chapter 21 CP

While examining the spine of an adult client, the nurse notes that the client has a flattened lumbar curvature. The nurse should refer the client to a physician for possible

herniated disc. Flattening of the lumbar curvature may be seen with a herniated lumbar disc or ankylosing spondylitis.

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

straighten the elbow The client should have full range of motion

A patient has been admitted to a medical unit. The nurse notes that the patient has irregular, uncoordinated movements. How would the nurse document this finding?

"Patient shows signs of ataxia." Ataxia (irregular uncoordinated movements) or loss of balance may be due to cerebellar disorders, Parkinson disease, multiple sclerosis, strokes, brain tumors, inner ear problems, or medications.

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

4/5 Muscle strength is rated on a 5-point scale with specific defining characteristics for each. Slight weakness with active motion against some resistance is 4 of 5 points. 2 of 5 points would indicate passive and poor range of motion. 3 of 5 points would indicate average weakness with active motion against gravity. 5 of 5 points would indicate normal findings with active motion against full resistance.

When testing muscle strength, a client has difficulty moving her right arm against resistance. Which of the following should the nurse do next?

Ask the client to move the part against gravity. If the client cannot move the part against resistance when testing muscle strength, then the nurse should ask the client to move the part against gravity and, if that is not possible, attempt to passively move the part through its full range of motion. Percussion is not indicated.

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

Ballottement test The ballottement test is used to detect large amounts of fluid in the knee. Phalen's test and Tinel's test would be used to assess for carpal tunnel syndrome. Lasegue's test is used to detect low back pain.

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

Calcium 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.

Mark is a contractor who recently injured his back. He was told he had a "bulging disc" to account for the burning pain down his right leg and slight foot drop. The vertebral bodies of the spine involve which type of joint?

Cartilaginous The vertebral bodies of the spine are connected by cartilaginous joints involving the discs. The elbow would be an example of a synovial joint and the sutures of the skull are an example of a fibrous joint

A client complains of chronic pain and fatigue. The nurse suspects fibromyalgia. What is a diagnosis of this condition based on?

Client's symptoms 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.

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?

Compare this finding to the range of motion to the right side : 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.

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

External rotation When the client brings the hands together behind the head with the elbows flexed, the nurse is testing external rotation. Abduction is tested by having the client bring both hands together overhead with the elbows straight; adduction is tested by having the client bring both hands together in front of the body, past the midline, with the elbows straight. Internal rotation is tested by having the client bring the hands together behind the back with the elbows flexed.

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

Flexion 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.

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 : 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.

A nurse is preparing a program on osteoporosis for a local women's group. Which of the following should the nurse cite as a risk factor?

History of smoking : Smoking is a risk factor for osteoporosis. Obesity, multiparity, and African-American ethnicity are not noted risk factors for this disease.

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

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

A client has suffered a suspected a rotator cuff tear. Which of the following would the nurse expect to find?

Limited abduction Painful and limited abduction accompanied by muscle weakness and atrophy are seen with a rotator cuff tear. Acute pain is expected. Chronic pain and limitation of all shoulder motion is seen with calcified tendonitis. Sharp catches of pain are associated with rotator cuff tendonitis.

A nurse is preparing a program on osteoporosis for a local women's group. Which of the following would the nurse include as a modifiable risk factor?

Low estrogen levels Modifiable risk factors include low estrogen levels. Small-boned thin frame, personal history of fractures, and age cannot be modified.

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

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

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 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.

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 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.

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

Percuss lightly on the inner aspect of the wrist The nurse should tap at the inner aspect of the wrist to percuss the median nerve because the median nerve is located at the inner aspect of the wrist where it enters the carpal canal. Palpation of the hollow area on the back of the wrist is done to examine the anatomic snuffbox. Asking the client to bend the wrist down and back and performing wrist movements against resistance are done to assess range of motion and muscle strength.

When assessing the elbow, a nurse asks a client to hold the arm out and turn the palm down. The nurse is testing which of the following?

Pronation Turning the palm down tests pronation. Having the client turn the palm up would test supination. Flexion is tested by having the client bend the elbow and bring the hand to the forehead. Rotation is not assessed for the elbow

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 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

The nurse is assessing an older adult with new onset dementia. The nurse is using the Morse Fall Scale; the client's score is 63. What does this tell the nurse?

That the client is at high risk for falling A score of 63 on the Morse Fall Scale represents a high risk for falling. Restraints are used only as a last possible resort in cases where the client poses a risk of violent harm to self or others. Restraints usually have serious legal ramifications and would not be appropriate for consideration in this situation

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

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

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

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

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

Torn medial meniscus : This maneuvre is called McMurray's test. Along with the medial joint line tenderness, the nurse should suspect a medial meniscus injury. Cruciate ligament tears should cause an anterior or posterior "drawer sign." Although we can't rule out a lateral meniscus tear, the tenderness along the medial joint line makes this the more likely site of injury

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

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

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 • Activity intolerance related to osteoporosis • Risk for injury related to osteoporosis Osteoporosis creates risks for injury, activity intolerance, and impaired mobility as consequences of musculoskeletal changes. The disease does not normally result in infection or impaired sensation.

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?

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

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?

Ask the client to raise the leg to the point of pain and then dorsiflex the foot 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.

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:

At the back of the client and nudge the sternum 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.

A nurse is caring for a client who is recovering from a stroke. The nurse assesses the muscle strength of the client's arm and finds that the joint exhibits active motion against gravity. Which of the following should the nurse document to classify muscle strength based on this finding?

Average weakness The nurse should document the finding as average weakness of the arm muscles. In passive range of motion (ROM), gravity is removed and the client performs ROM with assistance; in this case, the strength is classified as poor ROM. When the client is able to perform the active motion against some resistance, it is classified as slight weakness. If the client has only a slight flicker of contraction, muscle strength is classified as severe weakness.

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

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

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. 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.

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) 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.

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

Percuss lightly on the inner aspect of the wrist. The nurse should tap at the inner aspect of the wrist to percuss the median nerve because the median nerve is located at the inner aspect of the wrist where it enters the carpal canal. Palpation of the hollow area on the back of the wrist is done to examine the anatomic snuffbox. Asking the client to bend the wrist down and back and performing wrist movements against resistance are done to assess range of motion and muscle strength.

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? used to test individuals for tears in the meniscus of the knee.

Phalen's 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.

What finding should a nurse expect when performing Phalen's test on a client with suspected carpal tunnel syndrome?

Reports of tingling, numbness, and pain in the involved wrist 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.

Into which of the following positions should the client be placed for the nurse to effectively examine the tibiofemoral joint of the knee?

Sitting with knees in flexion ] To examine the tibiofemoral joint of the knee, the nurse should ask the client to sit on the edge of the examining table with the knees flexed. The supine position is used to assess muscle strength. The prone position with soles facing up is not the correct position for assessing this joint. The standing position is used to assess knee alignment and contours but should be used with the client standing up straight.

The nurse is performing the bulge test during the assessment of a client's knee. This test will allow the nurse to make what determination?

Whether the client's swollen knee is caused by tissue swelling or by fluid accumulation The bulge test is used to determine if knee swelling is due to accumulation of fluid or soft tissue swelling. It does not address range or motion. Knee swelling is never considered to be an age-related change.

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

flex the knee and hip while in a supine position. 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.

A client visits the clinic and tells the nurse that he has had lower back pain for the past several days. To perform Lasègue test, the nurse should ask the client to

lie flat and raise his leg to the point of pain.