CPU Chapter 18: Musculoskeletal System
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. Risk for infection related to osteoporosis Activity intolerance related to osteoporosis Impaired physical mobility related to osteoporosis Disturbed sensory perception related to osteoporosis Risk for injury related to osteoporosis
Activity intolerance related to osteoporosis Impaired physical mobility 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 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 touch the chin to the chest Palpate the spinous processes and the paravertebral muscles Instruct the client to bend forward and touch the toes Ask the client to raise the leg to the point of pain and then dorsiflex the foot
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 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 patient? Thyroid hormone Testosterone Vitamin C supplements Calcitonin
Calcitonin Although osteoporosis can be treated, no cure has been found. Prevention is very important, especially for women. Current treatment includes bisphosphonates, calcitonin, estrogen and/or HRT, raloxifene, and parathyroid hormone.
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 Gouty arthritis Diabetic neuropathy Osteoarthritis
Carpal tunnel syndrome The nurse has performed Phalen's test, which assesses for carpal tunnel syndrome. A positive result is not suggestive of neuropathy, osteoarthritis, or gouty arthritis.
A client presents to the health care clinic with reports of onset of neck pain three (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
Cervical strain The most common cause of neck pain is cervical strain. This can occur from sleeping in the wrong position, carrying a heavy load, or being in an automobile accident. Cervical disc degenerative disease is associated with impaired range of motion and pain that radiates to the back, shoulders, or arms. Cervical spinal cord compression causes neck pain with loss of sensation in the legs. Compression fractures of the neck may also cause loss of sensation in the legs if the spinal cord becomes compressed.
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? Ligament trauma Effusion in the knee joint Osteoarthritis Crepitus uteri flexion
Effusion in the knee joint 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.
Which movement should the nurse instruct the client to perform to assess range of motion for the knee? Rotation Flexion Circumduction Abduction
Flexion The nurse should instruct the client to perform flexion to assess the range of motion for the client's knee. Circumduction, rotation, and abduction movements are not possible in the knees. Circumduction is the circular motion of the joint. Rotation involves turning the head to the right shoulder then back to midline and then turning the head to the left shoulder then back to midline. Abduction refers to moving away from the midline of the body. The knees are capable of performing only flexion and extension.
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? Flashlight Goniometer Gradiometer Scale
Goniometer A goniometer measures the angle at which a joint can flex or extend. Nurses do not use flashlights or gradiometers during musculoskeletal assessments. The registered nurse would be more likely than the advanced practice nurse to use a scale to weigh a client.
During the physical exam, the nurse notes a very tender and painful, reddened, hot, and swollen metatarsophalangeal joint of the client's great toe. What would the nurse suspect? Gouty arthritis Rheumatoid arthritis Plantar fasciitis Degenerative joint disease
Gouty arthritis In gouty arthritis, the metatarsophalangeal joint of the great toe is tender, painful, red, hot, and swollen. Nodules of posterior ankle may be seen with rheumatoid arthritis. Pain and tenderness of the metatarsophalangeal joints are seen with inflammation, rheumatoid arthritis, and degenerative joint disease. Tenderness of the calcaneus of the bottom of the foot may indicate plantar fasciitis.
The nurse is assessing an elderly client and finds an exaggerated thoracic curve. This would be documented as what? Ankylosing spondylitis Lordosis Kyphosis Scoliosis
Kyphosis 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.
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? Phalen's McMurray's Bulge Ballottement
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.
The nurse asks the client to "raise the arm out to the side" in the position shown. What is the nurse assessing? Shoulder adduction Elbow adduction Shoulder abduction Elbow abduction
Shoulder abduction Raising the arms out to the side tests for should abduction. Moving the arm towards the midline assesses for shoulder adduction. The elbow is assessed for flexion, extension, pronation, and supination.
Assessment reveals that an older adult client has osteomalacia. What would be most important to include in the client's teaching plan? Keep exercise to a minimum to decrease pain. Practice risk prevention for fractures. Treat secondary arthritis proactively. Minimize movements to maintain joint stability.
Practice risk prevention for fractures. Bones lose density with age, which puts the older client at greater risk for fractures. If the older client has osteomalacia, the risk for fracture is even greater. Therefore, the nurse needs to emphasize fracture prevention. Exercise promotes bone density and should be encouraged. The client needs to maintain joint mobility with movement. Osteomalacia is not a direct risk factor for arthritis.
What finding should a nurse expect when performing the Phalen's test on a client with suspected carpal tunnel syndrome? Reports of tingling, numbness, and pain in the involved wrist A change in the color of the fingers from red to white (pale) Stiffness in the hands and fingers after holding and releasing a tight fist Inability to perform active range of motion with the involved wrist
Reports of tingling, numbness, and pain in the involved wrist The 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 the color of the fingers from red to white (pale) is seen in clients with Reynaud's disease.
What is increased muscle tone in both directions that is not rate dependent? Atrophy Spasticity Rigidity Atony
Rigidity Rigidity is increased resistance throughout the range of movement and in both directions (not rate dependent).
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 Trigeminal neuralgia Tumour of the mandible Temporal arteritis
Temporomandibular joint syndrome 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.
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 equally distributed on the neck The head is centered and in line with the backbone The head is straight up and down in accordance with the spine The head is midline and aligned with the spine
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."
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
Turning the palm of the hand upward Supination involves turning or facing upward, in this case turning the palm upward. Pronation involves turning or facing downward, in this case turning the palm downward. Flexion involves bending the extremity at the joint and decreasing the angle of the joint, in this case moving the tips of the fingers toward the forearm. Extension involves straightening the extremity at the joint and increasing the angle of the joint, in this case moving the tips of the fingers away from the forearm.
Articulation between the head of the femur and the acetabulum is in the knee joint. ankle joint. hip joint. tibial joint.
hip joint. Articulation between the head of the femur and the acetabulum occurs in the hip joint.