HHA, chp 24, ASSESSING MUSCULOSKELETAL SYSTEM
The nurse suspects that a client is experiencing osteoarthritis. What information about the client's pain caused the nurse to make this clinical determination? Select all that apply. a. Improves with rest b. Worse after sitting c. Worse in rainy weather d. Early morning stiffness e. Located in the right hip
A. Improves with rest C. Worse in rainy weather D. Early morning stiffness E. Located in the right hip Explanation: Osteoarthritis pain improves after rest. It usually begins in one set of joints, on one side of the body. The pain worsens with rainy weather and begins with stiffness in the morning. Rheumatoid arthritis pain is worse after sitting. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 535. Chapter 24: Assessing Musculoskeletal System - Page 535
A 38-year-old woman presents with multiple small joints that are symmetrically involved with pain, swelling, and stiffness. Which of the following is the most likely explanation? A. Rheumatoid arthritis B. Gout C. Trauma D. Septic arthritis
A. Rheumatoid arthritis Explanation: Rheumatoid arthritis is a systemic disease and accounts for multiple symmetrically involved joints. Septic arthritis is usually monoarticular, as are gout and trauma related joint pain. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 552. Chapter 24: Assessing Musculoskeletal System - Page 552
During palpation of the client's knee, the nurse compresses the suprapatellar pouch against the client's femur with one hand while feeling on each side of the patella with the opposite hand. For which of the following problems is the nurse assessing? A. Ligament trauma B. Effusion in the knee joint C. Crepitus uteri flexion D. Osteoarthritis
B. Effusion in the knee joint Explanation: The balloon sign is indicative of a large effusion in the knee joint when fluid is palpable medial to the patella when the suprapatellar pouch is depressed. The presence of crepitus, osteoarthritis, or ligament damage is not directly suggested by a positive balloon sign. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 556. Chapter 24: Assessing Musculoskeletal System - Page 556
Louise is a 60-year-old woman who complains of left knee pain associated with tenderness throughout, redness, and warmth over the joint. Which of the following is least helpful in determining if a joint problem is inflammatory? A. Redness B. Pain C. Tenderness D. Warmth
B. Pain Explanation: Pain is present in both inflammatory and non-inflammatory conditions. Warmth, redness, and tenderness to palpation should lead one to consider an inflammatory etiology for the pain. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 535. Chapter 24: Assessing Musculoskeletal System - Page 535
Skeletal muscles are attached to bones by A. ligaments. B. fibrous connective tissue. C. tendons. D. cartilage.
C. tendons. Explanation: Skeletal muscles attach to bones by way of strong, fibrous cords called tendons. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 528. Chapter 24: Assessing Musculoskeletal System - Page 528
The nurse is preparing information about osteoporosis for a community health fair. Which information should the nurse include as a handout for the participants? Select all that apply. CORRECT ANSWER: Avoid severe weight loss diets Ensure adequate calcium intake Engage in weight-bearing activities Avoid smoking and second-hand smoke Explanation: Teaching to avoid the development of osteoporosis should include avoiding severe weight loss diets, ensuring an adequate calcium intake, engaging in weight-bearing activities, and avoiding smoke and second-hand smoke. Heavy drinking should be avoided however all alcohol does not need to be avoided to prevent the development of osteoporosis. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 538. Chapter 24: Assessing Musculoskeletal System - Page 538
Question 1 See full question 50s Report this Question How many vertebrae make up the spinal column? You Selected: 33 Correct response: 33 Explanation: Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 533. Chapter 24: Assessing Musculoskeletal System - Page 533 Add a Note Question 2 See full question 1m 34s Report this Question A nurse performs a nudge test to assess the gait of a client with Parkinson's disease. Which action by the nurse demonstrates the correct technique for performing this test? The nurse should stand: You Selected: at the back of the client and nudge the sternum Correct response: at the back of the client and nudge the sternum Explanation: Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 541. Chapter 24: Assessing Musculoskeletal System - Page 541 Add a Note Question 3 See full question 3m 23s Report this Question A client receives physical therapy for carpal tunnel syndrome. Which action by the nurse is appropriate to assess the efficacy of the treatment? You Selected: Place the backs of both hands against each other Correct response: Place the backs of both hands against each other Explanation: Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 550. Chapter 24: Assessing Musculoskeletal System - Page 550 Add a Note Question 4 See full question 3m 51s Report this Question 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? You Selected: 1 Correct response: 1 Explanation: Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 540. Chapter 24: Assessing Musculoskeletal System - Page 540 Add a Note Question 5 See full question 4m 23s Report this Question The nurse suspects carpal tunnel syndrome after examining a patient in the clinic. A test result that would suggest this diagnosis would be You Selected: weak opposition of the thumb Correct response: weak opposition of the thumb Explanation: Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 551. Chapter 24: Assessing Musculoskeletal System - Page 551 Add a Note Question 6 See full question 2m 45s Report this Question During the health history of the musculoskeletal system, the client reports having low back pain that radiates into the leg with numbness and tingling. The nurse should further assess for spinal stenosis when the client makes which of the following statements? You Selected: "The pain improves when I am leaning over a shopping cart" Correct response: "The pain improves when I am leaning over a shopping cart" Explanation: Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.
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The nurse is preparing to perform a musculoskeletal examination on an adult client. The nurse has explained the examination procedure to the client. The nurse determines that the client needs further instructions when the client says A. "You'll continue with range of motion even if I have discomfort." B. "You'll be assessing the size and strength of my joints." C. "You'll be comparing bilateral joints." D. "You will be asking me to change positions often."
A. "You'll continue with range of motion even if I have discomfort." Explanation: Do not force the part beyond its normal range. Stop passive motion if the client expresses discomfort or pain. Be especially cautious with the older client when testing ROM. When comparing bilateral strength, keep in mind that the client's dominant side will tend to be the stronger side. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 539. Chapter 24: Assessing Musculoskeletal System - Page 539
To assess abduction of the shoulders and arms, a nurse should ask a client to do which of the following? A. Bring both hands together overhead starting with the arms at the sides B. Move the arms forward starting with the arms at the sides C. Move the arms to the sides starting with the hands together overhead D. Move the arms backward starting with the arms at the sides
A. Bring both hands together overhead starting with the arms at the sides Explanation: To elicit abduction, the nurse should ask the client to bring both hands together overhead. Asking the client to move the arms forward elicits flexion, and asking the client to move the arms backward elicits extension. Asking the client to move the arms to the sides starting with the arms overhead elicits adduction. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 546. Chapter 24: Assessing Musculoskeletal System - Page 546
Which nutrient deficiency should a nurse recognize as placing a client at risk for osteoporosis? A. Calcium B. Vitamin C C. Protein D. Vitamin D
A. Calcium Explanation: A calcium deficiency increases the risk osteoporosis. This causes the bones to become softer in nature because the rate at which bone is destroyed is occurring at a faster rate than new bone is made. Protein functions in muscle tone and growth. Vitamin C promotes healing of tissues and bones. Vitamin D deficiency causes osteomalacia, softening of the bones due to defective bone mineralization. Osteomalacia in children is known as rickets. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 536. Chapter 24: Assessing Musculoskeletal System - Page 536
A college age athlete presents to the clinic with pain in the tibiotalar joint. It is a hinge joint limited to flexion and extension. The terms used to describe these movements are what? A. Dorsiflexion and plantar flexion B. Adducting and abducting C. Supination and pronation D. Rotation and supination
A. Dorsiflexion and plantar flexion Explanation: The terms used to describe the movements of the tibiotalar joint are dorsiflexion and plantar flexion. Adducting means to move a part of the body toward the midline. Abducting is moving a part of the body away from the midline. Supination is a motion where the foot or palm of the hand is moved to a surface up position. Pronation is a motion where the foot or palm of the hand is moved to a surface down position. Rotation is simply the movement of the joint. Rotation could be either internal or external in nature. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 530. Chapter 24: Assessing Musculoskeletal System - Page 530
Risk factors in which of the following areas are most readily changed to reduce the potential risk for falls? A. Environmental B. Physiological C. Social D. Cognitive
A. Environmental Explanation: While adapting individuals' social, cognitive, and physiological circumstances can present challenges, modifications to address environmental threats to safety can often be made more easily. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 541. Chapter 24: Assessing Musculoskeletal System - Page 541
The nurse instructs the patient to raise his arm out to the side and overhead. The nurse is asking the patient to adduct his arm. A. False B. True
A. False Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 528. Chapter 24: Assessing Musculoskeletal System - Page 528
The nurse is assessing the range of motion (ROM) of a patient's joints. What would the nurse use to assess flexion and extension of a joint if the patient complains of pain on examination? A. Goniometer B. Scoliometer C. Angulator D. Calibrator
A. Goniometer Explanation: If ROM is limited, use a goniometer to measure the angle of the joint at its maximum flexion and extension. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 540. Chapter 24: Assessing Musculoskeletal System - Page 540
The nurse is developing a plan of care for a client found to have a strength problem. What would be an appropriate nursing diagnosis for this client? A. Impaired physical mobility B. Impaired walking C. Activity intolerance D. Self-care deficit
A. Impaired physical mobility Explanation: The most appropriate diagnosis would be impaired physical mobility related to reduced strength and ROM. Activity intolerance and self-care deficit would not correctly identify the situation at hand. Impaired walking is incorrect since it is limited in scope. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 560. Chapter 24: Assessing Musculoskeletal System - Page 560
A community health nurse is providing education to help reduce musculoskeletal injuries in adults. What should the nurse include in these instructions? (Select all that apply.) A. Importance of regular exercise B. Maintaining a body weight appropriate to height and frame C. Limiting intake of dairy products D. Maintaining a safe home environment E. Using proper body mechanics with lifting objects
A. Importance of regular exercise B. Maintaining a body weight appropriate to height and frame D. Maintaining a safe home environment E. Using proper body mechanics with lifting objects Explanation: Health promotion topics to prevent musculoskeletal injuries include engaging in regular exercise, maintaining a body weight appropriate to height and frame, using proper body mechanics with lifting or moving objects, and maintaining a safe home environment. Clients should not be told to limit dairy intake because this is a source of dietary calcium. Having the recommended daily intake of calcium can prevent risk factors for osteoporosis, therefore, musculoskeletal injuries. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 538. Chapter 24: Assessing Musculoskeletal System - Page 538
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? A. McMurray's B. Bulge C. Phalen's D. Ballottement
A. McMurray's Explanation: The nurse should perform McMurray's test to confirm meniscal tear. Pain or clicking during the test is indicative of a torn meniscus of the knee. The ballottement test and the bulge test are done to detect the presence of fluid in the knee joint. Phalen's test is done to test for carpal tunnel syndrome. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 556. Chapter 24: Assessing Musculoskeletal System - Page 556
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? A. Measure movement with a goniometer B. Note that the dominant side is stronger C. Assess the client's hand grips D. Notify the health care provider
A. Measure movement with a goniometer Explanation: If the nurse identifies a limitation in the range of motion for a joint, a goniometer should be used to measure the exact angle of movement present. The goniometer is placed at the joint and then moved to match the angle of the joint being assessed. It is not necessary to notify the health care provider until all information is collected. The hand grips test strength, not range of motion. The dominant side of the body is stronger but does not necessarily have greater range of motion. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 540. Chapter 24: Assessing Musculoskeletal System - Page 540
The nurse is working with a client who has leukemia, which affects the red marrow of the bones. The nurse understands that which of the following is characteristic of red marrow? A. Produces red blood cells B. Is composed mostly of fat C. Covers the bones and contains osteoblasts and blood vessels D. Is hard and dense and makes up the shaft and outer layers
A. Produces red blood cells Explanation: Bones contain red marrow that produces blood cells and yellow marrow composed mostly of fat. The periosteum covers the bones and contains osteoblasts and blood vessels that promote nourishment and formation of new bone tissues. Composed of osseous tissue, bones can be divided into two types: compact bone, which is hard and dense and makes up the shaft and outer layers; and spongy bone, which contains numerous spaces and makes up the ends and centers of the bones. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 528. Chapter 24: Assessing Musculoskeletal System - Page 528
A 68-year-old retired banker comes to your clinic for evaluation of left shoulder pain. He swims for 30 minutes daily each morning. He notes a sharp, catching pain and a sensation of something grating when he tries overhead movements of his arm. On physical examination, you note tenderness just below the tip of the acromion in the area of the tendon insertions. The drop arm test is negative, and there is no limitation with shoulder shrug. The client is not holding his arm close to his side, and there is no tenderness to palpation in the bicipital groove when the arm is at the client's side, flexed to 90 degrees, and then supinated against resistance. Based on this description, what is the most likely cause of his shoulder pain? A. Rotator cuff tendinitis B. Bicipital tendinitis C. Calcific tendinitis D. Rotator cuff tear
A. Rotator cuff tendinitis Explanation: Rotator cuff tendinitis is typically precipitated by repetitive motions, such as occurs with throwing or swimming. Crepitus/grating is noted in the shoulder with range of motion. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 546. Chapter 24: Assessing Musculoskeletal System - Page 546
After completing the musculoskeletal health history, the nurse determines that a client is at risk for osteoporosis. Which of the following risk factors were most likely identified in this client?(Select all that apply.) A. Sedentary lifestyle B. Current smoker C. Age 65 D. Weight 180 pounds E. Alcohol intake four drinks per day
A. Sedentary lifestyle B.Current smoker C. Age 65 E. Alcohol intake four drinks per day Explanation: Risk factors for the development of osteoporosis include age over 50 years, current smoker, sedentary lifestyle, and higher than the daily recommended allowance of alcohol intake. Body weight less than 70 kg or 154 pounds increases the client's risk for osteoporosis. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 538. Chapter 24: Assessing Musculoskeletal System - Page 538
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 A. arthritis. B. carpal tunnel syndrome. C. a neurologic disorder. D. osteoporosis.
A. arthritis. Explanation: Pain and stiffness in the joints is associated with arthritis. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 535. Chapter 24: Assessing Musculoskeletal System - Page 535
Joints may be classified as cartilaginous, synovial, or A. fibrous. B. articulate. C. flexible. D. immobile.
A. fibrous. Explanation: The joint (or articulation) is the place where two or more bones meet. Joints provide a variety of ranges of motion (ROM) for the body parts and may be classified as fibrous, cartilaginous, or synovial. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 530. Chapter 24: Assessing Musculoskeletal System - Page 530
While assessing the range of motion in an adult client's shoulders, the client expresses pain and exhibits limited abduction and muscle weakness. The nurse plans to refer the client to a physician for possible A. rotator cuff tear. B. nerve damage. C. tendonitis. D. cervical disc degeneration.
A. rotator cuff tear. Explanation: Painful and limited abduction accompanied by muscle weakness and atrophy are seen with a rotator cuff tear. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 546. Chapter 24: Assessing Musculoskeletal System - Page 546
A client has uneven height of the shoulders and hips. What should the nurse suspect this client is demonstrating? A. scoliosis B. sacroiliitis C. kyphosis D. lordosis
A. scoliosis Explanation: In scoliosis the shoulders and hips will have unequal height. There is an increase in the lumbar curvature in lordosis. There is an increase in the thoracic curvature in kyphosis. Sacroiliitis is associated with tenderness over the sacroiliac joint. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 562. Chapter 24: Assessing Musculoskeletal System - Page 562
A nurse is conducting a physical examination of the musculoskeletal system of a client who reports having joint pain. Which signs indicate there is inflammation in the joints? Select all that apply. A. tenderness B. warmth C. swelling D. subcutaneous nodules E. redness
A. tenderness B. warmth C. swelling E. redness Explanation: Swelling is palpable and involves the synovial membrane of the joints. The nurse should assess to note if the area surrounding the joints feels boggy and doughy. Nearby tissues of joints may feel warm to touch; heat is always generated as a result of the inflammation process. Redness is less common, but if present it is also a sign of inflammation around a joint. Due to pressure from swelling of the tissues surrounding affected joints, inflammation causes tenderness and is painful to touch. Subcutaneous nodules are extra-articular lesions associated with rheumatoid arthritis and is not one of the four signs of inflammation commonly seen in the tissues surrounding joints. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 542. Chapter 24: Assessing Musculoskeletal System - Page 542
Phil comes to the office with left "shoulder pain" that is markedly worse when his left arm is drawn across his chest (adduction). Which of the following is suspected? A. Adhesive capsulitis B. Acromioclavicular joint involvement C. Subacromial bursitis D. Rotator cuff tear
B. Acromioclavicular joint involvement Explanation: Adduction of the client's arm across his chest can cause pain if the acromioclavicular joint is involved. In adhesive capsulitis, this maneuvre may not be possible because of limited range of motion. Subacromial bursitis would present with tenderness inferior to the acromion. Rotator cuff injury would ordinarily not be associated with pain during this maneuvre. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 546. Chapter 24: Assessing Musculoskeletal System - Page 546
After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? (Select all that apply.) A. Asked the client to extend the tongue B. Asked the client to open and close the mouth C. Asked the client to swallow D. Asked the client to rock the jaw laterally E. Asked the client to jut the jaw forward
B. Asked the client to open and close the mouth D. Asked the client to rock the jaw laterally E. Asked the client to jut the jaw forward Explanation: Range of motion of the temporomandibular joint consists of three activities: opening and closing of the mouth, jutting the jaw forward, and rocking the jaw laterally. If the patient is able to perform these activities, then the joint has full range of motion. Range of motion of the jaw is not assessed by swallowing or extending the tongue. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 532. Chapter 24: Assessing Musculoskeletal System - Page 532
An adult client has been diagnosed with carpal tunnel syndrome. What type of working conditions may have contributed to this diagnosis? A. Substantial physical activity B. Frequent repetitive movements C. Prolonged sitting D. Heavy lifting
B. Frequent repetitive movements Explanation: Some working conditions present potential risks to the musculoskeletal system. Workers required to lift heavy objects may strain and injure their backs. Jobs requiring substantial physical activity, such as construction work and fire fighting, increase the likelihood of sprains, strains, and fractures. Frequent repetitive movements may lead to misuse disorders such as carpal tunnel syndrome, pitcher's elbow, or vertebral degeneration. Musculoskeletal injuries may also occur when people sit for long periods at desks with poor ergonomic design. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 536. Chapter 24: Assessing Musculoskeletal System - Page 536
A client presents to the health care clinic with reports of a swollen, tender, reddened joint in the left big toe. The nurse recognizes this finding as an indication of what inflammatory process? A. Verruca vulgaris (warts) B. Gouty arthritis C. Rheumatoid arthritis D. Degenerative joint disease
B. Gouty arthritis Explanation: Tender, painful, reddened, hot, and swollen metatarsophalangeal joint in the great (big) toe is seen in gouty arthritis. This is an inflammatory condition caused by an abnormal buildup of uric acid in the body that becomes deposited in the joints. Rheumatoid arthritis can occur in any joint but usually affects the hands first. Verruca vulgaris (warts) is a painful wart that occurs under a callus. Degenerative joint disease does not typically cause the joints to be reddened and hot because it is not an inflammatory process. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 557. Chapter 24: Assessing Musculoskeletal System - Page 557
A client presents to the health care clinic with reports of pain in the hands and right wrist. Additional history reveals that the client is a factory worker who spends all day performing the same repetitive task. The nurse performs Phalen's test and Tinel's test with positive results. The hand grips are unequal, with the right weaker than the left. What nursing diagnosis can the nurse confirm from this data? A. Risk for Trauma B. Impaired Physical Mobility C. Disturbed Body Image D. Activity Intolerance
B. Impaired Physical Mobility Explanation: This client is likely experiencing carpal tunnel syndrome because of the repetitive hand movements that inflame the median nerve as it passes through the wrist. Impaired Physical Mobility related to decreased muscle strength as evidenced by a weak right hand grip meets the major criteria to confirm this nursing diagnosis. Risk for Trauma cannot be confirmed because the client already has carpal tunnel syndrome so he is not at risk. Disturbed Body Image and Activity Intolerance do not meet any major defining characteristics to confirm these nursing diagnoses. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 560. Chapter 24: Assessing Musculoskeletal System - Page 560
Mary started a job 2 weeks ago that requires carrying heavy buckets. She presents with elbow pain worse on the right. On examination, it hurts her elbows to dorsiflex her hands against resistance when her palms face the floor. What condition does she have? A. Medial epicondylitis (golfer's elbow) B. Lateral epicondylitis (tennis elbow) C. Supracondylar fracture D. Olecrenon bursitis
B. Lateral epicondylitis (tennis elbow) Explanation: Mary's injury probably occurred by lifting heavy buckets with her palms down (toward the bucket). This caused her chronic overuse injury at the lateral epicondyle. Medial epicondylitis has reproducible pain when palmar flexion against resistance is performed and also features tenderness over the involved epicondyle. Olecranon bursitis produces erythema and swelling over the olecranon process. A supracondylar fracture of the humerus is a major injury and would present more acutely. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 548. Chapter 24: Assessing Musculoskeletal System - Page 548
The nurse is testing a client for carpal tunnel syndrome. The client flexes the wrists at an angle of 90° and holds the backs of the hands to each other for 60 seconds. The client tells the nurse that he is experiencing a burning pain as a result. Which test is the nurse performing on this patient? A. McMurray's B. Phalen's C. Ballottement D. Tinel's
B. Phalen's Explanation: Phalen's test evaluates for carpal tunnel syndrome. The client flexes the wrists at an angle of 90° and holds the backs of the hands to each other for 60 seconds. Normal response is denial of any discomfort. Positive signs include numbness, burning, or pain. Tinel's sign is a test to assess for irritated nerves. It is performed by lightly percussing over the nerve to elicit a sensation or tingling in the distribution of the nerve. Ballottement is a test to assess for increased fluid in the knee joint. The McMurray test is used to test individuals for tears in the meniscus of the knee. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 550. Chapter 24: Assessing Musculoskeletal System - Page 550
The nurse is receiving report on a client with a nursing diagnosis of activity intolerance. What would be an appropriate nursing intervention for this client? A. Use footwear that facilitates walking and prevents injury B. Promote reconditioning C. Use assistive devices D. Ask for input on habits and preferences
B. Promote reconditioning Explanation: For the client with activity intolerance, the nurse would determine the cause of intolerance and promote reconditioning. Footwear is not going to solve the problem of activity tolerance. The client does not have a problem with mobility, for which assistive devices would be most helpful. Assessing habits and presences is irrelevant. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System.
A 32-year-old warehouse worker presents for evaluation of low back pain. He notes a sudden onset of pain after lifting a heavier-than-usual set of boxes. He also states that he has numbness and tingling in the left leg. What test should the nurse perform to assess for a herniated disc? A. Phelan's test B. Straight leg raise test C. Tinel's test D. Leg length test
B. Straight leg raise test Explanation: The straight leg raise test involves having the client lie supine with the examiner raising the leg. If the client experiences a sharp pain radiating from the back down the leg in an L5 or S1 distribution, that suggests a herniated disc. Leg strength test, Tinel's test, and Phelan's test do not assess for a herniated disc. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, pp. 545-546. Chapter 24: Assessing Musculoskeletal System - Page 545-546
A client visits the clinic and tells the nurse that after playing softball yesterday, he thinks his knee is "locking up." The nurse should perform the McMurray test by asking the client to A. bend forward while trying to touch the toes. B. flex the knee and hip while in a supine position. C. move from a standing to a squatting position. D. raise his leg while in a supine position.
B. flex the knee and hip while in a supine position. Explanation: If the client complains of a "giving in" or "locking" of the knee, perform McMurray's test. With the client in the supine position, ask the client to flex one knee and hip. Then place your thumb and index finger of one hand on either side of the knee. Use your other hand to hold the heel of the foot up. Rotate the lower leg and foot laterally. Slowly extend the knee, noting pain or clicking. Repeat, rotating lower leg and foot medially. Again, note pain or clicking. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 556. Chapter 24: Assessing Musculoskeletal System - Page 556
An adult client tells the nurse that he eats sardines every day. The nurse should instruct the client that a diet high in purines can contribute to A. osteomalacia. B. gouty arthritis. C. osteomyelitis. D. bone fractures.
B. gouty arthritis. Explanation: A diet high in purine (e.g., liver, sardines) can trigger gouty arthritis. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 536. Chapter 24: Assessing Musculoskeletal System - Page 536
A client visits the health care facility with reports of lumbar back pain that radiates down the back. The nurse performs the straight leg test to determine the origin of the pain. Which techniques should the nurse use to perform this test? A. Palpate the spinous processes and the paravertebral muscles B. Instruct the client to touch the chin to the chest C. Ask the client to raise the leg to the point of pain and then dorsiflex the foot D. Instruct the client to bend forward and touch the toes
C. Ask the client to raise the leg to the point of pain and then dorsiflex the foot Explanation: To perform the straight leg test, the nurse should ask the client to raise the client's leg to the point of pain and then dorsiflex the foot to check for a herniated nucleus pulposus. Asking the client to bend forward and touch the toes facilitates assessment of range of motion of the lumbar spine. Asking the client to touch the chin to the chest evaluates range of motion of the cervical spine. The spinous processes and the paravertebral muscles on both sides of the spine are palpated for tenderness and pain and are not a part of the straight leg test. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 545. Chapter 24: Assessing Musculoskeletal System - Page 545C
A nurse has just finished assessing a client's spine and neck muscles. How would the nurse document normal findings? A. All findings within normal limits B. C8 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully developed, symmetrical, and nontender C. C7 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully developed, symmetrical, and nontender D. Neck assessment WNL
C. C7 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully developed, symmetrical, and nontender Explanation: Normal findings are that the C7 and T1 spinous processes are prominent. The paravertebral, sternocleidomastoid, and trapezius muscles are fully developed, symmetrical, and nontender. Therefore, other options are incorrect. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 543. Chapter 24: Assessing Musculoskeletal System - Page 543
A client waiting to be seen for a clinic appointment is observed periodically shaking the left wrist. On what should the nurse focus when assessing this client? A. Fractured wrist B. Paralysis C. Carpal tunnel syndrome D. Dupuytren contracture
C. Carpal tunnel syndrome Explanation: A motion that resembles shaking a thermometer could indicate the presence of carpal tunnel syndrome. The wrist and hand would not be mobile if the limb is paralyzed. Moving the hand and wrist would produce excruciating pain if the wrist is fractured. The inability to extend the ring and little finger is associated with a Dupuytren contracture. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 552. Chapter 24: Assessing Musculoskeletal System - Page 552
A nurse is working with a client who has cervical disc degenerative disease with resulting impaired range of motion and pain that radiates to the back. The nurse understands that joints between the vertebrae are which type of joint? A. Cartilaginous B. Compact C. Fibrous D. Synovial
C. Cartilaginous Explanation: Fibrous joints (e.g., sutures between skull bones) are joined by fibrous connective tissue and are immovable. Cartilaginous joints (e.g., joints between vertebrae) are joined by cartilage. Synovial joints (e.g., shoulders, wrists, hips, knees, ankles) contain a space between the bones that is filled with synovial fluid, a lubricant that promotes a sliding movement of the ends of the bones. Compact is a type of bone, not a type of joint. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 530. Chapter 24: Assessing Musculoskeletal System - Page 530
A client presents to the emergency department after falling off a ladder while doing some outside painting at home. The client's ankle appears swollen, out of alignment, and is painful to touch. What is the nurse's first action? A. Splint and immobilize the affected extremity. B. Apply an ice pack to the affected extremity. C. Check for a pulse, color, temperature, and capillary refill. D. Encourage early weight bearing and ambulation.
C. Check for a pulse, color, temperature, and capillary refill. Explanation: The first nursing actions include taking vital signs, monitoring pulses, and assessing color, temperature, and capillary refill distal to the injury to evaluate tissue perfusion. The ankle should then be immobilized after assessment. An ice pack may be applied after assessing for temperature and pulses, etc. The first action is no weight bearing until the ankle is fully assessed. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.
A client complains of chronic pain and fatigue. The nurse suspects fibromyalgia. What is a diagnosis of this condition based on? A. X-rays B. Range of motion tests C. Client's symptoms D. Lab tests
C. Client's symptoms Explanation: Fibromyalgia, manifested by chronic pain and fatigue, affects about 5 million Americans. Diagnosis is made based on a person's symptoms as no there are no objective findings on X-rays or lab tests or range of motion tests. Persistent pain and fatigue interferes with the client's activities of daily living. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 535. Chapter 24: Assessing Musculoskeletal System - Page 535
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? A. Muscle strength of the deltoids B. Internal rotation of the shoulder C. External rotation of the shoulder D. Elbow flexion
C. External rotation of the shoulder Explanation: Pointing the elbows laterally tests the shoulder's ability to rotate externally and abduct. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 546. Chapter 24: Assessing Musculoskeletal System - Page 546
A patient presents at the clinic with an enlarged, swollen, hot, and red metatarsophalangeal joint and bursa of the great toe. What medical diagnosis would the nurse suspect? A. Pes planus B. Hallux valgus C. Gouty arthritis D. Hammer toe
C. Gouty arthritis Explanation: An enlarged, swollen, hot, reddened metatarsophalangeal joint and bursa of the great toe indicates gouty arthritis. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 557. Chapter 24: Assessing Musculoskeletal System - Page 557
Loss of bone density that occurs with greatest frequency in postmenopausal women is called? A. Lordosis B. Kyphosis C. Osteoporosis D. Scoliosis
C. Osteoporosis Loss of bone density is termed osteoporosis. Some osteoporosis occurs in all people, but it is most evident in women with small bone frames. Women experience rapid loss of bone density for the first 5 to 7 years after menopause. Lordosis, kyphosis, and scoliosis are conditions that affect the spinal alignment. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 535. Chapter 24: Assessing Musculoskeletal System - Page 535
In assessing a client's temporomandibular joint (TMJ), the nurse asks the client to move the jaw forward. This movement is known as which of the following? A. Supination B. Retraction C. Protraction D. Pronation
C. Protraction Explanation: Protraction is moving forward. Retraction is moving backward. Pronation is turning or facing downward. Supination is turning or facing upward. Pronation and supination are not possible at the TMJ. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 530. Chapter 24: Assessing Musculoskeletal System - Page 530
The school nurse notes that the client carries her left shoulder higher than her right shoulder. You should recognize the likely presence of what health problem? A. Dislocated shoulder B. Broken clavicle C. Scoliosis D. Torn rotator cuff
C. Scoliosis Explanation: Scoliosis may cause elevation of one shoulder. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 562. Chapter 24: Assessing Musculoskeletal System - Page 562
A client has osteoarthritis of the elbow. Which assessment approach should the nurse expect to be impacted by this health problem? A. adduction B. abduction C. flexion D. rotation
C. flexion Explanation: A hinge joint provides movement in one plane such as flexion and extension. A ball and socket joint provides a wide range of movement including rotation, abduction, and adduction. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System.
An older adult client visits the clinic and tells the nurse that she has had shooting pain in both of her legs. The nurse should assess the client for signs and symptoms of A. metastases. B. osteoporosis. C. herniated intervertebral disc. D. rheumatoid arthritis.
C. herniated intervertebral disc. Explanation: Thirty-three bones: 7 concave-shaped cervical (C); 12 convexshaped thoracic (T); 5 concave-shaped lumbar (L); 5 sacral (S); and 3-4 coccygeal, connected in a vertical column. Bones are cushioned by elastic fibrocartilaginous plates (intervertebral discs) that provide flexibility and posture to the spine. Paravertebral muscles are positioned on both sides of vertebrae. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System.
On inspection of the spine of a 79-year-old man, the nurse might expect to find a(n) A. decreased cervical curve B. decreased lumbar curve C. increased thoracic curve D. increased cervical curve
C. increased thoracic curve Explanation: An exaggerated thoracic curve (kyphosis) is common with aging. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 543. Chapter 24: Assessing Musculoskeletal System - Page 543
A client is unable to externally rotate the left shoulder. What health problem should the nurse suspect is occurring with this client? A. anterior dislocation of the humerus B. carpal tunnel syndrome C. rotator cuff tear D. rotator cuff tendinitis
C. rotator cuff tear Explanation: In a complete tear of the supraspinatus tendon, or a rotator cuff tear, active abduction and forward flexion at the glenohumeral joint are severely impaired, producing a characteristic shrugging of the shoulder and a positive "drop arm" test. Rotator cuff tendonitis is characterized by acute, recurrent, or chronic pain of the supraspinatus tendon. Carpal tunnel syndrome effects the wrist and not the shoulder. Anterior dislocation of the humerus is characterized by the shoulder seeming to slip out of the joint. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 546. Chapter 24: Assessing Musculoskeletal System - Page 546 SAME THING (Rotator cuff tear) = painful and limited ABDUCTON (arm above head) muscle weakness and atrophy OR A client is unable to externally rotate the left shoulder. What health problem should the nurse suspect is occurring with this client? OR a characteristic shrugging of the shoulder and a positive "drop arm" test.
The subacromial bursae are contained in the A. elbow joint. B. wrist joint. C. shoulder joint. D. temporomandibular joint.
C. shoulder joint. Explanation: Articulation of the head of the humerus in the glenoid cavity of the scapula. The acromioclavicular joint includes the clavicle and acromion process of the scapula. It contains the subacromial and subscapular bursae. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 532. Chapter 24: Assessing Musculoskeletal System - Page 532
A nurse conducts a physical examination of the musculoskeletal system of a client who reports upper arm pain. Which instruction should the nurse provide the client when assessing flexion of the elbow? a. "With palms down, point your fingers toward the floor." b. "Turn your palms down." c. "Straighten your elbow." d. "Bend your elbow."
D. "Bend your elbow." Explanation: Asking the client to bend the elbow assesses for flexion. Asking the client to straighten the elbow assesses for extension. Asking the client turn the palms down assesses for pronation. Asking the client to turn the palms down and point fingers to the floor assesses flexion of the elbow. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 548. Chapter 24: Assessing Musculoskeletal System - Page 548
What is an appropriate question by the nurse to ask a client about the presence of temporomandibular joint dysfunction? A. "Please stick out your tongue sand move it from side to side" B. "Can you fully clench your teeth and feel the muscles in your jaw tense?" C. "Do you notice any swelling around the teeth or gums?" D. "Have you noticed a popping or grating sound when you chew?"
D. "Have you noticed a popping or grating sound when you chew?" Explanation: The temporomandibular joint (TMJ) provides the stability of the jaw to open and close. Often the joint can become swollen, causing pain and decrease in range of motion of the jaw. Decreased muscle strength and range of motion, along with a popping, clicking, or grating sound may be noted with TMJ dysfunction. Swelling around the teeth and gums is seen with gingivitis. Clenching the teeth test the integrity of cranial nerve V (trigeminal nerve). Asking the client to stick out the tongue and move it from side to side tests cranial nerve XII (hypoglossal nerve). Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 542. Chapter 24: Assessing Musculoskeletal System - Page 542
When assessing muscle tone and strength, the nurse would document expected findings as A. "upper extremity muscle strength is 5/5 bilaterally" B. "extremity muscle strength is 5/5 bilaterally" C. "upper and lower extremity muscle strength is 5/5" D. "upper and lower extremity muscle strength is 5/5 bilaterally"
D. "upper and lower extremity muscle strength is 5/5 bilaterally" Explanation: 5/5 (100%) normal muscle strength with complete ROM against gravity and full resistance. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 540. Chapter 24: Assessing Musculoskeletal System - Page 540
A client diagnosed with rheumatoid arthritis exhibits edema, redness, and tenderness of the fingers. What is the nurse's priority action? A. Notify the healthcare provider. B. Teach finger stretching exercises. C. Apply ice and immobilize the fingers. D. Administer prescribed anti-inflammatory.
D. Administer prescribed anti-inflammatory. Explanation: Rheumatoid arthritis (RA) may cause edema, redness, and tenderness of the finger and wrist joints. Arthritis is inflammation of the joints, and anti-inflammatories are commonly prescribed for relief. Applying ice, immobilizing fingers, and stretching exercise are not common treatments for RA. Notifying the healthcare provider is not the priority action because these findings are expected for RA. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.
A nurse performs a nudge test to assess the gait of a client with Parkinson's disease. Which action by the nurse demonstrates the correct technique for performing this test? The nurse should stand: A. In front of the client and nudge the back B. At the back of the client and nudge the back C. In front of the client and nudge the sternum D. At the back of the client and nudge the sternum
D. At the back of the client and nudge the sternum Explanation: To perform the nudge test, the nurse should stand at the back of the client and nudge his sternum. The nurse should put arms around the client to prevent a fall. Falling backward easily is seen with cervical spondylosis and Parkinson's disease. Standing in front of the client and nudging his sternum, standing at the back of the client and nudging his back, and standing in front of the client and nudging his back are inaccurate methods for performing the nudge test. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 541. Chapter 24: Assessing Musculoskeletal System - Page 541
A nurse notices that a client has decreased range of motion with lateral bending of the cervical spine to the left side. What should the nurse do next in relation to this finding? A. Finish with the assessment of the cervical spine before documenting B. Notify the health care provider for further orders C. Ask the client about previous injuries to the head and neck D. Compare this finding to the range of motion to the right side
D. Compare this finding to the range of motion to the right side Explanation: It is always important to compare both sides of the body for symmetry before making a judgment that data is abnormal. The nurse should then ask the client about previous injuries to the head and neck. All data must be properly documented in the client's record. If this finding is abnormal, the nurse should alert the health care provider for further orders. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 544. Chapter 24: Assessing Musculoskeletal System - Page 544
When determining a client's strength, it is necessary to implement what assessment? A. Assessing upper and lower extremities at the same time B. Assessing the extremities at the same time C. Comparing upper and lower extremities D. Comparing one side to the other
D. Comparing one side to the other Explanation: When assessing muscle tone and strength, it is necessary to compare one side to the other. It is not necessary to compare the upper extremities to the lower extremities or to assess them at the same time since doing so has no relevance to the strength of similar muscles. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 540. Chapter 24: Assessing Musculoskeletal System - Page 540
What range of motion is the nurse testing by asking a client to stoop to pick an object off the floor? A. Abduction B. Extension C. Rotation D. Flexion
D. Flexion Explanation: Stooping is another term for bending. The client must be able to flex the thoracic and lumbar spines and flex the knees. Extension is straightening the extremity at the joint and increasing the angle of the joint. Abduction is moving away from the midline of the body. Rotation is turning the head to the right and then the left. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 544. Chapter 24: Assessing Musculoskeletal System - Page 544
The nurse is assessing an elderly client and finds an exaggerated thoracic curve. This would be documented as what? A. Ankylosing spondylitis B. Lordosis C. Scoliosis D. Kyphosis
D. Kyphosis Explanation: Kyphosis is an exaggerated thoracic curve and is common with aging. Scoliosis is lateral curvature of the thoracic spine with an increase in the convexity on the curved side. An exaggerated lumbar curve is lordosis. Ankylosing spondylitis is associated with a flattening of the lumbar curvature. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 543. Chapter 24: Assessing Musculoskeletal System - Page 543
Increased lumbar curvature, which compensates for the enlarging uterus in pregnant women, is called what? A. Kyphosis B. Scoliosis C. Keracytosis D. Lordosis
D. Lordosis Explanation: Lordosis, increased lumbar curvature, compensates for the enlarging uterus. Kyphosis, overcurvature of the spine in the thoracic and sacral spine, can result from arthritis, osteoporosis, or trauma. Scoliosis is a side to side curvature of the spine. Keracytosis is a skin disorder and a distracter for this question. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 543. Chapter 24: Assessing Musculoskeletal System - Page 543
The nurse is planning a presentation on osteoporosis to a group of high school students. Which of the following should the nurse plan to include in the presentation? A. Approximately 5 million fractures in the United States are due to osteoporosis. B. Bone density in the Asian population is higher than in the white population. C. Bone density rises to a peak at age 50 for both sexes. D. Moderate strenuous exercise tends to increase bone density.
D. Moderate strenuous exercise tends to increase bone density. Explanation: Regular exercise promotes flexibility, bone density, and muscle tone and strength. It can also help to slow the usual musculoskeletal changes (progressive loss of total bone mass and degeneration of skeletal muscle fibers) that occur with aging. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 536. Chapter 24: Assessing Musculoskeletal System - Page 536
What finding should a nurse expect when performing Phalen's test on a client with suspected carpal tunnel syndrome? A. Stiffness in the hands and fingers after holding and releasing a tight fist B. Inability to perform active range of motion with the involved wrist C. A change in the color of the fingers from red to white (pale) D. Reports of tingling, numbness, and pain in the involved wrist
D. Reports of tingling, numbness, and pain in the involved wrist Explanation: Phalen's test is performed by asking the client to place the backs of both hands against each other while flexing the wrists 90 degrees downward. The client holds this position for 60 seconds. A positive test would be the report of tingling, numbness, and pain in the involved wrist by the client. Inability to perform active range of motion with the involved wrist and stiffness in the hands and fingers after holding and releasing a tight fist may be seen in clients with arthritis in the joints. A change in color of the fingers from red to white (pale) is seen in clients with Raynaud's disease. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 550. Chapter 24: Assessing Musculoskeletal System - Page 550
A nurse is inspecting a client's gait. Which of the following would indicate an abnormal finding? A. Posture is erect B. Weight is evenly distributed C. Arms swing in opposition D. Toes point out
D. Toes point out Explanation: 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. Posture being erect, arms swinging in opposition, and weight being evenly distributed are all normal findings. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 541. Chapter 24: Assessing Musculoskeletal System - Page 541
When providing teaching to clients in the community, a nurse is accurate in stating that the musculoskeletal system is most closely aligned with which other body system? A. renal system B. gastrointestinal system C. integumentary system D. neurological system
D. neurological system Explanation: The musculoskeletal system is enervated by the neurological system. Examination of the two systems are closely aligned. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 528. Chapter 24: Assessing Musculoskeletal System - Page 528
The external covering of the bone that contains osteoblasts and blood vessels is termed the A. cartilage. B. synovial membrane. C. connective tissue. D. periosteum.
D. periosteum. Explanation: The periosteum covers the bones; it contains osteoblasts and blood vessels that promote nourishment and formation of new bone tissues. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 528. Chapter 24: Assessing Musculoskeletal System - Page 528
One of the functions of a bone is to A. produce secretions. B. store fat. C. store protein. D. produce blood cells.
D. produce blood cells. Explanation: Bones provide structure, give protection, serve as levers, store calcium, and produce blood cells. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 528. Chapter 24: Assessing Musculoskeletal System - Page 528
The nurse is caring for an adult client who is in a cast because of a fractured arm. To promote healing of the bone and tissue, the nurse should instruct the client to eat a diet that is high in A. whole grains. B. vitamin E. C. vitamin B. D. vitamin C.
D. vitamin C. Explanation: Adequate protein in the diet promotes muscle tone and bone growth; vitamin C promotes healing of tissues and bones. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 536. Chapter 24: Assessing Musculoskeletal System - Page 536
The nurse is preparing information about osteoporosis for a community health fair. Which information should the nurse include as a handout for the participants? Select all that apply. a. Avoid severe weight loss diets b. Avoid all alcohol c. Avoid smoking and second-hand smoke d. Engage in weight-bearing activities e. Ensure adequate calcium intake
Flexion Explanation: Bending forward to touch the toes assesses for spinal flexion. Twisting the spine from side to side assesses for spinal rotation. Bending the back as far as possible assesses spinal extension. Bending to the side from the waist assesses for lateral flexion. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 544. Chapter 24: Assessing Musculoskeletal System - Page 544
When the client performs straight leg flexion, the client complains of pain that radiates down his leg. The nurse understands that this may indicate what? A. Hip fracture B. Arthritis C. Degenerative joint disease D. Herniated disc
Herniated disc Explanation: Straight leg flexion that produces back and leg pain radiating down the leg may indicate a herniated disc. One leg longer than the other may indicate a hip fracture. Arthritis is accompanied by pain and stiffness. Asymmetry, discomfort when touched, or crepitus during movement may occur with degenerative joint disease. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 545. Chapter 24: Assessing Musculoskeletal System - Page 545
When assessing the gait pattern of a client diagnosed with Alzheimer disease, the nurse should expect to observe which finding? A. Difficulty initiating a slow, shuffling gait B. A waddling gait while ambulating in hallway C. Lifting the leg high so that toes clear the ground D. Limping when not wearing adaptive shoes
a. Difficulty initiating a slow, shuffling gait Explanation: Apraxic gait occurs when the client has difficulty initiating walking, then exhibits a slow, shuffling gait. It is often seen in clients with Alzheimer disease. Footdrop or steppage, raising the leg high when walking, occurs with nerve injuries or damage to spinal nerve roots. Limping is indicative of short leg gait. A waddling gait is often seen with hip dysplasia or muscular dystrophy. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.
While sitting a client raises both legs while the nurse holds the lower legs below the knee. What does this finding indicate? A. flexion deformity of both legs B. proximal muscle symmetric weakness C. normal quadriceps muscle strength D. distal muscle symmetric weakness
c. normal quadriceps muscle strength Explanation: An active movement against full resistance without evidence of fatigue is considered normal muscle strength. If the client is unable to keep the opposite leg extended, when one leg is flexed, it suggests a flexion deformity of the opposite leg's hip. Symmetric weakness of the proximal muscles suggests a myopathy or muscle disorder. Symmetric weakness of distal muscles suggests a polyneuropathy, or disorder of peripheral nerves. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Assessing Musculoskeletal System, p. 555. Chapter 24: Assessing Musculoskeletal System - Page 555
