Chapter 61 Assessment of the M/S System
The nurse is performing a musculoskeletal assessment of an older adult patient whose mobility has been decreasing progressively in recent months. How should the nurse best assess the patient's range of motion (ROM) in the affected leg? 1 Observe the patient's unassisted ROM in the affected leg 2 Perform passive ROM, asking the patient to report any pain 3 Ask the patient to lift progressive weights with the affected leg 4 Move both of the patient's legs from a supine position to full flexion
Answer: 1 Passive ROM should be performed with extreme caution, and may be best avoided when assessing older patients. Observing the patient's active ROM is more accurate and safer than asking the patient to lift weights with her legs.
A middle-aged patient is reporting a sore shoulder after raking the yard. The nurse should suspect which problem? 1 Bursitis 2 Fasciitis 3 Sprained ligament 4 Achilles tendonitis
Answer: 1 Bursitis is common in adults over age 40 and with repetitive motion, such as raking. Plantar fasciitis frequently occurs as a stabbing pain at the heel caused by straining the ligament that supports the arch. A sprained ligament occurs when a ligament is stretched or torn from a direct injury or sudden twisting of the joint, not repetitive motion. Achilles tendonitis is an inflammation of the tendon that attaches the calf muscle to the heel bone, not the shoulder, and it causes pain with walking or running.
A patient is scheduled for magnetic resonance imaging (MRI). What nursing interventions should the nurse perform to prepare the patient for the procedure? Select all that apply. 1 Offer ear plugs or music. 2 Inform the patient to remain still throughout the procedure. 3 Ensure that patient is not wearing metal such as zippers or jewelry. 4 Ensure that the patient is shaved completely and also catheterize the patient. 5 Explain that the machine will make loud tapping noises intermittently, and there is no cause for alarm.
Answer: 1, 2, 3, & 5 The nurse should inform the patient that the procedure is painless. Offer ear plugs or music to listen to so that the patient will be relaxed during the procedure. Inform the patient to remain still throughout procedure. The patient should have no metal on the clothing. Explain to the patient that the machine will make loud tapping noises intermittently, and there is no cause for alarm. Inform patients who are claustrophobic that they may experience symptoms during examination. Administer an antianxiety agent if indicated and ordered. The procedure is noninvasive, so the patient need not be shaved or catheterized.
A patient presents with pain in the wrist joint radiating up the entire arm. What should the nurse ask the patient while taking the health history? Select all that apply. 1 Nature of work 2 Food preference 3 Respiratory function 4 Mechanism of injury if any 5 Safety practices followed at work
Answer: 1, 4, & 5 The nature of work helps in knowing about potential injuries in the workplace. The safety practices at work also aid the nurse in assessing the severity of the condition. Knowing how the injury exactly occurred is an important factor that enables the nurse to determine the cause and severity of the injury. Food preferences affect the general health and nutritional status but do not specifically lead to wrist joint problems. Respiratory functioning is an important component of overall general health but is not specifically related to this scenario involving the musculoskeletal problem.
After assessing the muscle strength of a patient, the nurse scores it as 1 on the Muscle Strength Scale. What does the score mean? 1 No detection of muscular contraction 2 A barely detectable flicker or trace of contraction with observation or palpation 3 Active movement of the body part with elimination of gravity 4 Active movement against gravity only and not against resistance
Answer: 2
A patient is about to have a bone scan. What information should be included when teaching the patient about this procedure? 1 Two additional follow-up scans will be required 2 There will be only mild pain associated with the procedure 3 The procedure takes approximately 15 to 30 minutes to complete 4 The patient will be asked to drink increased fluids after the procedure
Answer: 4 Patients are asked to drink increased fluids after a bone scan to aid in excretion of the radioisotope, if not contraindicated by another condition. No follow-up scans and no pain are associated with bone scans, which take one hour of lying supine.
A patient with musculoskeletal fatigue is weak. How does the nurse best provide safety when the patient needs to go to the bathroom? 1 By providing a bedpan 2 By providing a bedside commode 3 By assisting the patient to the bathroom 4 By assessing the patient's ability to walk to the bathroom
Answer: 4 The nurse needs to assess whether the patient can safely walk to the bathroom before determining if assistance is necessary or a bedside commode or bedpan is used.
A patient has been on bed rest for several days due to an acute illness. The patient is finally able to get up in a chair. Of what will the patient most likely complain? 1 Heart racing 2 Sore muscles 3 Trouble breathing 4 Fatigue or tiredness
Answer: 4 The patient will most likely complain of fatigue or tiredness due to prolonged immobility. Sore muscles, trouble breathing, and heart racing are signs of intolerance to a chair activity or signs that a patient may have after going from prolonged bed rest to walking quickly.
During the nursing musculoskeletal assessment, the nurse assesses the joint movements. On the nurse's instruction, the patient flexes the ankle and toes toward the shin. As what should the nurse record this movement? 1 Inversion 2 Eversion 3 Dorsiflexion 4 Plantar flexion
answer: 3 Flexion of the ankle and toes toward the shin is called dorsiflexion. Eversion refers to turning of the sole outward away from midline of body. Inversion means turning of the sole inward toward the midline of body. Plantar flexion means flexion of the ankle and toes toward the plantar surface of the foot.
A patient complains he or she is unable to sleep in the hospital. What can the nurse do to promote rest? 1 Leave the door open at night. 2 Leave the room light on at night. 3 Keep the patient up during the day. 4 Provide pillows and blankets for comfort.
answer: 4 The nurse can promote rest by providing pillows and blankets for comfort, and closing the doors to reduce noise at night. The patient can benefit from a nap during the day to reduce feelings of tiredness. The nurse should also turn the light off at night.
A nurse is taking a patient's health history related to musculoskeletal system. What are the common symptoms of musculoskeletal impairments? Select all that apply. 1 Stiffness 2 Weakness 3 Joint crepitation 4 Redness and blisters 5 Changes in pigmentation
Answer 1, 2, 3 Stiffness and loss of range of motion are very commonly seen symptoms in musculoskeletal impairments. Weakness is also a common symptom. Joint crepitation is also seen in such disorders. Redness and blisters are not common symptoms seen in musculoskeletal impairments. Redness and blisters are associated with burns and infections. Similarly, a change in pigmentation is not a common symptom. It is usually a result of hormonal changes, aging, or other dermatologic conditions.
A nurse is assessing a fracture of a patient's hand. Which phenomenon would the nurse note as the bone fragments rub against each other? 1 Crepitation 2 Resorption 3 Subluxation 4 Proliferation
Answer: 1 Crepitation is the grating sensation and sound produced when broken bone fragments rub against one another. Resorption is the loss of bone mass due to a loss of calcium resulting in porous, weak bones. Proliferation is reproduction or multiplication of similar forms, usually referring to increases of cells. Subluxation is a partial or incomplete dislocation or displacement of a bone from its normal position.
The nurse is grading a muscle-strength test on the patient and obtains a score of 4/5. What best describes this score? 1 Active movement against gravity and some resistance 2 Active movement of body part with elimination of gravity 3 Active movement against full resistance without evident fatigue 4 Active movement against gravity only and not against resistance
Answer: 1 0/5 - No detection of muscular contraction 1/5 - A barely detectable flicker or trace of contraction with observation or palpation 2/5 - Active movement of body part with elimination of gravity 3/5 - Active movement against gravity only and not against resistance 4/5 - Active movement against gravity and some resistance 5/5 - Active movement against full resistance without evident fatigue (normal muscle strength)
When working with patients, the nurse knows that patients have the most difficulties with diarthrodial joints. Which joints are included in the group of diarthrodial joints? Select all that apply. 1 Hinge joint of the knee 2 Ligaments joining the vertebrae 3 Fibrous connective tissue of the skull 4 Ball and socket joint of the shoulder or hip 5 Cartilaginous connective tissue of the pubis joint
Answer: 1 & 4 The diarthrodial joints include the hinge joint of the knee and elbow, the ball and socket joint of the shoulder and hip, the pivot joint of the radioulnar joint, and the condyloid, saddle, and gliding joints of the wrist and hand. The ligaments and cartilaginous connective tissue joining the vertebrae and pubis joint and the fibrous connective tissue of the skull are synarthrotic joints.
A patient is scheduled for a technetium [Tc]-99m bone scan. What nursing interventions are appropriate for the patient? Select all that apply. 1 Increase fluid intake after the examination. 2 Ensure that patient's bladder is emptied before scan. 3 Explain to the patient that blood sample will be obtained in the test. 4 Explain to the patient that radioisotope is given 2 hours before the procedure. 5 Explain to the patient that it will be painless, because general anesthesia will be administered.
Answer: 1, 2, & 4 A bone scan involves injecting a radioisotope (usually technetium [Tc]-99m) that is absorbed by the bone. A uniform uptake of the isotope is normal. The patient should empty the bladder before the procedure. The nurse should explain to the patient that radioisotope is given two hours before procedure. The patient should be informed that the procedure requires one hour while the patient lies supine and that no pain or harm will result from isotopes. Fluid intake should be increased after the examination to help elimination of the radioisotope through urine. No blood sample is needed, and anesthesia is not administered during this test.
During a physical assessment, the nurse asks the patient to perform inversion movement of the foot. What instruction should the nurse give to the patient? 1 Flex your ankle and toes toward the shin. 2 Turn the sole inward toward the midline of the body. 3 Turn the sole outward away from the midline of the body. 4 Flex your ankle and toes toward the plantar surface of the foot.
Answer: 2 To perform inversion movements of the foot, the nurse should instruct the patient to turn the sole inward toward the midline of the body. Flexion of the ankle and toes toward the shin is called dorsiflexion. Turning the sole outward away from the midline of the body is called eversion, and flexion of ankle and toes toward the plantar surface of the foot is called plantar flexion.
A patient with a long-standing history of rheumatoid arthritis has sought care because of increasing stiffness in the right knee that has culminated in complete fixation of the joint. The nurse would document the presence of which problem? 1 Atrophy 2 Ankylosis 3 Crepitation 4 Contracture
Answer: 2 Ankylosis is stiffness or fixation of a joint, whereas contracture is reduced movement as a consequence of fibrosis of soft tissue (muscles, ligaments, or tendons). Atrophy is a flabby appearance of muscle leading to decreased function and tone. Crepitation is a grating or crackling sound that accompanies movement.
A patient asks the nurse why an arthrogram has been scheduled. The nurse should reply that this test is designed to identify which condition? 1 Fractures of the bone 2 The risk for osteoporosis 3 Disorders of the cartilage 4 Peripheral vasculature patency
Answer: 3 An arthrogram involves the injection of a radiopaque solution into a joint to outline the joint for visualization of cartilage and joint structures. It is useful in diagnosing an arthropathy. An arthrogram may show fractures, but this is not its primary purpose. An arthrogram will not show bone abnormalities such as osteoporosis. The test does not show vasculature structures or abnormalities.
The nurse has documented that a patient with a musculoskeletal injury is experiencing fatigue. Which part of the nursing process has the nurse used? 1 Planning 2 Evaluation 3 Assessment 4 Nursing diagnosis
Answer: 3 Identifying a characteristic symptom like fatigue is part of the assessment. Planning would involve devising an intervention to resolve the fatigue. A nursing diagnosis is a statement the nurse makes as to the problem, cause, and evidence of fatigue. Evaluation is an assessment to determine whether an intervention has worked.
A nurse is taking the health history of a patient suffering from severe knee pain. Which question related to the sexuality-reproductive pattern are important in this scenario for assessment? 1 What are your sexual preferences? 2 How many sexual partners do you have? 3 Which method of contraception do you use? 4 Do you face any sexual concerns related to your mobility?
Answer: 4 In a patient suffering from knee pain, few questions related to sexual pattern should be asked. Knowing whether the patient experiences any sexual concerns due to knee pain gives an indication of the severity of the complaint. The patient's sexual preferences, number of sexual partners, and method of contraception are important in assessing a patient for sexually transmitted infection (STI), but not for musculoskeletal system.
What is a common complaint after a patient has completed physical therapy? 1 Dry skin 2 Blindness 3 Constipation 4 Fatigue or tiredness
Answer: 4 A patient may complain of fatigue or tiredness after physical therapy. Bowel activity may be improved after physical therapy. The skin may be warm, flushed, and moist after physical therapy. Blindness is not related to physical therapy.