HA, Chapter 25

The nurse is assessing a client whose chief complaint is an inability to move the fourth and fifth fingers. The nurse notes severe flexion in both of the affected fingers. Upon palpation, there are no complaints of pain from the client. Based on this data, which diagnosis does the nurse suspect? 1. Dupuytren contracture. 2. Carpal tunnel syndrome. 3. Bursitis. 4. Osteoarthritis.

Correct Answer: 1 Global Rationale: Dupuytren contracture involves inability to extend the fourth and fifth fingers, but is a painless, inherited disorder. Carpal tunnel is a condition caused by compression of the median nerve. In carpal tunnel syndrome the client feels numbness, tingling, and pain in the hands and wrists. Bursitis involves inflammation of the bursae. The condition is manifested by redness, warmth, swelling, and tenderness. Osteoarthritis is the degeneration of the joints. The condition typically causes pain and limitations in movement, but not numbness and tingling.

The nurse is assessing a client with a suspected femur fracture. Which assessment finding supports this diagnosis? 1. External rotation of the lower leg and foot. 2. Internal rotation of the lower leg and foot. 3. Limited hip internal rotation. 4. Limited hip external rotation.

Correct Answer: 1 Global Rationale: External rotation, not internal rotation, of the lower leg and foot is a classic sign of a fractured femur. Limitations of internal and external rotation in the hip signify inflammatory or degenerative joint diseases.

The nurse notes an exaggerated lumbar curve while inspecting the spine of a client. Which term will the nurse use when documenting this finding in the medical record? 1. Lordosis. 2. Scoliosis. 3. Kyphosis. 4. Flattened curve.

Correct Answer: 1 Global Rationale: Lordosis is an exaggerated lumbar curve and is often present in pregnancy, obesity, or other skeletal changes. The spine leans to the left or right in a list, and a line drawn from the thoracic one (T1) vertebrae does not fall between the gluteal cleft. Scoliosis results when the spine curves to the right or left. It is noted in the thoracic region. Kyphosis is an exaggerated thoracic dorsal curve that causes asymmetry between the sides of the posterior thorax. A flattened lumbar curve is a concave curvature of the lumbar areas and occurs when lumbar muscles spasm.

The clinical nurse educator is teaching a group of nursing students about conducting a focused interview on a client being admitted to the facility with complaints of leg pain. Which statement by the student nurse indicates the need for further education? 1. "The focused interview will be guided by the physical assessment that was completed by the healthcare provider prior to admission." 2. "Subjective information is contained in the focused assessment." 3. "The age, gender, and past medical history of the client are used to guide the questions in the focused assessment." 4. "A focus interview on the musculoskeletal system is individualized for each client."

Correct Answer: 1 Global Rationale: The focused interview is used to guide the physical assessment on the client. The information obtained in the focused interview is subjective. The nurse will consider the client's age, gender, race, culture, past and current medical history to guide the interview questions. thus making the interview individualized.

The nurse is discharging a client with osteoarthritis. Which points will the nurse include in this client's discharge teaching? Standard Text: Select all that apply. 1. Obesity increases the risks of bone, muscle, and joint disorders. 2. Musculoskeletal health is influenced by the diet. 3. Exercise is important in the prevention of osteoarthritis. 4. Smoking and alcohol contribute to the development of osteoarthritis. 5. As the condition progresses the hands may develop contractures that resemble swan necks.

Correct Answer: 1, 2, 3 Global Rationale: Osteoarthritis is a condition that results from degeneration of the joints. Risk factors include aging, obesity, congenital abnormalities, and occupations that place excessive stress on the joints. Dietary intake has an impact on musculoskeletal health. Calcium and vitamin D both promote strong bones. Regular exercise will promote healthful musculoskeletal functioning. Exercise increases muscle strength and flexibility. Smoking and alcohol contribute to the development of osteoporosis, not osteoarthritis. Swan-neck contractures are a deformity noted in the hand of an individual diagnosed with rheumatoid arthritis. Rheumatoid arthritis is a systemic disorder of autoimmune origin.

A client comes to the emergency department (ED) complaining of a painful injury to the right knee received while playing basketball. Which examination techniques will the nurse include during the physical assessment of this client? Standard Text: Select all that apply. 1. Inspection. 2. Palpation. 3. Bulge sign testing. 4. Ballottement. 5. Percussion.

Correct Answer: 1, 2, 3, 4 Global Rationale: The assessment of a client presenting with an injury to the knee would include inspection, palpation, bulge sign testing, and ballottement. The nurse would visually inspect the knee's general appearance, including the presence or redness, swelling and dislocation. The knee's appearance would be contrasted with the unaffected knee. The area would be palpated for tenderness and warmth. The bulge sign test is used to detect the presence of small amounts of fluid (4 to 8 ml) in the suprapatellar bursa. The test involves placing the client in the supine position and then using firm pressure to stroke the medial aspect of the knee upward several times, displacing any fluid. As the pressure is applied to the lateral side of the knee the medial side is observed for bulging. Ballottement is a technique used to detect fluid, or to examine or detect floating body structures. The nurse displaces body fluid and then palpates the return impact of the body structure. Percussion is the use of tapping actions by the examiner. This tapping elicits sounds that can be evaluated for tone and depth to detect the presence of abnormalities. Percussion is normally utilized to assess the lungs and abdominal cavity. It is not used to assess for knee injuries.

The nurse is assessing a client with suspected rheumatoid arthritis (RA). Which musculoskeletal changes would contribute to a positive diagnosis of RA? Standard Text: Select all that apply. 1. Ulnar deviation. 2. Bouchard nodes. 3. Heberden nodes. 4. Swan-neck deformity. 5. Symmetrical loss of function in extremities.

Correct Answer: 1, 4, 5 Global Rationale: Rheumatoid arthritis is an autoimmune condition. The disease may impact multiple body systems. Symptoms of the condition include pain and inflammation. In rheumatoid arthritis there is chronic inflammation of the metacarpophalangeal and interphalangeal joints leading to ulnar deviation. Another manifestation of rheumatoid arthritis involves what are known as swan-neck contractures. These result when the proximal interphalangeal joints are hyperextended while the distal interphalangeal joints are fixed in flexion. The impact on the extremities is typically symmetrical in rheumatoid arthritis. The nodes that may appear on the fingers such as Bouchard and Heberden nodes are associated with osteoarthritis. Osteoarthritis is a condition of joint degeneration.

The client is recovering from orthopedic surgery on a fractured arm. When discussing the effects of the fracture with the client, which skeletal bone functions will the nurse include in the teaching session? Standard Text: Select all that apply. 1. Provide a body framework. 2. Provide movement. 3. Maintain posture. 4. Generate heat. 5. Calcium storage.

Correct Answer: 1, 5 Global Rationale: Skeletal bones provide a framework for the body and they store minerals such as calcium and phosphorus. It is the skeletal muscles that provide movement, maintain posture, and generate heat.

The nurse is caring for a client with a right femur fracture. Which type of bone does the nurse identify the femur as when discussing the fracture with the client? 1. Short. 2. Long. 3. Flat. 4. Irregular.

Correct Answer: 2 Global Rationale: Bones are classified according to shape and composition. Long bones include the femur and humerus; short bones include the carpals and tarsals; flat bones include the parietal skull bone and sternum; and irregular bones include the vertebrae and hips.

The nurse is conducting an assessment for a client whose chief complaint is numbness and tingling in the hands. This sensation is exacerbated when bending the wrist downward and pressing the backs of the hands together. Based on this data, which condition does the nurse suspect? 1. Arthritis of the wrists. 2. Carpal tunnel syndrome. 3. Crepitus of the wrists. 4. Dupuytren contracture.

Correct Answer: 2 Global Rationale: Carpal tunnel is a condition caused by compression of the median nerve. The test described is called Phalen's test, and when used on individuals with carpal tunnel syndrome, 80 percent experience pain, tingling, and numbness that radiates to the arm, shoulder, neck, or chest within 60 seconds. Another assessment for carpal tunnel syndrome is called Tinel's sign, and is elicited by percussing lightly over the median nerve in each wrist. The test is positive if the client feels numbness, tingling, and pain along the median nerve. Arthritis typically causes pain and limitations in movement but not numbness and tingling. Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative disease, trauma, or inflammatory conditions. Dupuytren's contracture involves inability to extend the fourth and fifth fingers but is a painless, inherited disorder.

The nurse notes asymmetry of the iliac crests and gluteal folds while inspecting the spine of a client. The client's spine has a slight curvature to the right, but client denies complaints of pain. Based on this data, which term will the nurse use when documenting this finding in the medical record? 1. Kyphosis. 2. Scoliosis. 3. Spinal list. 4. Lordosis.

Correct Answer: 2 Global Rationale: In scoliosis the spine curves to the right or left, causing an exaggerated thoracic convexity on that side. Kyphosis results in an exaggerated thoracic dorsal curve that causes asymmetry between the sides of the posterior thorax. The spine leans to the left or right in a spinal list. A plumb line drawn from T1 does not fall between the gluteal cleft. This condition may occur with spasms in the paravertebral muscles or a herniated disk. Lordosis refers to an exaggerated curve of the lumbar spine. It is seen most commonly in conditions such as pregnancy and obesity.

The nurse assesses a client whose chief complaint is tenderness and stiffness in the wrist and elbow. The client reports the discomfort is worsened with activity. Based on this data, which condition does the nurse suspect? 1. Carpal tunnel syndrome. 2. Osteoarthritis. 3. Crepitus of the wrists. 4. Dupuytren contracture.

Correct Answer: 2 Global Rationale: Osteoarthritis is also known as degenerative joint disease. It is associated with pain and stiffness of the joints. Carpal tunnel syndrome is caused by compression of the median nerve. Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative joint disease, trauma, or inflammatory conditions. Dupuytren contracture involves inability to extend the fourth and fifth fingers, but is a painless, inherited disorder.

The school nurse is assessing adolescent females for scoliosis. Which area of the spine does the nurse plan to assess? 1. A. 2. B. 3. C. 4. D.

Correct Answer: 2 Global Rationale: Scoliosis is a screening frequently completed on teenaged girls. Scoliosis is the abnormal curvature of the thoracic spine.

The nurse is caring for a client with an injury to the arm. Which degree of wrist movement is appropriate when assessing extension? 1. 90 degrees. 2. 70 degrees. 3. 30 degrees. 4. 20 degrees.

Correct Answer: 2 Global Rationale: The appropriate wrist movement when assessing extension is 70 degrees. Appropriate wrist movement for flexion is 90 degrees; for hyperextension is 30 degrees; and for radial deviation is 20 degrees.

The nurse is performing the bulge test on a client's left knee. Which area will the nurse assess for bulging during this test? 1. A. 2. B. 3. C. 4. D.

Correct Answer: 2 Global Rationale: The bulge sign can be assessed to check for the presence of fluid. If fluid is present there will be a bulging on the medial side. To perform the test, assist the client to a supine position. Use firm pressure to stroke the medial aspect of the knee upward several times displacing any fluid. Next apply pressure to the lateral side of the knee while observing the medial side. In a normal test no fluid is present.

The nurse is caring for a client with a knee injury. When documenting this injury in the medical record, the nurse identifies the knee as which type of joint? 1. Saddle. 2. Hinge. 3. Pivot. 4. Plane.

Correct Answer: 2 Global Rationale: The knee and elbows are hinge joints; the thumbs are saddle joints; the neck is a pivot joint; the intercarpals and intertarsals are plane joints.

The nurse notes a child sitting in reverse tailor position during a well-child examination. Which action by the nurse is the most appropriate based on this data? 1. Notify the healthcare provider so that X-rays can be obtained. 2. Explain to the parent that this can cause joint stress. 3. Continue with the examination. 4. Assess the child for back problems.

Correct Answer: 2 Global Rationale: The reverse tailor position stresses the hip, knee, and ankle joints of the growing child. The position has the individual sitting flat on the floor with the legs bent back, similar to an "upside down W." Children should be encouraged to try other sitting positions to prevent these problems, and teaching the parent and the child regarding this is best done at the time the position is noted. There is no need for the nurse to anticipate that X-rays will be needed as this position does not indicate deformities requiring diagnostic tests. The examination is a period of time in which the nurse can provide teaching to the patient. It would be remiss to discuss this potential problem with the parents at the time noted. Thus, continuation of the examination should not be done before the education has taken place. The reverse tailor position does not promote back problems for the child.

The nurse is preparing to assess a client's spine for abnormalities. Which command to the client during this assessment is most appropriate for the nurse to initiate? 1. Sit down, then stand as the nurse looks from the front of the client. 2. Stand, bend back slowly, then to the right and left while the nurse looks from the back. 3. Bend over, stand tall, and stretch arms over the head. 4. Sit down, then lean forward and dangle the arms at the sides of the body.

Correct Answer: 2 Global Rationale: The spine should be visually inspected by viewing the back of the client. The client should be asked to stand during this assessment. This will allow the nurse to assess for symmetry. The spine should appear straight when viewed from the back. The cervical and lumbar spine should appear concave, and the thoracic spine should appear convex. Bending and stretching will not illicit the needed information about the spine. Range of motion and flexibility may be assessed by asking the client to bend over or stretch.

The nurse is assessing the client's lateral flexion. Which commands by the nurse to the client will assess lateral flexion during the physical assessment? Standard Text: Select all that apply. 1. "Tilt your head back and look at the ceiling." 2. "Lean your head to the side and attempt to touch your ear to your shoulder." 3. "Bend sideways to the right and to the left while I stabilize your pelvis." 4. "Attempt to raise your shoulders up toward your ears." 5. "Attempt to rotate your head in a circular manner."

Correct Answer: 2, 3 Global Rationale: Lateral flexion of the head is attempted by touching each shoulder of the ear on the same side. It is also assessed by sitting or standing behind the client and asking the client to bend sideways to the right and the left while stabilizing the pelvis. Tilting the head back to look at the ceiling would be an example of hyperflexion. Raising the shoulders toward the ears and rotating the head are methods to assess mobility and flexibility of the client but do not demonstrate lateral flexion.

The nurse is caring for an older adult client. Which does the nurse suspect based on the client's age? 1. No bone changes are associated with aging. 2. Increased osteoblastic activity. 3. Decreased calcium absorption. 4. Increase in bone density.

Correct Answer: 3 Global Rationale: As an individual ages, physiologic changes take place in the bones, muscles, connective tissue, and joints. These changes may affect the older client's mobility and endurance. Elderly persons who are housebound and immobile or whose dietary intake of calcium and vitamin D is low may also experience reduced bone mass and strength. During aging, bone resorption occurs more rapidly than new bone growth, resulting in the loss of bone density typical of osteoporosis. The entire skeleton is affected, but the vertebrae and long bones are especially impacted. The elderly client will experience decreased calcium absorption. Bone changes include decreased calcium absorption and reduced osteoblast production. Osteoblasts are the cells responsible for bone production. Osteoblast activity is reduced, not increased, with aging. Bone density decreases, not increases, in the elderly.

The nurse is admitting a client with a shoulder dislocation. The client tells the nurse that the healthcare provider diagnosed a dislocated shoulder. The client asks the nurse what this diagnosis means. Which response by the nurse is the most appropriate? 1. "I cannot tell you without your healthcare provider's permission." 2. "You have a muscle tear at the shoulder." 3. "Your shoulder bone has come apart from the shoulder joint." 4. "Your shoulder is fractured and separated from the joint."

Correct Answer: 3 Global Rationale: Dislocation is a displacement of the bone from its usual anatomical location in the joint. A dislocation is not the same as a muscle tear, or a fracture of the shoulder. The client has a concern and the nurse has the obligation to attempt to answer the questions presented within the nurse's scope of practice and responsibility.

A pregnant client at 38 weeks gestation is complaining of lower back pain. The nurse notes a slight lordosis and waddling gait in the client. Based on this data, which action by the nurse is the most appropriate? 1. Suggest the client begin bed rest. 2. Notify the healthcare provider of the findings. 3. Document the findings as normal. 4. Ask the client if she has been lifting.

Correct Answer: 3 Global Rationale: During pregnancy, estrogen and other hormones soften the cartilage in the pelvis and increase the mobility of the joints. Lordosis, exaggeration of the lumbar spinal curve, and a waddling gait are the result of compensation for the enlarging fetus. The woman's center of gravity shifts forward, and her weight shifts farther back on the lower extremities, causing lower back pain. These are all normal findings during the late stages of pregnancy and do not require bed rest or notification of the healthcare provider. Lordosis and waddling gait in the later stages of pregnancy are not the result of lifting.

The nurse is caring for an older adult client. Which does the nurse expect based on the client's age? 1. Difficulty with dexterity. 2. Increased bone production. 3. Risk for fractures. 4. Pain when ambulating.

Correct Answer: 3 Global Rationale: Elderly clients are at risk for fractures due to decreased calcium absorption and loss of bone density. Difficulty with dexterity is not a normal age related change. The rate of bone production is not increased but decreased with aging. Pain with ambulation is not a direct result of aging; however, some chronic conditions of aging may be associated with varying levels and types of discomfort.

The nurse assesses a client and finds that a grating sound is present when a joint is bent and straightened. Which term will the nurse use when documenting this finding in the medical record? 1. Subluxation. 2. Grinding. 3. Crepitation. 4. Joint dislocation.

Correct Answer: 3 Global Rationale: Grinding sounds may be heard or felt with musculoskeletal disorders but it is not appropriate medical terminology. It is important to use proper terminology when reporting findings. Crepitation is the proper term when a grating sound is present in a joint. Crepitation results when the joint articulating surfaces have lost their cartilage. Subluxation refers to a partial joint dislocation. There is inadequate information to determine if the joint is dislocated.

The nurse notes swelling and tenderness of the olecranon process during palpation. The client's chief complaint is pain upon movement of the forearm and wrist. Based on this data, which condition does the nurse suspect? 1. Arthritis. 2. Bursitis. 3. Epicondylitis. 4. Crepitus.

Correct Answer: 3 Global Rationale: Lateral epicondylitis, also called tennis elbow, results from constant, repetitive movements of the wrist and/or forearm. Pain occurs when the client attempts to extend the wrist against resistance. Medial epicondylitis, also called pitcher's or golfer's elbow, results from constant, repetitive flexion of wrist. Pain occurs when the client attempts to flex the wrist against resistance. Rheumatoid arthritis will typically produce nontender nodules along the extensor surface of the ulna. Bursitis is characterized by a painful area of inflammation. Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative disease, trauma, or inflammatory conditions.

The nurse is planning a program to promote Healthy People 2020 focus areas relating to osteoporosis. Which program would appropriately serve as primary prevention? 1. The development of a program to address available medication therapies for the individual with osteoporosis. 2. Community screening programs to identify individuals who have early onset osteoporosis. 3. Community education programs to discuss methods that can be implemented to reduce the chance of developing osteoporosis. 4. The development of community support programs for individuals who have been diagnosed with osteoporosis.

Correct Answer: 3 Global Rationale: Primary prevention seeks to provide education and reduce the incidence of disease. Secondary prevention seeks to promote early diagnosis of conditions. Tertiary prevention's goal is to manage existing conditions while seeking to prevent related complications. Programs to reduce the incidence of osteoporosis are an example of primary prevention. Secondary prevention activities would include screening programs to identify individuals with early onset osteoporosis. Programs seeking to discuss treatment options or to offer support for clients with the disorder are examples of tertiary prevention.

A young adult client is seen in the clinic complaining of a lump on the left wrist, but states it is not painful. The nurse notes a round mass on the back of the wrist. Based on this data, which condition does the nurse suspect? 1. Rheumatoid arthritis. 2. Osteoarthritis. 3. Ganglion. 4. Carpal tunnel syndrome.

Correct Answer: 3 Global Rationale: The findings describe a ganglion, a painless, round, fluid-filled mass that arises from the tendon sheaths on the dorsum of the wrist and hand. Rheumatoid arthritis is an autoimmune disorder that presents with joint pain and tenderness. The joint regions may exhibit warmth and swelling. Osteoarthritis is a condition in which the joints degenerate. The condition manifests with joint pain and stiffness. Carpal tunnel syndrome results from compression of the median nerve. It manifests with discomfort in the wrist and potentially the reduction in the ability to grasp objects.

The nurse is preparing to assess the posterior spine of a client. Which is the landmark the nurse will use to determine symmetry? 1. A. 2. B. 3. C. 4. D.

Correct Answer: 3 Global Rationale: The iliac crests are used as landmarks on the posterior spine. They are used to assess for symmetry.

The nurse is providing care to a client whose chief complaint is pain in the right foot. During the physical assessment, the nurse notes a deviation of the great toe from the midline and crowding of the remaining toes. There is also enlargement and inflammation noted in the area. Based on this data, which condition does the nurse suspect? 1. Flat foot. 2. Gouty arthritis. 3. Hammertoe. 4. Bunion.

Correct Answer: 4 Global Rationale: A hallux valgus, or bunion, causes a deviation of the great toe from the midline, and crowding of the remaining toes. The metatarsophalangeal joint and bursa become enlarged and inflamed. In pes planus, or flat foot, the arch of the foot is flattened, sometimes coming in contact with the floor. In gouty arthritis the metatarsophalangeal joint of the great toe is swollen, hot, red, and extremely painful. Hammertoe produces flexion of the proximal interphalangeal joint of a toe, while the distal metatarsophalangeal joint hyperextends.

The nurse asks the client to pull the toes up towards the nose during an examination of the lower extremities. Which is the nurse assessing based on this description? 1. Inversion. 2. Plantar flexion. 3. Eversion. 4. Dorsiflexion.

Correct Answer: 4 Global Rationale: Dorsiflexion is the movement of pulling the toes upward toward the nose. Inversion is the movement of pointing the sole of the foot inward. Plantar flexion is the movement of pointing the toes toward the floor. Eversion is the movement of pointing the sole of the foot outward.

The nurse notes full range of motion against gravity with moderate resistance when assessing muscle strength of the upper extremities in a client. When documenting the client's muscle strength, which term is appropriate? 1. Poor. 2. Normal. 3. Fair. 4. Good.

Correct Answer: 4 Global Rationale: Full range of motion against gravity with full resistance is considered normal muscle strength, also rated a 5. A rating of good, or a 4, would be full range of motion against gravity with moderate resistance. A rating of fair, or a 3, would be full range of motion with gravity. A rating of poor, or a 2, would be full range of motion without gravity, or passive motion.

The nurse is examining a client with a chief complaint of pain in the right great toe. The nurse notes hardened nodules on the lateral aspect of the toe, as well as redness and swelling. Based on this data, which condition does the nurse suspect? 1. Bunion. 2. Synovitis. 3. Hammertoe. 4. Gout.

Correct Answer: 4 Global Rationale: The manifestations are consistent with a diagnosis of gout. Gout is a form of arthritis. It results from an excess of uric acid. The uric acid crystals deposit in the affected joints. The findings describe tophi, which are the hardened nodules associated with the altered purine metabolism of gout. Bunions are thickening and inflammation of the bursa of the joint of the great toe. Synovitis occurs in the knee. In hammertoe the metatarsophalangeal joint of the toe hyperextends with flexion of the interphalangeal joint of the toe.