PrepU: HHA-Ch.24 Musculoskeletal System

The external covering of the bone that contains osteoblasts and blood vessels is termed the

-connective tissue. -*periosteum.* P528 -cartilage. -synovial membrane.

Joints may be classified as cartilaginous, synovial, or...?

-immobile. -*fibrous.* P530 -articulate. -flexible.

Skeletal muscles are attached to bones by:

-ligaments. -fibrous connective tissue. -*tendons.* P528 -cartilage.

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

-rheumatoid arthritis. -metastases. -*herniated intervertebral disc.* -osteoporosis. 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.

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

-tendonitis. -*rotator cuff tear.* P546 -nerve damage. -cervical disc degeneration.

The subacromial bursae are contained in the

-wrist joint. -*shoulder joint.* -temporomandibular joint. -elbow joint.

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?

-*Gouty arthritis* P565, 557 -Hallux valgus -Hammer toe -Pes planus

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.

*Early morning stiffness* *Worse in rainy weather* *Improves with rest* Located in the right hip Worse after sitting

A nurse tells a client that the next step in the musculoskeletal assessment is to perform range of motion of the thoracic and lumbar spine. The nurse should demonstrate which movements for the client to facilitate the examination? Select all that apply.

*Flexion* Extension *Lateral bending Circumduction *Rotation* Exp: To assess the range of motion of the thoracic and lumbar spine, the client should be shown the muscle movements of flexion, lateral bending (right and left), rotation (twisting the shoulders one way then the other), and bending backwards (hyperextension). Circumduction is moving is a circular motion. P546

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?

*Goniometer* P540 Angulator Scoliometer Calibrator

A school age client has been diagnosed with genu valgum. What is the other name for this disease?

*Knock kneed* P554 Flatfeet Bowlegs (genu varum) Clubfoot

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?

*Phalen's* (for CT) McMurray's Tinel's (also for CT) Flick signal (also for CT) Ballottement

The nurse is assessing a client with joint pain and is trying to decide whether it is inflammatory or non-inflammatory. Which of the following symptoms is consistent with an inflammatory process?

*Tenderness* Ecchymosis Cool temperature Nodules Explanation: Tenderness implies an inflammatory process along with increased temperature. Nodules and ecchymosis are not typically associated with inflammatory processes. P542

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.

*false* P528

The nurse is assessing the spine of an adult client and detects lateral curvature of the thoracic spine with an increase in convexity on the left curved side. The nurse suspects that the client is experiencing

*scoliosis* P563

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?

-"Turn your palms down." -*"Bend your elbow."* -"With palms down, point your fingers toward the floor." -"Straighten your elbow." Exp: 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. P548

When assessing a client's strength, it is necessary to

-*Compare one side to the other* -Assess the extremities at the same time -Assess upper and lower extremities at the same time -Compare upper and lower extremities

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?

-*Effusion in the knee joint* -Crepitus uteri flexion -Osteoarthritis -Ligament trauma 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. P556

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?

-*Herniated disc* -Hip fracture -Degenerative joint disease -Arthritis Exp: 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. P545

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* P540 -Assess the client's hand grips -Notify the health care provider -Note that the dominant side is stronger

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* -Rheumatoid arthritis -Fibromyalgia -Bone fracture Exp: Osteoarthritis is characterized by pain with motion that increases throughout the day. Rheumatoid arthritis discomfort decreases with motion. A bone fraction causes a sharp, knife-lie pain. Chronic pain and fatigue is a symptom of fibromyalgia. P535

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?

-*Scoliosis* P562 -Torn rotator cuff -Dislocated shoulder -Broken clavicle

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* -Temporal arteritis -Tumour of the mandible -Trigeminal neuralgia Explanation: Explanation: Temporomandibular joint syndrome is a very common cause of pain with chewing. Ischemic pain with chewing, or jaw claudication, can occur with temporal arteritis, but the lack of tenderness of the scalp overlying the artery makes this less likely. Trigeminal neuralgia can be associated with extreme tenderness over the branches of the trigeminal nerve. While a tumour of the mandible is possible, it is much less likely than the other choices. P534

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

-*arthritis.* -osteoporosis. -a neurologic disorder. -carpal tunnel syndrome. Exp: Pain and stiffness in the joints is associated with arthritis. P535

On inspection of the spine of a 79-year-old man, the nurse might expect to find a(n):

-*increased thoracic curve* -decreased lumbar curve -decreased cervical curve -increased cervical curve Exp: An exaggerated thoracic curve (kyphosis) is common with aging. P543

How would the nurse document normal muscle strength?

-2&2 -*5/5* -1:1 -4+ Explanation Scale for grading muscle strength: muscle strength is graded on a 0 to 5 scale: 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. P540

A nurse has just finished assessing a client's spine and neck muscles. How would the nurse document normal findings?

-All findings within normal limits -C8 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully developed, symmetrical, and nontender -*C7 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully developed, symmetrical, and nontender* P543 -Neck assessment WNL

A client presents to the health care clinic with reports of onset of neck pain 3 days ago. The nurse recognizes that the most common cause of neck pain is what condition?

-Cervical disc degenerative disease -Cervical spinal cord compression -Compression fractures -*Cervical strain* P543

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?

-Degenerative joint disease -Verruca vulgaris (warts) -*Gouty arthritis* -Rheumatoid 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. P557

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?

-Disturbed Body Image -Risk for Trauma -Activity Intolerance -*Impaired Physical* Mobility Exp: 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. P560

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

-Weight is evenly distributed -Arms swing in opposition -*Toes point out* -Posture is erect Exp: 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. P541

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?

-Fractured wrist -Paralysis -Dupuytren contracture -*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. P552

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?

-Instruct the client to bend forward and touch the toes -Instruct the client to touch the chin to the chest -Palpate the spinous processes and the paravertebral muscles -*Ask the client to raise the leg to the point of pain and then dorsiflex the foot* P545

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?

-Is composed mostly of fat -*Produces red blood cells* -Is hard and dense and makes up the shaft and outer layers -Covers the bones and contains osteoblasts and blood vessels

A nurse performs inspection and palpation of a client's knee and detects swelling. What is the appropriate test the nurse should perform next to determine the cause of the swelling?

-McMurray's test -*Bulge test* -Range of motion -Ballottement test Explanation: If swelling is detected in the knee, the nurse should perform the bulge test to determine if the swelling is due to an accumulation of fluid or soft-tissue swelling. The bulge test will help to detect small amounts of fluid in the knee. Ballottement is a knee test used to assess for the presence of large amounts of fluid in the knee. McMurray's test is useful to confirm a meniscal tear. Pain or clicking during the test is indicative of a torn meniscus of the knee. Range of motion is not useful in determining the cause of swelling.P555

A nurse is testing the range of motion of a client's wrist for supination. Which movement will this involve?

-Moving the tips of the fingers toward the forearm -Moving the tips of the fingers away from the forearm -*Turning the palm of the hand upward* -Turning the palm of the hand downward

The nurse is assessing an elderly client and finds an exaggerated thoracic curve. This would be documented as what?

-Scoliosis -Ankylosing spondylitis -Lordosis -*Kyphosis* Exp: 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. P543

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?

-Splint and immobilize the affected extremity. -Encourage early weight bearing and ambulation. -*Check for a pulse, color, temperature, and capillary refill.* -Apply an ice pack to the affected extremity. Exp: 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.

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?

-Supination and pronation -Rotation and supination -*Dorsiflexion and plantar flexion* -Adducting and abducting Exp: 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. P530

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?

-Tinel's test -Phalen's test -*Straight leg raise test* -Leg length test Exp: 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. P545-546

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

-Vitamin D -Protein -*Calcium* -Vitamin C

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

-bend forward while trying to touch the toes. -move from a standing to a squatting position. -*flex the knee and hip while in a supine position.* P556 -raise his leg while in a supine position.

Moving a part of the body away from the midline is called?

Adduction Rotation Extension *Abduction* P528

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?

Bouchard's nodes *Heberden's nodes* Painful corns Inflamed bursa Exp: The nurse should document the hard, painless nodules over the distal interphalangeal joints as Heberden's nodes. Inflamed bursa is an inappropriate term because bursae are not found in interphalangeal joints. Bouchard's nodes are seen over the proximal interphalangeal joints. Painful corns are thickenings of the skin that occur over bony prominences and at pressure points. P552

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?

Bulge Ballottement *McMurray's* P556 Phalen's

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?

Impaired walking Self-care deficit Activity intolerance *Impaired physical mobility* Exp: 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. P560

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

Palpate the hollow area on the back of the wrist -*Percuss lightly on the inner aspect of the wrist* P551 -Ask the client to bend the wrist down and back -Perform wrist movements against resistance

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?

Trauma Gout Septic arthritis *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. P552

A client is unable to externally rotate the left shoulder. What health problem should the nurse suspect is occurring with this client?

carpal tunnel syndrome rotator cuff tendinitis anterior dislocation of the humerus *rotator cuff tear* Exp: 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. P546

Bones contain yellow marrow that is composed mainly of

cartilage. *fat.* protein. carbohydrates.

A client with insulin-dependent diabetes visits the clinic and complains of painful hip joints. The nurse should assess the client carefully for signs and symptoms of

gait difficulties. *osteomyelitis.* scoliosis. arthritis. Exp: Having diabetes mellitus, sickle cell anemia, or SLE places the client at risk for development of musculoskeletal problems such as osteoporosis and osteomyelitis. P535

A female client visits the clinic and tells the nurse that she began menarche at the age of 16 years. The nurse should instruct the client that she is at a higher risk for

osteomyelitis. *osteoporosis.* lordosis. rheumatoid arthritis. Explanation: Women who begin menarche late or begin menopause early are at greater risk for development of osteoporosis because of decreased estrogen levels, which tend to decrease the density of bone mass. P535

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

whole grains. *vitamin C.* vitamin B. vitamin E. Exp: Adequate protein in the diet promotes muscle tone and bone growth; vitamin C promotes healing of tissues and bones. P536