Adult Gerontology - Musculoskeletol System
When Maxwell, age 12, slid into home plate while playing baseball, he injured his ankle. The nurse practitioner is trying to differentiate between a sprain and a strain. A sprain A. is an injury to the ligaments that attach to bones in a joint. B. is an injury to the tendons that attach to the muscles in a joint. C. is an injury resulting in extensive tears of the muscles. D. is an injury that does not result in joint instability.
Answer: A A sprain is defined as an injury to the ligaments that connect bone to bone in a joint that results from a twisting motion and may cause joint instability. A strain is defined as an injury to the muscles and/or the tendons that attach muscles to bones.
Jill, age 49, has recently begun a rigorous weight- lifting regimen. She presents to the primary care office with a shoulder dislocation. Which of the following clinical manifestations lead the nurse practitioner to suspect an anterior shoulder dislocation over a posterior dislocation? A. Inability to shrug the shoulder B. Absence of pain C. Inability to rotate the shoulder externally D. Shortening of the arm
Answer: A Clinical manifestations of an anterior shoulder dislocation, which is far more common than a posterior dislocation, include the inability to shrug the shoulder, pain, and lengthening of the arm. The inability to rotate the shoulder externally is a clinical manifestation of a posterior shoulder dislocation, along with the inability to elevate the arm.
What part of the body is affected by Dupuytren's contracture? A. The fourth and fifth fingers B. The great toe C. The tibia D. The penis
Answer: A Dupuytren's contracture manifests itself by nodular thickening of the connective tissue of one or both hands, usually affecting the fourth and fifth fingers. There is tenderness with the inability to extend the fingers. Pain, tenderness, erythema, and swelling of the first metatarsal joint are the typical presentation for gout. Peyronie's disease is a connective tissue disorder that results in painful curvature of the erect penis.
First- line drug therapy for acute low back pain includes the use of A. NSAIDs. B. muscle relaxants. C. opioids. D. antidepressants.
Answer: A First- line drug therapy for acute low back pain includes the use of NSAIDs. NSAIDs, as well as acetaminophen (Tylenol), have been shown to be as effective as muscle relaxants and opioids for the control of acute low back pain but without the potential for dependence and abuse. Evidence has shown that muscle relaxants are no more effective than NSAIDs in the relief of acute low back pain. Antidepressant drug therapy, particularly tricyclic antidepressants, have been trialed in patients with chronic low back pain even without clinical depression.
During assessment of a client's foot, the nurse practitioner notes that the foot is in alignment with the long axis of the lower leg and that weight-bearing falls on the middle of the foot, from the heel, along the mid-foot, to between the second and third toes. These findings best describe A. a normal foot. B. Hallux valgus. C. Talipes equinovarus. D. hammertoes.
Answer: A If you note during your assessment of your client's foot that the foot is in alignment with the long axis of the lower leg and that weight- bearing falls on the middle of the foot, from the heel along the midfoot to between the second and third toes, you would diagnose a normal foot. Hallux valgus is a common deformity in which a lateral or outward deviation of the toe with medial prominence of the head of the first metatarsal is present. A hammertoe deformity is common in hallux valgus and is a deformity in the second, third, fourth, or fifth toes that includes hyperextension of the metatarsophalangeal joint and flexion of the proximal interphalangeal joint. Talipes equinovarus (clubfoot) is a congenital defect; it presents as a rigid and fi xed malposition of the foot, including inversion, forefoot adduction, and the foot pointing downward.
John, age 16, works as a stock boy at the local supermarket. He is in the office for a routine visit. You notice that he had an episode of low back pain 6 months ago from improperly lifting heavy boxes. In discussing proper body mechanics with him to prevent future injuries, you tell him, A. "Bend your knees and face the object straight on." B. "Hold boxes away from your body at arm's length." C. "Bend and twist simultaneously as you lift." D. "Keep your feet firmly together."
Answer: A In discussing proper body mechanics with John to prevent future injuries, you tell him to bend his knees and face the object straight on, to hold boxes close to his body and not at arm's length, and to spread his feet about shoulder- width apart. Using legs and arms, facing objects straight on, and keeping a wide stance provides a broad base of support and allows for use of supporting muscles, relieving stress on the back muscles. Never bend and twist simultaneously, but rather keep the spine straight to minimize injury
Which of the following tests assesses the patency of the radial and ulnar arteries? A. Allen test B. Finkelstein's test C. Phalen's test D. Tinel's sign
Answer: A The Allen test assesses the patency of the radial and ulnar arteries in the arterial arch. Have the client make a fist and use your fi ngers to occlude both radial and ulnar arteries. Then, have the client open the hand, and you release the radial pressure. Observe for rapid refill of color to the palm indicating patency of the radial artery. Repeat the same maneuver, releasing ulnar pressure to assess ulnar artery competency. Finkelstein's test assesses for de Quervain's tenosynovitis. Phalen's test and Tinel's sign assess for carpal tunnel syndrome.
Which of the following tests for hand and wrist problems assesses the patency of the radial and ulnar arteries and the arterial arch? A. Allen's test B. Phalen's test C. Tinel's sign D. Finkelstein's test
Answer: A The Allen's test assesses the patency of radial and ulnar arteries and the arterial arch. The Phalen's test and Tinel's sign assesses for median nerve compression/compression neuropathy. The Finkelstein's test assesses for de Quervain's disease
The straight leg-raising maneuver can be used to diagnose A. nerve root compression. B. a fractured hip. C. an anterior cruciate ligament tear. D. tendinitis.
Answer: A The straight leg-raising maneuver can be used to diagnose nerve root compression by eliciting radiating pain down the leg in the affected dermatomal distribution. The leg is straight and lifted by the heel. The leg may also be brought across the body to increase the sensitivity of this maneuver. Leg shortening and external rotation may be present with a fractured hip. Extending the knee will elicit pain if an anterior cruciate ligament tear is present. Pressure over an affected tendon will elicit pain if tendinitis is present.
A 50- year- old patient has been diagnosed with adhesive capsulitis often referred to as "frozen shoulder." The medical management often includes all of the following except A. application of moist heat. B. aspiration with concurrent corticosteroid injection. C. gentle stretching exercises. D. NSAIDs and nonnarcotic analgesics
Answer: A Treatment for adhesive capsulitis consists of moist heat application and use of analgesics followed by a gentle stretching program. Aspiration to remove local deposits of calcium while concurrently injecting an anesthetic with corticosteroid preparation can provide relief for calcific tendinitis, not adhesive capsulitis.
In assessing the skeletal muscles, the nurse practitioner turns the patient's forearm so that the palm is up. This is called A. supination. B. pronation. C. abduction. D. eversion.
Answer: A Turning the forearm so that the palm is up is supination. Turning the forearm so that the palm is down is pronation. Abduction is moving a limb away from the midline of the body. Eversion is moving the sole of the foot outward at the ankle.
When wrist and fi nger extension causes pain over the extensor carpi radialis brevis tendon, the extensor carpi radialis longus tendon, and the extensor digitorum communis, you would suspect A. tennis elbow. B. golfer's elbow. C. de Quervain's disease. D. intersection syndrome.
Answer: A With tennis elbow, wrist and fi nger extension causes pain over the extensor carpi radialis brevis tendon, the extensor carpi radialis longus tendon, and the extensor digitorum communis. With golfer's elbow, pain is experienced on wrist flexion over the flexor carpi radialis, the flexor carpi ulnaris, and the pronator teres tendons. With de Quervain's disease, pain is experienced on thumb extension over the abductor pollicis longus and the extensor pollicis brevis tendons. With intersection syndrome, pain is experienced with a grip and wrist extension over the extensor carpi radialis brevis and the extensor carpi radialis longus tendons.
You are assessing Jamal, age 16, after a football injury to his right knee. You elicit a positive anterior/posterior drawer sign. This test indicates an injury to the A. lateral meniscus. B. cruciate ligament. C. medial meniscus. D. collateral ligament.
Answer: B A positive anterior or posterior drawer sign indicates an injury to the anterior or posterior cruciate ligaments, respectively. The drawer test, or Lachman test, is utilized to assess for cruciate ligament injury. Meniscus tears are also a common cause of knee joint pain or injury, with the medial meniscus being injured more frequently than the lateral meniscus. The most consistent physical finding of a meniscal tear is tenderness to palpation along the joint line. To examine for a meniscal tear, perform the McMurray test by fully flexing the knee with leg externally rotated for medial meniscus and internally rotated for lateral meniscus. Then firmly extend the leg. A painful cartilage click is considered a positive McMurray test for meniscal injury. The abduction, or valgus, stress test and the adduction, or varus, stress test are used to test the medial collateral ligament (MCL) and lateral collateral ligament (LCL), respectively.
Ankylosis is defined as A. muscle shortening. B. joint stiffness. C. malposition of a joint. D. dislocation of a joint.
Answer: B Ankylosis is defined as stiffness or immobility in a joint caused by bones fusing as a result of disease or injury or intentionally through surgery. It is not a result of muscles shortening or of joint malposition or dislocation
What is the type of joint that is freely movable, such as the shoulder joint, called? A. The synarthrosis joint B. The amphiarthrosis joint C. The diarthrosis joint D. The juxtarthrosis joint
Answer: C The type of joint that is freely movable, such as the shoulder joint, is called a diarthrosis joint. Diarthrosis, or synovial, joints include the joints of the limbs, shoulders, and hips. They can be further divided into what is noted as ball and socket, hinge, gliding, pivot, and compound joints. Synarthrosis, or fibrous, joints are immovable and include skull sutures, epiphyseal plates, ribs, and the manubrium of the sternum. Amphiarthrosis, or cartilaginous, joints are slightly movable joints, such as the vertebral bodies of the spine. There is no such thing as a juxtarthrosis joint.
Manny, age 52, is a postal worker who drives a truck every day. He presents with low back pain and has decreased sensation to a pinprick in the lateral leg and web of the great toe. This indicates discogenic disease in the dermatomal pattern of which area? A. L3/L4 (L4 root involvement) B. L4/L5 (L5 root involvement) C. L5/S1 (S1 root involvement) D. None of the above
Answer: B If a client presents with low back pain and has decreased sensation to a pinprick in the lateral leg and web of the great toe, this indicates a dermatomal pattern of discogenic disease in the L4/L5 area (L5 root involvement). L3/L4 (L4 nerve root) innervates the sensory function of the distal thigh to medial calf to the arch of the foot. L5/S1 (S1 nerve root) innervates the sensory function of the lateral lower leg/calf to the fi fth toe.
Mike, age 42, a golf pro, has had chronic back pain for many years. His work- up reveals that it is not the result of a degenerative disk problem. His back "goes out" about twice per year, and he is out of work for about a week each time. Which of the following should the nurse practitioner advise him to do? A. Consider changing careers to a less physical job B. Begin a planned exercise program to strengthen back muscles C. Make an appointment with a neurosurgeon for a surgical consultation D. Start on a daily low- dose narcotic to take away the pain
Answer: B In this case, Mike may benefit from a regular planned exercise program to strengthen back muscles and attempt to reduce the probability of future episodes of back pain. Surgery is recommended only for clients with low back pain caused by degenerative disk disorders, and then only when severe neurological involvement has occurred. Surgery benefi ts only approximately 1% of persons with low back problems. Suggesting a career change should be considered only in cases of disability or inability to safely continue one's current employment. Narcotic pain medications are not considered first- line treatment for mechanical back pain.
Upon assessment, the nurse practitioner notes unilateral back pain that had an acute onset and increases when standing and bending. A straight-leg test is negative. The most likely differential diagnosis is A. herniated nucleus pulposus. B. muscle strain. C. osteoarthritis. D. spondylolisthesis.
Answer: B Muscle strain is usually located in the low back and is unilateral in location. The onset is acute, and pain increases with standing and bending and decreases when sitting. The straight leg-raising test and plain film x- ray are both negative. Herniated nucleus pulposus (HNP) causes unilateral back pain that is acute and increases when sitting or bending but decreases when standing. The straight leg-raising test is positive, and the plain film x- ray is negative. Back pain related to osteoarthritis is usually bilateral in nature and has an insidious onset. Pain increases when standing and decreases when sitting. A straight leg-raising test is negative, with a plain film x- ray that is positive. Spondylolisthesis has an insidious onset, and low back pain increases when standing or bending and decreases when sitting. A straight leg-raising test is negative, while a plain film x- ray is positive.
June, age 67, presents with back pain with no precipitating event. The pain is located over her lower back and muscles without sciatica, and it is aggravated by sitting, standing, and certain movements. It is alleviated with rest. Palpation localizes the pain, and muscle spasms are felt. There was an insidious onset with progressive improvement. What is the most likely differential diagnosis? A. Ankylosing spondylitis B. Musculoskeletal strain C. Spondylolisthesis D. Herniated disk
Answer: B Pain over the lower back and spine as well as the muscles without sciatica is musculoskeletal strain. Often there is no precipitating event, and there is an insidious onset. It is aggravated by sitting, standing, and certain movements. Palpation localizes the pain, and muscle spasms may be felt. It is alleviated by rest, and there is progressive improvement. Ankylosing spondylitis is back pain and stiffness over several months, where there is a systemic inflammatory condition of the vertebral column and sacroiliac joints. Painful ankylosed sacroiliac joints, reduced chest wall expansion, and excessive thoracic kyphosis are also present. It most frequently affects males between the ages of 20 and 30, causing chronic low back pain that is worse in the morning. There is relief with exercise and reduced mobility of the spine. A herniated disk is often preceded by years of recurrent episodes of localized back pain, and there is usually leg pain that overshadows the back pain. With spondylolisthesis, there is a defect or fracture of the pars interarticularis with forward shifting of one vertebra on top of another. This can cause nerve irritation and damage if the vertebrae are pressing on a spinal nerve root.
Anna, age 42, is pregnant and was just given a diagnosis of carpal tunnel syndrome. She is worried that this will affect her in caring for the baby. What do you tell her? A. "Don't worry; we'll find a brace that is very malleable." B. "After childbirth, your carpal tunnel syndrome may resolve." C. "If we do surgery now, you'll be recovered by the time the baby arrives." D. "You should prepare yourself for the probability of being unable to care for your baby."
Answer: B Pregnant women have an increased incidence of carpal tunnel syndrome (CTS) but often have their carpal tunnel syndrome resolve after delivery. Although repetitive use of the hand can lead to carpal tunnel syndrome, certain medical conditions such as diabetes, obesity, and thyroid disease also increase the likelihood of CTS. Often, the cause of CTS is unknown. Most likely, Anna will be able to care for her baby and will not need surgery and/or a brace.
Christian, age 22, is a carpenter who is right- hand dominant. He comes to the clinic for follow-up from the emergency department where he was seen for right forearm pain. He states he was diagnosed with right forearm tendinitis and wants the provider to explain this diagnosis to him. Patient teaching should explain that he has inflammation of one or more tendons, which are A. the rope-like bundles of collagen fibrils that connect bone to bone. B. the collagen fibers that connect muscle to bone. C. the pouches of synovial fluid that cushion bone and other joint structures. D. the fibrocartilaginous disks that separate bony surfaces.
Answer: B Tendons are the collagen fibers that connect muscle to bone. Ligaments connect bone to bone in the joints. Bursae are the pouches of synovial fluid that reduce friction between bones, muscles, or tendons. Fibrocartilaginous disks separate bony surfaces such as those between the vertebrae in the spine.
A clinical manifestation of symmetric neurogenic pain may indicate A. radiculopathy. B. reflex sympathetic dystrophy. C. entrapment neuropathy. D. peripheral neuropathy
Answer: D Symmetric neurogenic pain (burning, numbness, and tingling) will include peripheral neuropathy and myelopathy. Asymmetric neurogenic pain will include radiculopathy, reflex sympathetic dystrophy, and entrapment neuropathy. A claudication pain pattern will be present in peripheral vascular disease, giant- cell arteritis (with jaw pain), and lumbar spinal stenosis. These conditions all include the clinical manifestations of neurogenic pain.
Margaret, age 55, presents to you for evaluation of left hand and wrist pain and swelling after a slip and fall on the ice yesterday. On examination, you note tenderness at her "anatomical snuffbox." You knows this probably indicates a(n) A. ulnar styloid fracture. B. scaphoid fracture. C. hamate fracture. D. radial head fracture.
Answer: B There is tenderness over the "anatomical snuffbox" in a scaphoid (aka navicular) fracture, the most common injury of the carpal bones. Poor blood supply puts the scaphoid bone at risk for avascular necrosis; therefore, wrist pain and tenderness in the anatomical snuffbox, even without history of antecedent trauma, warrants a wrist x- ray. A fracture of the hook of the hamate is an uncommon fracture seen in golfers and in players of other racket sports and involves pain and tenderness on the ulnar side of the palm. An ulnar styloid fracture would produce tenderness at the distal ulna. A radial head fracture would result in pain at the elbow joint where the radial head lies proximal to the distal humerus. Be sure not to confuse the radial head (proximal end of the radius) with the radial styloid (distal end of the radius at the wrist).
A Baker's cyst is A. an inflammation of the bursa. B. a form of tendinitis. C. the buildup of synovial fluid behind the knee. D. the result of a "swollen" ligament.
Answer: C A Baker's cyst, also called popliteal cyst, is the buildup of synovial fluid behind the knee. It usually results from inflammation related to knee arthritis or a cartilage (especially meniscal) tear. It consists of local pain, inability to extend the knee, and symptoms related to compression of surrounding structures. The latter symptoms may mimic venous thrombophlebitis. It does not affect the tendons and/or ligaments.
The most common cause of cauda equina syndrome is A. fracture. B. hematoma. C. lumbar intervertebral disk herniation. D. space- occupying lesion.
Answer: C A herniated lumbar intervertebral disc is the most common cause of cauda equina syndrome (CES). Other causes of CES include trauma, fracture, hematoma, abscess, lymphoma, tumor, and other space- occupying lesions that compress the spinal nerve roots.
The nurse practitioner is trying to distinguish between an articular and nonarticular musculoskeletal complaint of a 26- year- old patient complaining of pain in the elbow area. Which of the following would characterize nonarticular bursitis? A. Deep or diffuse pain B. Limited ROM on active and passive movement C. Point or focal tenderness D. Swelling and instability
Answer: C Disorders of articular structures are characterized by deep or diffuse pain, limited ROM on both active and passive movement, swelling, crepitation, instability, and deformity. Nonarticular disorders are characterized by painful active but not passive movement and point or focal tenderness in regions far from articular surfaces.
Daniel, age 45, is of northern European ancestry and has a dysfunctional and disfiguring condition affecting the palmar tissue between the skin of the distal palm and fourth and fifth fingers. What do you suspect? A. Hallux valgus B. de Quervain's tenosynovitis C. Dupuytren's contracture D. Hallux rigidus
Answer: C Dupuytren's contracture affects the palmar tissue between the skin and the distal palm and fingers, most often in the fourth and fifth fingers, but also in the thumb- index finger web space. It is progressiveand results in flexor contracture while not affecting the flexor tendons. Most frequently occurring in males between the ages of 40 and 60, it is common among persons of Northern European ancestry. It is dysfunctional and disfiguring. Although not actually painful, it may be tender. Surgery is recommended when the inability to straighten the fingers limits the client's hand function. Hallux valgus, commonly referred to as a bunion, is an osseous deformity at the MTP joint of the great toe with medial deviation of the toe. Hallux rigidus is a common condition of arthritis at the base of the great toe at the MTP joint, causing stiffness and decreased movement of the great toe.
Heidi, age 29, is a nurse who has an acute episode of back pain. You have determined that it is a simple "mechanical" backache and order A. bedrest for 2 days. B. muscle relaxants. C. her to continue activities as the pain permits. D. back- strengthening exercises
Answer: C Faster symptomatic recovery has been seen in clients with a simple "mechanical" backache who continue normal activities as much as they can with "pain being their guide" than in clients who use traditional medical treatments, such as bedrest and use of NSAIDs. Muscle relaxants should be ordered only if muscle spasms are actually present, although acetaminophen (Tylenol) and NSAIDs have also been shown to help the muscle spasms adequately. Back- strengthening exercises should be started within 6 weeks of the onset of pain.
Sandra, a computer programmer, has just been given a new diagnosis of carpal tunnel syndrome. The nurse practitioner's next step is to A. refer her to a hand surgeon. B. take a more complete history. C. try neutral position wrist splinting and order an oral NSAID. D. order a nerve conduction study such as an electromyography (EMG).
Answer: C For the client who has just been given a diagnosis of carpal tunnel syndrome, your next step is to try neutral position wrist splinting and order an oral NSAID. For symptoms of less than 10 months' duration, conservative treatment should be tried first. Taking a more complete history is not essential at this point because a diagnosis has already been made. Nerve conduction studies (i.e., electromyography [EMG]) confirm focal median nerve conduction delay within the carpal canal and also provide information about disease severity. For refractory cases, median nerve decompression may be accomplished by surgery, but complete recovery is not possible if atrophy is pronounced.
Which of the following is NOT a management principal for an acute musculoskeletal injury that does not require emergent treatment? A. RICE B. NSAIDs or acetaminophen C. Imaging studies D. Skeletal muscle relaxants
Answer: C Imaging studies such as radiograph, CT scan, and MRI are usually not indicated for acute musculoskeletal injuries. Rest, ice for 48 hours, compression with an ace wrap, and elevation (which make up the acronym RICE) are commonly employed. NSAIDs and acetaminophen are the first- line choices for medication management in acute injury or pain. Skeletal muscle relaxants prescribed for a 1- to 2- week course may be valuable if the injury is accompanied by spasm or tightness.
The knee is an example of a A. spheroidal joint. B. hinge joint. C. condylar joint. D. fibrous joint.
Answer: C In a condylar joint, such as the knee and temporomandibular joint, the articulating surfaces are convex or concave and are termed condyles. Spheroidal joints have a ball-and socket configuration— a rounded convex surface articulating with a cuplike cavity, allowing a wide range of rotary movement, as in the shoulder and hip. Often the knee is mistakenly referred to as a hinge joint, but hinge joints are fl at and uniplanar, allowing only a gliding motion in a single plane, as in flexion and extension of the interphalangeal joints. In fibrous joints, such as the sutures of the skull, intervening layers of fi brous tissue or cartilage hold the bones together. The bones are almost in direct contact, which allows no appreciable movement.
The four cardinal signs of inflammation related to musculoskeletal disorders include which of the following? A. Erythema, warmth, fever, or morning stiffness B. Fatigue, morning stiffness, fever, or effusion C. Erythema, warmth, pain or swelling D. Effusion, pain, fever, or swelling
Answer: C Inflammatory disorders may be infectious or idiopathic and are identified by all or some of the four cardinal signs of inflammation: erythema, warmth, pain, and swelling. Fatigue, morning stiffness, and fever, along with weight loss, are considered systemic symptoms related to inflammation.
When a provider elicits a painful Finkelstein's sign, he or she is testing for A. carpal tunnel syndrome. B. bursitis of the shoulder. C. de Quervain's tenosynovitis. D. tennis elbow
Answer: C Pain elicited when the Finkelstein's test is performed indicates de Quervain's tenosynovitis at the base of the thumb. The test is performed by flexion of the thumb across the palm, with ulnar deviation of the wrist. Gliding the infl amed tendons will produce pain, which is considered a positive Finkelstein's test. Tinel's sign and Phalen's test are used to diagnose carpal tunnel syndrome. The tennis elbow test evaluates for lateral epicondylitis. The client's elbow is stabilized in the examiner's hand and the thumb of that hand positioned on the client's lateral epicondyle. The client makes a fist, pronates the forearm, and radially deviates and extends the wrist while the examiner applies a resisting force at the wrist. This test is positive if pain is elicited in the area of the lateral epicondyle. There is no specific test for shoulder bursitis.
Alexander, age 18, sprained his ankle playing ice hockey. He is confused as to whether to apply heat or cold. What should the nurse practitioner tell him? A. "Use continuous heat for the first 12 hours and then use heat or cold to your own preference." B. "Use continuous cold for the first 12 hours and then use heat or cold to your own preference." C. "Apply cold for 20 minutes, then take it off for 30 to 45 minutes; repeat this for the first 24 to 48 hours while awake." D. "Alternate between cold and heat for 20 minutes each for the first 24 to 48 hours."
Answer: C Tell a client who has sprained his ankle to apply cold for 20 minutes, then take it off for 30 to 45 minutes, and repeat that procedure for the first 24 to 48 hours while awake. Cold will cause vasoconstriction and decrease edema, preventing any further bleeding into the tissues. Ice has been proven to speed recovery in ankle sprains; however, ice should never be applied continuously because it could hinder proper circulation and cause frostbite. Therefore, always recommend a protective padding between the ice and the skin. Applying heat may increase swelling and subsequently slow recovery. After any sprain, use the principles of RICE: Rest, Ice, Compression, and Elevation.
The Valgus stress test, Varus stress test, Lachman test, and Thumb test are all considered standard tests to check the integrity of the ligaments of the knee. Which test would the nurse practitioner choose to assess the anterior cruciate ligament, which is the most commonly involved structure in severe knee injury? A. Valgus stress test B. Varus stress test C. Lachman test D. Thumb sign
Answer: C The Lachman test assesses the anterior cruciate ligament (ACL) while the Thumb test assesses the posterior cruciate ligament (PCL). The Valgus stress test assesses stability of the medial collateral ligament (MCL), and the Varus stress test determines stability of the lateral collateral ligament (LCL).
Which test is used to diagnose an Achilles' tendon rupture? A. The Boutonniere test B. The Lachman test C. The Thompson test D. The drawer test
Answer: C The Thompson test is used to diagnose an Achilles tendon rupture. With an Achilles tendon rupture, there is local swelling and bruising and a weak push- off. The Thompson test is positive when the gastrocnemius muscle belly is firmly squeezed and the foot does not plantar flex. Boutonniere deformity, not test, usually results from an injury at the proximal interphalangeal joint, involving the extensor slip that attaches to the middle phalanx. It can also develop in infl ammatory disorders such as rheumatoid arthritis. The Lachman test assesses for an anterior cruciate ligament (ACL) tear. The knee is fl exed 30 degrees, the examiner places one hand on the distal femur and the other on the proximal tibia, and an anterior force is applied to the proximal tibia. An intact ACL should prevent forward movement of the tibia. Any perceived contralateral difference is usually signifi cant. The
Mr. McKinsey, age 69, was recently given a diagnosis of degenerative joint disease. Which assessment test should the nurse practitioner use to check for effusion of the patient's knee? A. The Thomas test B. Tinel's sign C. The bulge test D. Phalen's test
Answer: C The bulge test assesses for an effusion of the knee. If effusion is present, a bulge will appear to the sides of or below the patella when the practitioner compresses the area above the patella. The Thomas test is used to assess for hip problems. Both the Tinel's sign and Phalen's test assess for carpal tunnel syndrome.
Bursitis is an inflammatory process that may be caused by infection, trauma, repetitive movement disorders, gout, or neoplastic disease. The most common cause of septic bursitis due to infection is from which of the following? A. Mycobacterium tuberculosis B. Candida C. Staphylococcus aureus D. Streptococcus
Answer: C The most common causative organism of septic bursitis is Staphylococcus aureus (80% of cases), followed by streptococci. However, many other organisms have been implicated in septic bursitis, including mycobacteria (both tuberculous and nontuberculous strains), fungi ( Candida ), and algae (Prototheca wickerhamii ). Factors predisposing to infection include diabetes mellitus, steroid therapy, uremia, alcoholism, skin disease, and trauma. A history of noninfectious inflammation of the bursa also increases the risk of septic bursitis.
Jim, age 22, a stock boy, has an acute episode of low back pain. The nurse practitioner orders an NSAID and should educate him in which of the following? A. Maintain moderate bedrest for 3 to 4 days. B. Call the office for narcotic medication if there is no relief with the NSAID after 24 to 48 hours. C. Begin lower back strengthening exercises depending on pain tolerance. D. Wear a Boston brace at night.
Answer: C Years ago, muscle relaxants and bedrest were the treatments of choice for low back pain. Studies have now shown that resuming normal activity within the limits imposed by the pain has an effect as good as, if not better than, 2 days of bedrest. The expression is "let pain be your guide." Exercise should begin as soon as possible after the acute injury and is directed at building endurance and stamina with consideration given to one's pain tolerance. NSAIDs, not narcotics, are generally the first- line medication treatment of low back pain without the risk of opioid dependency. A Boston brace may be used in the treatment of scoliosis.
Beth, age 49, comes in with low back pain. An x- ray of the lumbar/sacral spine is within normal limits. Which of the following diagnoses do you explore further? A. Scoliosis B. Osteoarthritis C. Spinal stenosis D. Herniated nucleus pulposus
Answer: D A plain x- ray film will not show a herniated nucleus pulposus or a muscle strain. It will show spondylolisthesis, scoliosis, osteoarthritis, and spinal stenosis. Note that x- rays of the spine are not indicated in low back pain unless the cause of the pain is thought to have a bony origin or to be traumatic in nature or to rule out systemic disease
Sandy, age 49, presents with loss of anal sphincter tone, impaired micturition, incontinence, and progressive loss of strength in the legs. You suspect cauda equina syndrome. What is your next action? A. Order physical therapy B. Order a lumbar/sacral x- ray C. Order extensive lab work D. Refer to a neurosurgeon
Answer: D A prompt referral to a neurosurgeon is required when a diagnosis of cauda equina syndrome is suspected. Cauda equina syndrome is a widespread neurological disorder in which there is loss of anal sphincter tone; impaired micturition and incontinence; saddle anesthesia at the anus, perineum, or genitals; and motor weakness or sensory loss in both legs. An x- ray is not helpful in the diagnosis of cauda equina , and precious time should not be wasted in a client with suspected cauda equina . An MRI can be a useful diagnostic tool, but prompt evaluation by a neurosurgeon is an essential first step to prevent permanent neurological damage.
The nurse practitioner (NP) suspects a herniated disk in a 72- year- old patient. The NP elevates the patient's affected leg when she is in the supine position, and it elicits back and sciatic nerve pain, which indicates a positive test. This is known as which test or sign? A. Femoral stretch test B. Cross straight leg-raising test C. Doorbell sign D. Straight leg-raising test
Answer: D All of the tests listed as possible options are tests done to assess for a herniated disk. In the straight leg-raising test, you elevate the affected leg when the client is in the supine position; back pain and sciatic nerve pain (radiating leg pain) indicate a herniated disk. In the cross straight leg-raising test, elevation of the uninvolved leg produces sciatic pain down the contralateral leg. The doorbell sign is the development of sciatica when the spinous process over the protruded disk is deeply palpated. The femoral stretch test is done with the client prone and the leg extended and the knee fl exed. Pain radiating to the anterior thigh indicates an L4 radiculopathy.
Which of the following statements is true regarding range of motion (ROM) of a joint? A. The normal active ROM of a joint is greater than the passive ROM of the same joint. B. If there is a limitation of active ROM, you should not attempt passive ROM to avoid further injury to the joint. C. Active and passive ROM of a joint should be equal, full, and cause only mild discomfort. D. Active and passive ROM of a joint should be equal, full, and pain- free.
Answer: D Both active range of motion (AROM) and passive range of motion (PROM) of a joint should normally be equal, full, and pain- free. AROM requires strength against gravity, and PROM is performed by the examiner without the effects of muscle contraction or gravity. Any pain or limitation with range of motion should be further investigated to determine the cause. If you note a limitation of AROM, you should gently attempt passive motion to further assess the joint.
What is the name of the test used to assess for nerve- root compression? A. The Apley scratch test B. The drop arm test C. Finkelstein's test D. Spurling's maneuver
Answer: D Spurlings maneuver is used to assess nerve- root compression of the neck. With the patient's neck in extension, the neck is rotated to the affected side. Downward pressure is applied to the head, and the patient is assessed for limb pain or paresthesia. The Apley scratch test is used to evaluate the ROM, e.g., abduction and external rotation and internal rotation and adduction of the shoulder. The drop-arm test is used to confirm a suspected rotator cuff tear while the Finkelstein test assesses for de Quervain's disease.
Hilda, age 73, presents with a complaint of low back pain. Red flags in her history of a minor fall, osteopenia, and prolonged steroid use for systemic lupus erythematosus suggest the possibility of which of the following serious underlying conditions as the cause of her low back pain? A. Cancer B. Cauda equina syndrome C. Neurological compromise D. Spinal fracture
Answer: D The red fl ags for spinal fracture include major trauma or a direct blow the back in adults, a minor fall or heavy lifting in a potentially osteoporotic or elderly person, prolonged steroid use, and age over 70. Low back pain accompanied by acute onset of urinary retention or overflow incontinence, loss of anal sphincter tone or fecal incontinence, loss of sensation in the buttocks and perineum, and motor weakness in the lower extremities are red flags for cauda equina syndrome or severe neurologic compromise. Cancer may be suspected if the low
To aid in the diagnosis of meniscus damage, which test should a nurse practitioner perform? A. The bulge test B. The Lachman test C. The drawer test D. Apley's compression test
Answer: D To aid in the diagnosis of meniscus damage such as a torn meniscus, you should perform Apley's compression test. With the client in the prone position, the suspected knee is flexed to 90 degrees and then downward pressure is exerted on the foot so that the tibia is firmly opposed to the femur. The leg is then rotated externally and internally. If the knee locks and there is pain or clicking with this maneuver, it is a positive Apley's sign, indicating the presence of a loose body, such as a torn cartilage, trapped in the joint articulation. The bulge test assesses for effusion in the knee joint. The Lachman test is an indicator of injury to the anterior cruciate ligament. The drawer test assesses for stability of the anterior and posterior cruciate ligaments.
For an adult patient with a knee injury, the nurse practitioner orders an NSAID to be taken on a routine basis for the next 2 weeks. Patient teaching should include which of the following? A. "You may take this medication on an empty stomach as long as you eat within 2 to 3 hours of taking it." B. "If one pill does not seem to help, you can double the dose for subsequent doses." C. "If you notice nausea/vomiting or black or bloody stools, take the next dose with a glass of milk or a full meal." D. "If you have additional pain, an occasional acetaminophen (Tylenol) is permitted in between the usual doses of the NSAID."
Answer: D When teaching clients about NSAIDs, tell them not to take these drugs on an empty stomach but to take them with food or milk and to stop the medication and call immediately if they notice any nausea/vomiting, coffee- ground emesis, black stools, or blood in the stool. If the client is having additional pain, acetaminophen (Tylenol) may be taken in conjunction with an NSAID because it is not an NSAID and will not potentiate gastric bleeding. Clients should be taught to never take more than the prescribed dose of an NSAID due to the likelihood of increasing the chances of gastrointestinal (GI) damage and kidney damage