out when and how the trauma occurred. The client's age, lifestyle, or duration and location of discomfort or pain, although important, have little influence on the focus of the initial history and assessment of the client.
Which of the following is an example of a gliding joint? Carpal bones in the wrist Joint at base of thumb Knee Hip
Carpal bones in the wrist Explanation: Gliding joints allow for limited movement in all directions and are represented by the joints of the carpal bones in the wrist. Hinge joints permit bending in one direction only and include the knee and elbow. The hip is a ball-and-socket joint. The joint at the base of the thumb is a saddle joint.
A group of students are reviewing the structure and function of bones. The students demonstrate understanding of the information when they state that cortical bone is found primarily in which of the following? Diaphyses Osteoblasts Epiphyses Rounded irregular ends
Diaphyses Explanation: Cortical bony tissue is found chiefly in the long shafts, or diaphyses, of bones in the arms and legs. Cancellous bone is found at the rounded, irregular ends, or epiphyses, of long bones. Osteoblasts are cells that build bones
A nurse performs a neurovascular assessment on a client 2 weeks after a wrist cast had been removed. The nurse documents in the client's chart that there is normal sensation in the ulnar nerve. What finger assessment test will the nurse perform on this client? Prick the top or distal surface of the index finger. Prick the skin midway between the thumb and second finger. Prick the distal fat pad on the small finger. Prick the top of the middle finger.
Prick the distal fat pad on the small finger. Explanation: See Table 40-2 in the text. The ulnar nerve runs near the ulnar bone and enters the palm of the hand. It branches to the fifth finger (small finger) and the ulnar side of the fourth finger.
A group of students are studying for an examination on joints. The students demonstrate understanding of the material when they identify which of the following as an example of a synarthrodial joint? In the fingers At the hip Between the vertebrae Skull at the temporal and occipital bones
Skull at the temporal and occipital bones Explanation: A synarthrodial joint is immovable and can be found at the suture line of the skull between the temporal and occipital bones. Amphiarthrodial joints are slightly moveable and are found between the vertebrae. The finger and hip joints are examples of diarthrodial joints that are freely moveable.
The nurse assesses soft subcutaneous nodules along the line of the tendons in a patient's hand and wrist. What does this finding indicate to the nurse? The patient has rheumatoid arthritis. The patient has lupus erythematosus. The patient has osteoarthritis. The patient has neurofibromatosis.
The patient has rheumatoid arthritis. Explanation: The subcutaneous nodules of rheumatoid arthritis are soft and occur within and along tendons that provide extensor function to the joints. Osteoarthritic nodules are hard and painless and represent bony overgrowth that has resulted from destruction of the cartilaginous surface of bone within the joint capsule. Lupus and neurofibromatosis are not associated with the production of nodules.
A client visits the health care provider for a routine checkup. The history reveals that the client was diagnosed with a spinal curvature. Which region of the spine should the nurse assess for complications? Sacral Lumbar Cervical Thoracic
Thoracic Explanation: The nurse should assess the thoracic region of the spine because a progressive curvature of more than 65 degrees in this region may lead to cardiopulmonary failure as well as less serious signs and symptoms, such as fatigue, back pain, decreased height, and cosmetic deformity. Although a curvature may affect any part of the spine, life-threatening complications aren't associated with curvature of the cervical, lumbar, or sacral regions.
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 lordosis. epiphysis. scoliosis. diaphysis.
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
The nurse is preparing to perform a musculoskeletal assessment for a client with chronic muscle pain. Which assessment technique would be an appropriate tool to evaluate this type of pain? Palpate for the balloon sign. Flex the bicep against resistance. Measure the girth of the thigh. Listen for cracking with movement.
Flex the bicep against resistance. Explanation: Evaluating muscle strength is a part of the musculoskeletal system. Strength of the bicep muscles can be tested by having the client flex the bicep against resistance. Palpating for the balloon sign assesses for fluid around the knee joint. Measuring the girth of the thigh evaluates for muscle size. Cracking with movement may indicate a ligament slipping over a bony prominence.
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 Arthrocentesis Bone scan
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.
What is the term for a rhythmic contraction of a muscle? Atrophy Crepitus Hypertrophy Clonus
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.
Which term refers to the shaft of the long bone? Epiphysis Lordosis Scoliosis Diaphysis
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.
A client is seen in the emergency room for a knee injury that happened during a basketball game. Diagnostic tests reveal torn cords of fibrous connective tissue that connect muscles to bones. What type of tear has this client sustained? Bursa Tendon Fascia Ligament
Tendon Explanation: Tendons are broad, flat sheets of connective tissue that attach muscles to bones, soft tissue, and other muscles. Ligaments bind bones together. A bursa is a synovial-filled sac, and fascia surround muscle cells.
The nurse is performing a neurological assessment. What will this assessment include? Ask the client to plantar flex the toes. Observe for capillary refill of the great toe. Palpate the dorsalis pedis pulse. Inspect the foot for edema.
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.
The nurse is performing a neurovascular assessment of a client's injured extremity. Which would the nurse report? Capillary refill of 3 seconds Skin warm to touch Dusky or mottled skin color Positive distal pulses
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.
Choose the correct statement about the endosteum, a significant component of the skeletal system: Supports the attachment of tendons to bones Facilitates bone growth Contains blood vessels and lymphatics Covers the marrow cavity of long bones
Covers the marrow cavity of long bones Explanation: The endosteum is a thin vascular membrane that covers the marrow cavity of long bones and the spaces in cancellous bone. Osteoclasts are located near the endosteum.
Which of the following is the priority nursing diagnosis for the client preparing for a bone marrow biopsy? Risk for infection Acute pain Deficient knowledge: procedure Risk for ineffective peripheral tissue perfusion
Deficient knowledge: procedure Explanation: The client needs adequate information before experiencing the procedure. Information about its purpose, the actual steps of the procedure, and the client's role during and after the procedure is essential. Appropriate nursing diagnoses following the procedure would include risk for infection, acute pain, and risk for ineffective peripheral tissue perfusion.
Which of the following is the most common site of joint effusion? Knee Elbow Hip Shoulder
Knee Explanation: The most common site for joint effusion is the knee. If inflammation or fluid is suspected in a joint, consultation with a provider is indicated. The elbow, hip, and shoulder are not the most common site of joint effusion.
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 Kyphosis Lordosis 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.
Which laboratory study indicates the rate of bone turnover? Serum calcium Serum phosphorous Urine calcium Serum osteocalcin
Serum osteocalcin Explanation: Serum osteocalcin (bone GLA protein) indicates the rate of bone turnover. Urine calcium concentration increases with bone destruction. Serum calcium concentration is altered in clients with osteomalacia and parathyroid dysfunction. Serum phosphorous concentration is inversely related to calcium concentration and is diminished in osteomalacia associated with malabsorption syndrome.
The nurse is preparing the client with a right neck mass for magnetic resonance imaging (MRI). Which question should the nurse ask? Select all that apply. "When is the last time you had food or drink?" "Are you wearing any jewelry?" "Have you removed your hearing aid?" "Do you have a pacemaker?" "Did you take your medications this morning?"
"Are you wearing any jewelry?" "Have you removed your hearing aid?" "Do you have a pacemaker?" Explanation: Magnetic resonance imaging (MRI) is a noninvasive imaging technique that uses magnetic fields, radio waves, and computers to demonstrate abnormalities of soft tissue. Individuals with any metal implants, clips, or pacemakers are not candidates for MRI. Individuals do not need to be NPO and can take usual medications.
A client is recovering from a fractured hip. What would the nurse suggest that the client increase intake of to facilitate calcium absorption from food and supplements? Vitamin D Amino acids Dairy products Vitamin B6
Vitamin D Explanation: The nurse must advise a client recovering from a fractured hip to increase the intake of vitamin D, because vitamin D protects against bone loss and decreases the risk of recurring fracture by facilitating calcium absorption from food and supplements. Amino acids and vitamin B6, though 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.
Which hormone inhibits bone resorption and increases the deposit of calcium in the bone? Vitamin D Sex hormones Growth hormone Calcitonin
Calcitonin Explanation: Calcitonin, secreted by the thyroid gland in response to elevated blood calcium levels, inhibits bone reabsorption and increases the deposit of calcium in the bone.
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? Resorption Epiphyses and diaphysis formation Remodeling Ossification and calcification
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.
Which of the following is the final stage of fracture repair? Remodeling Angiogenesis Cartilage calcification Cartilage removal
Remodeling Explanation: The final stage of fracture repair consists of remodeling the new bone into its former structural arrangement. During cartilage calcification, enzymes within the matrix vesicles prepare the cartilage for calcium release and deposit. Cartilage removal occurs when the calcified cartilage is invaded by blood vessels and becomes reabsorbed by chondroblasts and osteoclasts. Angiogenesis occurs when new capillaries infiltrate the hematoma, and fibroblasts from the periosteum, endosteum, and bone marrow produce a bridge between the fractured bones.
Which statement describes paresthesia? Abnormal sensations Absence of muscle movement suggesting nerve damage Absence of muscle tone Involuntary twitch of muscle fibers
Abnormal sensations Explanation: Abnormal sensations, such as burning, tingling, and numbness, are referred to as paresthesias. The absence of muscle tone suggesting nerve damage is referred to as paralysis. A fasciculation is the involuntary twitch of muscle fibers. A muscle that holds no tone is referred to as flaccid.
Which is a circulatory indicator of peripheral neurovascular dysfunction? Paralysis Weakness Paresthesia Cool skin
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.
Which cells are involved in bone resorption? Osteocytes Osteoblasts Chondrocytes Osteoclasts
Osteoclasts Explanation: Osteoclasts carry out bone resorption by removing unwanted bone while new bone is forming in other areas. Chondrocytes are responsible for forming new cartilage. Osteoblasts are bone-forming cells that secrete collagen and other substances. Osteocytes, derived from osteoblasts, are the chief cells in bone tissue.
While reading a client's chart, the nurse notices that the client is documented to have paresthesia. The nurse plans care for a client with absence of muscle tone. abnormal sensations. involuntary twitch of muscle fibers. absence of muscle movement suggesting nerve damage.
abnormal sensations. Explanation: Abnormal sensations, such as burning, tingling, and numbness, are referred to as paresthesias. The absence of muscle tone suggesting nerve damage is referred to as paralysis. A fasciculation is the involuntary twitch of muscle fibers. A muscle that holds no tone is referred to as flaccid.
Skull sutures are an example of which type of joint? Diarthrosis Aponeuroses Synarthrosis Amphiarthrosis
Synarthrosis Explanation: Skull sutures are considered synarthrosis joints and are immovable. Amphiarthrosis joints allow limited movement, such as a vertebral joint. Diarthrosis joints are freely movable joints such as the hip and shoulder. Aponeuroses are broad, flat sheets of connective tissue.
The older client asks the nurse how best to maintain strong bones. What is the nurse's best response? "Weight-resistance exercises can strengthen bones." "Weight-bearing exercises can strengthen bones." "Cardio training is the best way to build bones." "Range-of-motion exercises build bone mass."
"Weight-bearing exercises can strengthen bones." Explanation: Weight-bearing exercises maintain bone mass. Weight-resistance exercises maintain and strengthen muscles. Cardio training is important for heart health and weight maintenance/reduction. Range-of-motion exercises are essential for joint mobility.
The nurse is educating a group of students about peroneal nerve damage. The nurse knows that which assessment will show this type of nerve damage? Stretching of the client's thumb above the wrist Skin prick along the client's skin with the index finger Dorsiflexion of the foot and extension of the toes Pricking of the skin along the medial side of the foot
Dorsiflexion of the foot and extension of the toes Explanation: Assessment of peripheral nerve function has two key elements: evaluation of sensation and evaluation of motion. To assess motion of the peroneal nerve, the client should be asked to dorsiflex the foot and extend the toes. Pricking the skin along the top of the index finger assesses sensation of the median nerve. Having the client stretch the thumb away from the wrist assesses motion of the radial nerve. Pricking the skin between the medial and lateral surface of the sole will assess tibial nerve sensation.
After a person experiences a closure of the epiphyses, which statement is true? The bone grows in length but not thickness. The bone increases in thickness and is remodeled. Both bone length and thickness continue to increase. No further increase in bone length occurs.
No further increase in bone length occurs. Explanation: After closure of the epiphyses, no further increase in bone length can occur. The other options are inappropriate and not related to closure of the epiphyses.
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. joint stiffness increase in height decreased endurance increased muscle strength decreased range of motion
decreased endurance joint stiffness decreased range of motion 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.
The nurse is performing an assessment for a patient who may have peripheral neurovascular dysfunction. What signs does the patient present with that indicate circulation is impaired? (Select all that apply.) Tenting skin turgor Cool temperature of the extremity More than 3-second capillary refill Pale, cyanotic, or mottled color Limited range of motion
Pale, cyanotic, or mottled color Cool temperature of the extremity More than 3-second capillary refill Explanation: Indicators of peripheral neurovascular dysfunction include pale, cyanotic, or mottled skin color; cool temperature of the extremities; and a capillary refill of more than 3 seconds.
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 metoprolol furosemide prednisone
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.
A client undergoes an arthroscopy at the outpatient clinic. After the procedure, the nurse provides discharge teaching. Which response by the client indicates the need for further teaching? "My physician may prescribe pain pills after the procedure." "I may notice some bruising or swelling in my knee." "Elevating my leg will reduce swelling after the procedure." "I should use my heating pad this evening to reduce some of the pain in my knee."
"I should use my heating pad this evening to reduce some of the pain in my knee." Explanation: The client requires additional teaching if he states that he'll use a heating pad to reduce pain the evening of the procedure. The client shouldn't use heat at the procedure site during the first 24 hours because doing so may increase localized swelling. Ice is indicated during this time. Elevating the extremity helps reduce swelling. The client may experience some discomfort after the procedure for which the physician may order medication. Bruising and swelling are common after an arthroscopy.
The nurse is assessing a client with a musculoskeletal system condition. Which statement indicates to the nurse that the client is experiencing bone pain? "I have soreness and aching like cramps in both of my arms." "The pain feels tender, hurts, and is worse when I move." "The pain is sharp in my arms but is relieved by not moving." "The pain feels deep in my legs and keeps me awake at night."
"The pain feels deep in my legs and keeps me awake at night." Explanation: Bone pain is typically described as a dull, deep ache that is "boring" in nature. This pain is not typically related to movement and may interfere with sleep. Muscular pain is described as soreness or aching and is referred to as "muscle cramps." Joint pain is felt around or in the joint and typically worsens with movement. 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.
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.
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? Active phase, dormant phase, restructure phase Reactive phase, reparative phase, remodeling phase First intention, secondary intention, third intention Primary phase, secondary phase, third 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.
A client has undergone arthroscopy. After the procedure, the site where the arthroscope was inserted is covered with a bulky dressing. The client's entire leg is also elevated without flexing the knee. What is the appropriate nursing intervention required in caring for a client who has undergone arthroscopy? Assist with performing ROM exercises. Provide a gentle massage. Apply warm compresses to the insertion site. Apply a cold pack at the insertion site.
Apply a cold pack at the insertion site. Explanation: After covering the arthroscope insertion site with a bulky dressing and elevating the client's entire leg, the nurse needs to apply a cold pack at the site to minimize any chances of swelling.
A client is having repeated tears of the joint capsule in the shoulder, and the health care provider orders an arthrogram. What intervention should the nurse provide after the procedure is completed? Select all that apply. Actively exercise the area immediately after the procedure. Apply a compression bandage to the area. Apply heat to the area for 48 hours. Inform the client that a clicking or crackling noise in the joint may persist for a couple of days. Administer a mild analgesic.
Apply a compression bandage to the area. Administer a mild analgesic. Inform the client that a clicking or crackling noise in the joint may persist for a couple of days. Explanation: The client having an arthrogram may feel some discomfort or tingling during the procedure. After the arthrogram, a compression elastic bandage may be applied if prescribed, and the joint is usually rested for 12 hours. Strenuous activity should be avoided until approved by the primary provider. The nurse provides additional comfort measures (e.g., mild analgesia, ice) as appropriate and explains to the client that it is normal to experience clicking or crackling in the joint for 24 to 48 hours after the procedure until the contrast agent or air is absorbed.
A patient has had a stroke and is unable to move the right upper and lower extremity. During assessment the nurse picks up the arm and it is limp and without tone. How would the nurse document this finding? Tetanic Rigidity Flaccidity Atonic
Flaccidity Explanation: A muscle that is limp and without tone is described as flaccid; a muscle with greater-than-normal tone is described as spastic. Conditions characterized by lower motor neuron destruction (e.g., muscular dystrophy), denervated muscle becomes atonic (soft and flabby) and atrophies.
The nurse is preparing to assess the spine of an older adult. Which actions will the nurse take during this assessment? Select all that apply. Ask the client to bend backward Measure height Observe the client walk away and then return Ask the client to bend forward at the waist Assess for crepitus
Measure height Ask the client to bend backward Ask the client to bend forward at the waist Explanation: During inspection of the spine, the entire back, buttocks, and legs are exposed. Older adults experience a loss in height due to the loss of vertebral cartilage and osteoporosis-related vertebral compression fractures. Because of this, an adult's height should be measured during each health screening. The client should be instructed to bend forward at the waist while the nurse assesses the curvature of the spine, symmetry of the shoulders, scapula, and hips. The client should then be directed to bend backward while supporting the client's posterior iliac spine. Assessing for crepitus is used to determine integrity of the client's bones. Observing the client walk is used to evaluate gait.
A client scheduled to undergo an electromyography asks the nurse what this test will evaluate. What is the correct response from the nurse? Bone density Metastatic bone lesions Muscle composition Muscle weakness
Muscle weakness Explanation: Electromyography tests the electric potential of the muscles and nerves leading to the muscles. It is done to evaluate muscle weakness or deterioration, pain, disability, and to differentiate muscle and nerve problems. A bone biopsy is done to identify bone composition. Bone densitometry is done to evaluate bone density. A bone scan would be appropriate to detect metastatic bone lesions.
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? Osteoblasts Cortical bone Osteoclasts 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.
Which serum level indicates the rate of bone turnover? Aspartate aminotransferase Myoglobin Creatinine kinase Osteocalcin
Osteocalcin Explanation: Serum osteocalcin (bone GLA protein) indicates the rate of bone turnover. Serum myoglobin is assessed to evaluate muscle trauma. Serum enzyme levels of creatinine kinase and aspartate aminotransferase become elevated with muscle damage.
The nurse is assessing a client's ulnar nerve. What technique will the nurse use? Ask the client to stretch the thumb, then the wrist, then the fingers. Prick the distal fat pad of the small finger. Ask the client to flex the wrist. Prick the skin mid-way between the thumb and second finger.
Prick the distal fat pad of the small finger. Explanation: To assess the ulnar nerve, the nurse would prick the distal fat pad of the small finger.
The nurse is caring for a client who experienced a crushing injury of the lower extremities. Which of the following symptoms is essential to be reported to the physician? Ischemia Pulselessness Coolness Pain
Pulselessness Explanation: Neurovascular checks (circulation, sensation, motion) are essential with a crushing injury. The absence of a pulse is a critical assessment finding to report to the physician. The other options are symptoms that need regular assessment.
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? Raise the left leg above the level of the heart. Tell the client to flex the left foot frequently. Apply heat to the ankle. 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.
A client undergoes an invasive joint examination of the knee. What will the nurse closely monitor the client for? Signs of depression Lack of sleep and appetite Serous drainage Signs of shock
Serous drainage Explanation: When the client undergoes an invasive knee joint examination, the nurse should inspect the knee area for swelling, bleeding, and serous drainage. An invasive joint examination does not cause lack of sleep or appetite, depression, or shock. The client may be in shock due to the injury itself.
The nurse is performing a musculoskeletal assessment of a client in a nursing home who had a stroke 2 years ago and who has right-sided hemiplegia. The nurse notes that the girth of the client's right calf is 2 inches less in diameter than the left calf. The nurse attributes the decreased girth to atrophy of right calf muscle. increased use of left calf muscle. bruising in right lower extremity. edema in left lower extremity.
atrophy of right calf muscle. Explanation: Girth of an extremity may increase as a result of exercise, edema, or bleeding into the muscle. However, a client with right-sided hemiplegia is unable to use the right lower extremity. This client may experience atrophy of the muscles from lack of use, which results in a subsequent decrease in the girth of the calf muscle.
A client tells the health care provider about shoulder pain that is present even without any strenuous movement. The health care provider identifies a sac filled with synovial fluid. What condition will the nurse educate the client about? osteoarthritis of the shoulder ankylosing spondylitis a fracture of the clavicle bursitis
bursitis Explanation: A bursa is a small sac filled with synovial fluid. Bursae reduce friction between areas, such as tendon and bone and tendon and ligament. Inflammation of these sacs is called bursitis. A fracture of the clavicle is a bone break. Osteoarthritis is an inflammatory disease. Ankylosing spondylitis is a form of arthritis affecting the spine.
There are thousands of components of the musculoskeletal system that facilitate mobility and independent function. The function of skeletal muscle is promoting: All options are correct. organ function. movement of skeletal bones. involuntary function.
movement of skeletal bones. Explanation: The skeletal muscles promote movement of the bones of the skeleton.