nurs chapter 18

The nurse is planning the care of a 77-year-old woman who has recently been diagnosed with osteoporosis. What nursing diagnoses should the nurse address in the client's plan of care? Select all that apply.

-Impaired physical mobility related to osteoporosis -Risk for injury related to osteoporosis -Activity intolerance related to osteoporosis

A client is being discharged home from the hospital. This client has a history of falling at home. A caregiver is not able to stay with the client all the time. What can be done to decrease the risk for falling at the client's home? Select all that apply.

-Install grab bars in the bathroom -Make sure house hallways are well lit -Correct environmental hazards in the home

The nurse has had a client place the backs of both her hands against each other while flexing her wrists 90 degrees with fingers pointed downward and wrists dangling. The presence of pain or tingling during this test suggests what health problem to the nurse?

Carpal tunnel syndrome

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

Difficulty chewing

A nursing student is preparing to demonstrate how to test the range of motion for the elbow. Which of the following would the student include? Select all that apply.

Flexion Extension Supination

The nurse is assessing the range of motion (ROM) of a client's joints. What would the nurse use to assess flexion and extension of a joint if the client complains of pain on examination?

Goniometer

Which of the following tools would a nurse practitioner be more likely than a registered nurse to use during the performance of a musculoskeletal assessment on a client to measure maximum flexion of a joint?

Goniometer

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?

Impaired Physical Mobility

A client has rheumatoid arthritis most prominent in the hands, where the client has decreased range of motion (ROM), pain, and tenderness. What is an appropriate nursing diagnosis for this client?

Impaired physical mobility related to reduced strength and ROM

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?

Lateral epicondylitis (tennis elbow)

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

Measure movement with a goniometer

The 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?

Moderate strenuous exercise tends to increase bone density.

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

The nurse is conducting a musculoskeletal assessment of an older adult client. What aspect of the client's medical history requires the nurse to alter the usual sequence or content of this assessment?

The client had a total hip replacement 2 years ago.

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

The head is midline and aligned with the spine

A 70-year-old woman has come to the clinic to follow up her bone density testing. The results suggest that she has osteoporosis. What is a medication that might be ordered for this client?

calcitonin

The nurse instructs the client to raise his arm out to the side and overhead. The nurse is asking the client to adduct his arm.

false

What range of motion is the nurse testing by asking a client to stoop to pick an object off the floor?

flexion

While assessing the knee joint of a client, a nurse also explains about the typical motions associated with that joint. What would the nurse include?

flexion

A nurse inspects a child's legs while standing and notices that the knees turn inward. How should this finding be documented in the medical record?

genu valgum

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?

gouty arthritis

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

herniated intervertebral disc.

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?

mcmurrays

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?

protraction

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

rotator cuff tear

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

rotator cuff tear

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

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

The nurse asks the client to "raise the arm out to the side" in the position shown. What is the nurse assessing?

shoulder abduction

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?

straight leg raise test