EXAM 4 NUR 2830

Assessment reveals that a client has slight weakness with active range of motion against some resistance. The nurse would document this as which of the following?

4/5 Slight weakness with active motion against some resistance is 4 of 5 points.

Which nutrient deficiency should a nurse recognize as placing a client at risk for osteoporosis?

A calcium deficiency increases the risk osteoporosis

A nurse inspects a flattened lumbar curvature in a client. Which of the following conditions should the nurse most suspect in this client?

A flattened lumbar curvature may be seen with a herniated lumbar disc or ankylosing spondylitis

Abduction

Abduction refers to moving away from the midline of the body.

Inspection of a client's knee reveals swelling, and the nurse suspects that there is significant fluid in the knee. Which of the following would the nurse use to confirm the suspicion?

Ballottement test The ballottement test is used to detect large amounts of fluid in the knee

Circumduction

Circumduction is the circular motion of the joint.

test carpal tunnel syndrome

Phalen's test

A client receives physical therapy for carpal tunnel syndrome. Which action by the nurse is appropriate to assess the efficacy of the treatment?

Place the backs of both hands against each other The nurse should ask the client to place the backs of both hands against each other while flexing the wrist 90 degrees downwards for 60 seconds for the Phalen's test.

discomfort decreases with motion

Rheumatoid arthritis

flexion and extension.

The knees are capable of performing only flexion and extension. Asking the client to move the arms forward Flexion is bending the extremity at the joint and decreasing the angle of the joint. Extension is straightening the extremity at the joint and increasing the angle of the joint.

a sharp, knife-lie pain

bone fraction

Chronic pain and fatigue

fibromyalgia

is used to assess muscle strength.

supine position

When assessing muscle tone and strength, the nurse would document expected findings as

upper and lower extremity muscle strength is 5/5 bilaterally"

Which joint movement is a nurse testing when asking a client to move an extremity towards the body?

Adduction

calcified tendonitis.

Chronic pain and limitation of all shoulder motion

The nurse is examining an older adult client. During the physical assessment, the client appears to be getting fatigued. What can the nurse do to help the client finish the assessment?

Divide the assessment into portions

is a side to side curvature of the spine.

Scoliosis

Mrs. Fletcher presents to the office with chronic unilateral pain when chewing. She does not have facial or scalp tenderness. Which of the following is the most likely cause of her pain?

Temporomandibular joint syndrome Temporomandibular joint syndrome is a very common cause of pain with chewing.

Assessment reveals that a client has slight weakness with active range of motion against some resistance. The nurse would document this as which of the following?

4/5 Slight weakness with active motion against some resistance is 4 of 5 points. 2 of 5 points would indicate passive and poor range of motion. 3 of 5 points would indicate average weakness with active motion against gravity. 5 of 5 points would indicate normal findings

How would you document normal muscle strength?

5/5 0—No muscular contraction detected 1— A barely detectable flicker or trace of contraction 2— Active movement of the body part with gravity eliminated 3— Active movement against gravity 4— Active movement against gravity and some resistance 5— Active movement against full resistance without evident fatigue. This is normal muscle strength.

Rotation

Rotation involves turning the head to the right shoulder then back to midline and then turning the head to the left shoulder then back to midline

The nurse suspects carpal tunnel syndrome after examining a patient in the clinic. A test result that would suggest this diagnosis would be

weak opposition of the thumb If the client cannot raise the thumb up from the plane and stretch the thumb pad to the little finger pad, this indicates thumb weakness in carpal tunnel syndrome.

After a physical assessment, the nurse determines that a patient has full range of motion of the temporomandibular joint. What did the nurse assess in this patient? (Select all that apply.)

• Opened and closed the mouth • Jutted the jaw forward • Rocked the jaw laterally

adduction

Asking the client to move the arms to the sides starting with the arms overhead Adduction is the movement towards the midline of the body.

Bones in synovial joints are joined together by

Bones in synovial joints are joined by ligaments, which are strong, dense bands of fibrous connective tissue.

To assess abduction of the shoulders and arms, a nurse should ask a client to do which of the following?

Bring both hands together overhead starting with the arms at the sides

A 50-year-old woman presents with "left hip pain" of several weeks duration. She is exquisitely tender when the nurse presses over her proximal lateral thigh. What is her most likely health problem?

Bursitis is usually accompanied by tenderness on examination. This location is consistent with trochanteric bursitis.

A nurse is providing health education about osteoporosis to a community group. What ethnicity is considered to be an independent risk factor for osteoporosis?

Caucasian ethnicity is a risk factor for osteoporosis.

Increased lumbar curvature, which compensates for the enlarging uterus in pregnant women, is called what?

Lordosis, increased lumbar curvature, compensates for the enlarging uterus.

A client complains of temporomandibular joint (TMJ) pain. Which of the following would the nurse most likely assess?

Difficulty chewing A client with temporomandibular joint problems may describe the jaw "getting locked" or difficulty chewing.

A nurse asks a client to bring the hands together behind the head with the elbows flexed. The nurse is testing which of the following?

External rotation When the client brings the hands together behind the head with the elbows flexed, the nurse is testing external rotation.

When assessing the client's upper extremities, the nurse instructs the client to put the hands behind the neck with the elbows pointed laterally. This positioning facilitates assessment of which of the following functions?

External rotation of the shoulder Pointing the elbows laterally tests the shoulder's ability to rotate externally and abduct.

Upon examination of an elderly client, the nurse finds hard, painless nodules over the distal interphalangeal joints. What is the appropriate term the nurse should use to document this finding in the client's medical records?

Heberden's nodes The nurse should document the hard, painless nodules over the distal interphalangeal joints as Heberden's nodes.

Upon examination of an elderly client, the nurse finds hard, painless nodules over the distal interphalangeal joints. What is the appropriate term the nurse should use to document this finding in the client's medical records?

Heberden's nodes The nurse should document the hard, painless nodules over the distal interphalangeal joints as Heberden's nodes.

overcurvature of the spine in the thoracic and sacral spine, can result from arthritis, osteoporosis, or trauma

Kyphosis

When examining a client with a rotator cuff tear, which of the following would the nurse expect to find?

Limited abduction Painful and limited abduction accompanied by muscle weakness and atrophy are seen with a rotator cuff tear.

A client expresses to the nurse that he has a "giving in" or "locking" sensation in the knee. Which test should the nurse perform to elicit related findings of a possible tear in the meniscus of the client's knee?

McMurray's The nurse should perform McMurray's test to confirm meniscal tear.

A nurse obtains an order to measure a client's leg length. How should a nurse correctly implement this order?

Measure from the anterior superior iliac spine to the medial malleolus To correctly measure leg length, ask the client to lie with legs extended. With a tape measure, measure the distance between the anterior superior iliac spine and the medial malleolus, crossing the tape on the medial side of the knee

A nurse notices that a client's flexibility of the right elbow is less than the left elbow. What is an appropriate action by the nurse in regard to this finding?

Measure movement with a goniometer

The client is complaining that his lower joints are increasingly painful as the day progresses. The nurse suspects the client is experiencing what musculoskeletal disorder?

Osteoarthritis is characterized by pain with motion that increases throughout the day.

A client visits the clinic and tells the nurse that she has joint pain in her hands, especially in the morning. The nurse should assess the client further for signs and symptoms of

Pain and stiffness in the joints is associated with arthritis.

Assessment of a client's ankle joint includes palpation along the Achilles tendon to look for which of the following?

Palpation of the Achilles tendon involves assessing for tenderness or nodules

A patient presents at the clinic with a history of cerebral palsy. When examining the patient you note increased resistance that is rate dependent and increases with rapid movement. What would you chart about this patient?

Patient demonstrates spasticity Spasticity is increased resistance that worsens at the extremes of range. Spasticity, seen in central corticospinal tract diseases, is rate dependent, increasing with rapid movement.

Which action by a nurse is a correct method for performing Tinel's test to determine the presence of carpel tunnel syndrome?

Percuss lightly on the inner aspect of the wrist The nurse should tap at the inner aspect of the wrist to percuss the median nerve because the median nerve is located at the inner aspect of the wrist where it enters the carpal canal

Which action by a nurse is a correct method for performing the Tinel's test to determine the presence of carpel tunnel syndrome?

Percuss lightly on the inner aspect of the wrist.

While assessing the elbow of an adult client, the client complains of pain and swelling. The nurse should further assess the client for

Redness, heat, and swelling may be seen with bursitis of the olecranon process due to trauma or arthritis.

rotator cuff tendonitis

Sharp catches of pain

test are done to detect the presence of fluid in the knee joint.

The Ballottement test and the Bulge test

The nurse is performing an assessment of a client's musculoskeletal system. The nurse should begin the assessment by examining which of the following?

The client's gait Gait inspection provides a valuable overview of musculoskeletal function. For this reason, it is usually performed at the beginning of the objective exam and prior to more detailed assessments

After assessing the client for posture and body alignment, how would the nurse document head position in relation to the spine if alignment is normal with noticeable defect?

The head is midline and aligned with the spine The correct documentation would be "the trunk and head are erect with weight distributed equally on both feet. The head is midline and aligned with the spine."

Which movement should the nurse instruct the client to perform to assess range of motion for the knee?

The nurse should instruct the client to perform flexion to assess the range of motion for the client's knee.

A client is brought to the health care facility with a sudden loss of movement on the right side of the body. Upon assessment, the nurse finds that the client has a slight flicker of contraction in the muscles on the right side. What should the nurse document as the muscle strength rating?

The nurse should rate the muscle strength as 1. Muscle rating 4 is given when the client is able to perform active motion against some resistance. When the client is able to perform active movements against gravity, the muscle strength is graded as 3. If the client is able to perform passive ROM, the muscle strength is rated as 2

After teaching a group of students about the bones and their functions, the instructor determines that the teaching was successful when the students state that blood cells are produced in which of the following?

The red marrow of the bone is responsible for producing red blood cells

Sarah presents with left lateral knee pain and has some locking in full extension. There is tenderness over the medial joint line. When the knee is extended with the foot externally rotated and some valgus stress is applied, a click is noted. What is the most likely diagnosis?

This maneuvre is called McMurray's test. Along with the medial joint line tenderness, the nurse should suspect a medial meniscus injury.

In which position should the nurse assist the patient when preparing to examine the tibiofemoral joint of the knee?

To examine the tibiofemoral joint of the knee, the nurse should ask the patient to sit on the edge of the examining table with the knees flexed.

A nurse is inspecting a client's gait. Which of the following would indicate an abnormal finding?

Toes point out Abnormal findings in gait include the following: uneven weight bearing is evident; client cannot stand on heels or toes; toes point in or out; client limps, shuffles, propels forward, or has wide-based gait

While assessing muscle strength in an older adult client, the nurse determines that the client's knee joint has a rating of 3 and exhibits active motion against gravity. The nurse should document the client's muscle strength as being/having

average weakness. Muscle strength that is active motion against gravity is rated as a 3 or average weakness.

The nurse is preparing an educational offering to help reduce musculoskeletal injuries for members of a community. What should the nurse include in these instructions?

• Using proper body mechanics with lifting objects • Importance of regular exercise • Maintaining a safe home environment • Maintaining a body weight appropriate to height and frame

While reviewing a client's chart before seeing the client for the first time, the nurse notes that the client has a diagnosis of Dupuytren contracture. The nurse anticipates that the client will exhibit

inability to extend the ring and little finger.

is used to assess the integrity of the Achilles' tendon.

prone position

is used to assess knee alignment and contours.

standing position

The nurse is going to test range of motion in a patient. To test extension of the triceps muscle, the nurse would instruct the patient to

straighten the elbow The client should have full range of motion.