Ch 40 NCLEX
The homecare nurse is evaluating the musculoskeletal system of a geriatric patient whose previous assessment was within normal limits. The nurse initiates a call to the health care provider and/or emergency services when which of the following changes are found? a) Decreased right-sided muscle strength b) Increased joint stiffness c) Decreased flexibility d) Decreased agility
a) 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.
The nurse is assessing the muscle tone of a patient with cerebral palsy. Which of the following descriptions does the nurse determine to be an expected assessment of this patient's muscle tone? a) Hypertonic b) Atrophied c) Atonic d) Flaccid
a) Hypertonic Explanation: In patients with conditions characterized by upper motor neuron destruction, such as in cerebral palsy, the muscles are often hypertonic. However, in conditions with lower motor neuron destruction, the muscles become atonic and/or atrophied and/or flaccid.
A patient 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? a) Joints b) Muscles c) Ligaments d) Bones
a) 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).
The nurse is conducting a musculoskeletal assessment on a patient documented to have rheumatoid arthritis. Which of the following would the nurse anticipate finding when inspecting the patient's fingers? a) Soft, subcutaneous nodules along the tendons b) Hard nodules adjacent to the joints c) Soft nodules along the palmar surface d) Hard nodules of bony overgrowth
a) Soft, subcutaneous nodules along the tendons Explanation: The subcutaneous nodules of rheumatoid arthritis are soft and occur within and along tendons that provide extensor function to the joints. The nodules of gout are hard and lie within and immediately adjacent to the joint capsule itself. 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.
The nurse is conducting a community education program on hip fracture risk. The nurse evaluates that the participants understand the program when the program determines that the person at highest risk for a hip fracture is which of the following? a) High school football player b) 80-year-old widow c) 30-year-old pregnant woman d) Toddler just starting to walk
b) 80-year-old widow Explanation: Hip fracture occurs with greater incidence in elderly people and is often a life-altering event that has a negative impact on the person's mobility and quality of life.
The nurse is assessing a young girl during her school's annual sports physical. The assessment reveals that the girl has lateral curving of the spine. The nurse reports to the health care professional that the assessment revealed which of the following? a) Lordosis b) Epiphysis c) Scoliosis d) Diaphysis
c) Scoliosis Explanation: Scoliosis is a lateral curving of the spine. Lordosis is an increase in the lumbar curvature of the spine. Diaphysis is the shaft of a long bone. Epiphysis is the end of a long bone.
Which hormone inhibits bone reabsorption and increases calcium deposit in the bone? a) Sex hormones b) Vitamin D c) Growth hormone d) Calcitonin
d) 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. The other answers do not apply.
The nurse is reading the admission note of a patient with a bone fracture that requires surgery. The note indicates the presence of crepitus. The nurse interprets this as being which of the following? a) Ecchymosis b) Closed fracture c) Bleeding d) Crackling sound
d) Crackling sound Explanation: Crepitus is a sound or sensation elicited by the rubbing together of fragments of bone, as in a fracture, or in irregular joint surfaces. The sound/sensation can be described as "grating" or "crackling."
The nurse working in the ER receives a call from the x-ray department communicating that the patient the nurse is caring for has a fracture in the shaft of the tibia. The nurse tells the physician that the patient's fracture is which of the following? a) Epiphysis b) Scoliosis c) Lordosis d) Diaphysis
d) 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.
Which of the following terms refers to muscle tension being unchanged with muscle shortening and joint motion? a) Fasciculation b) Isometric contraction c) Contracture d) Isotonic contraction
d) Isotonic contraction Explanation: Exercises such as swimming and bicycling are isotonic. Isometric contraction is characterized by increased muscle tension, unchanged muscle length, and no joint motion. Contracture refers to abnormal shortening of muscle, joint, or both. Fasciculation refers to the involuntary twitch of muscle fibers.
After a fracture, during which stage or phase of bone healing is devitalized tissue removed and new bone reorganized into its former structural arrangement? a) Inflammation b) Reparative c) Revascularization d) Remodeling
d) Remodeling Explanation: Remodeling is the final stage of fracture repair. During inflammation, macrophages invade and débride the fracture area. Revascularization occurs within about 5 days after the fracture. Callus formation occurs during the reparative stage, but is disrupted by excessive motion at the fracture site.
Which of the following describes an osteon? a) A microscopic functional bone unit b) A mature bone cell c) A bone-forming cell d) A bone resorption cell
a) A microscopic functional bone unit Explanation: The center of an osteon contains a capillary, a microscopic functional bone unit. An osteoblast is a bone-forming cell. An osteoclast is a bone resorption cell. An osteocyte is a mature bone cell.
What is the term for a rhythmic contraction of a muscle? a) Clonus b) Hypertrophy c) Crepitus d) Atrophy
a) Clonus Explanation: Clonus is a rhythmic contraction of the muscle. Atrophy is a shrinkagelike 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 of the following terms refers to mature compact bone structures that form concentric rings of bone matrix? a) Lamellae b) Cancellous bone c) Trabecula d) Endosteum
a) Lamellae Explanation: Lamellae are mineralized bone matrices. Endosteum refers to the marrow cavity lining of hollow bone. Trabecula refers to latticelike bone structure. Cancellous bone refers to spongy, latticelike bone structure.
The nurse reading a patient's chart notices that the patient is documented to have paresthesia. The nurse plans care for a patient with which of the following? a) Absence of muscle tone b) Absence of muscle movement suggesting nerve damage c) Abnormal sensations d) Involuntary twitch of muscle fibers
c) 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 termed flaccid.
The nurse is evaluating a patient's peripheral neurovascular status. Which of the following should the nurse report to the health care provider as a circulatory indicator of peripheral neurovascular dysfunction? a) Paresthesia b) Paralysis c) Cool skin d) Weakness
c) 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 of the following is an indicator of neurovascular compromise? a) Pain on active stretch b) Warm skin temperature c) Diminished pain d) Capillary refill of more than 3 seconds
d) 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 on passive stretch, and absence of feeling. Cool skin temperature is an indicator of neurovascular compromise. Unrelenting pain is an indicator of neurovascular compromise. Pain on passive stretch is an indicator of neurovascular compromise.
The nurse is creating a teaching plan for a 65-year-old woman on prevention of osteoporosis. The nurse should include which of the following on the teaching plan? Select all that apply. a) Daily intake of 1,000 IU of vitamin D b) Daily intake of 800 mg of calcium c) Increased consumption of low-fat milk d) Increased consumption of fish
a) Daily intake of 1, 000 IU of vitamin D, c) Increased consumption of low-fat milk, d) Increased consumption of fish Explanation: Diet is an essential component of maintaining adult bone mass and preventing osteoporosis. Recommended daily intake of calcium is 1,000-1,200 mg. Good sources of calcium include low-fat milk, yogurt, and cheese and calcium-fortified foods. To ensure absorption of calcium, vitamin D intake should range from 800-1,000 IU for adults over the age of 50. Good sources of vitamin D include vitamin D-fortified milk and cereals, egg yolks, saltwater fish, and liver.
The nurse is performing a musculoskeletal assessment of a patient 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 patient's right calf is 2 inches less in diameter than the left calf. The nurse attributes the decreased girth to which of the following? a) Increased use of left calf muscle b) Atrophy of right calf muscle c) Edema in left lower extremity d) Bruising in right lower extremity
b) Atrophy of right calf muscle Explanation: Girth of an extremity may increase due to exercise, edema, or bleeding into the muscle. However, a patient with right-sided hemiplegia is unable to use the right lower extremity. This patient may experience atrophy of the muscles from lack of use, which will result in a subsequent decrease in the girth of the calf muscle.
The nurse is conducting a musculoskeletal assessment of a patient in a nursing home. The patient is unable to dorsiflex his right foot or extend his toes. The nurse evaluates this finding as an injury to which of the following nerves? a) Achilles b) Sciatic c) Femoral d) Peroneal
d) Peroneal Explanation: Injury to the peroneal nerve as a result of pressure may cause foot drop or the inability to dorsiflex the foot and extend the toes.
During which stage or phase of bone healing after fracture does callus formation occur? a) Revascularization b) Reparative c) Inflammation d) Remodeling
b) Reparative Explanation: Callus formation occurs during the reparative stage, but is disrupted by excessive motion at the fracture site. Remodeling is the final stage of fracture repair during which the new bone is reorganized into the bone's former structural arrangement. During inflammation, macrophages invade and débride the fracture area. Revascularization occurs within about 5 days after the fracture.
Which nerve is assessed when the nurse asks the patient to spread all fingers? a) Median b) Peroneal c) Radial d) Ulnar
d) Ulnar Explanation: Asking the patient 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 patient to dorsiflex the ankle and to extend the toes. The radial nerve is assessed by asking the patient to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. The median nerve is assessed by asking the patient to touch the thumb to the little finger.
Which nerve is being assessed when the nurses asks the patient to dorsiflex his ankle and extend his toes? a) Median b) Ulnar c) Radial d) Peroneal
d) Peroneal Explanation: The motor function of the peroneal nerve is assessed by asking the patient to dorsiflex the ankle and to extend the toes, while pricking the skin between the great toe and center toe assesses the sensory function. The radial nerve is assessed by asking the patient to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. The median nerve is assessed by asking the patient to touch the thumb to the little finger. Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation.
The nurse working in the orthopedic surgeon's office is asked to schedule a shoulder arthrography. The nurse determines that the surgeon suspects which of the following findings? a) Decreased bone density b) Injury to the radial nerve c) Fracture of the clavicle d) Tear in the joint capsule
d) Tear in the joint capsule Explanation: Arthrography is useful in identifying acute or chronic tears of the joint capsule or supporting ligaments of the knee, shoulder, ankle, hip, or waist. X-rays are used to diagnose bone fractures. Bone densitometry is used to estimate bone mineral density. An electromyogram (EMG) provides information about the electrical potential of the muscles and nerves leading to them.
The nurse is caring for patient scheduled to have magnetic resonance imaging (MRI). The nurse contacts the health care provider to cancel the MRI when the nurse reads which of the following in the patient's medical history? a) Cochlear implant b) Skin graft c) Colostomy d) Tumor removal
a) Cochlear implant Explanation: Nonremovable cochlear devices can become inoperable when exposed to MRI. Therefore, it is contraindicated for a patient with a cochlear implant to have an MRI. Also, transdermal patches (e.g., nicotine patch [NicoDerm], nitroglycerin transdermal [Transderm-Nitro], scopolamine transdermal [Transderm Scop], clonidine transdermal [Catapres-TTS]) that have a thin layer of aluminized backing must be removed before MRI because they can cause burns. The primary provider should be notified before the patches are removed. Additionally, the patient should remove all jewelry, hair clips, hearing aids, credit cards with magnetic strips, and other metal-containing objects; otherwise, these objects can become dangerous projectiles or cause burns.
