Musculoskeletal Assessment Quiz 1

A nurse wants to assess the prevertebral muscles of a client who reports neck stiffness. In order to effectively conduct the physical examination of this area, the nurse should give which instruction to the client? "Look over one shoulder and then the other." "Look up at the ceiling." "Bring your ear to your shoulder." "Bring your chin to your chest."

"Bring your chin to your chest."

A client has been admitted to a medical unit. The nurse notes that the client has irregular, uncoordinated movements. How would the nurse document this finding? "Patient shows signs of ataxia." "Patient demonstrates hypotonicity." "Patient is atonic." "Patient exhibits spasticity."

"Patient shows signs of ataxia."

During the health history of the musculoskeletal system, the client reports having low back pain that radiates into the leg with numbness and tingling. The nurse should further assess for spinal stenosis when the client makes which of the following statements? "The pain is relieved when I am sitting to have a bowel movement" " The pain is relieved when I cough or sneeze" "The pain improves when I exercise" "The pain improves when I am leaning over a shopping cart"

"The pain improves when I am leaning over a shopping cart"

A client is able to actively move the right arm against gravity. How should the nurse document this finding using the muscle strength grading scale? 4 2 1 3

3

After completing the musculoskeletal health history, the nurse determines that a client is at risk for osteoporosis. Which of the following risk factors were most likely identified in this client?(Select all that apply.) Age 65 Alcohol intake four drinks per day Sedentary lifestyle Weight 180 pounds Current smoker

Age 65 Alcohol intake four drinks per day Sedentary lifestyle Current smoker

When testing muscle strength, a client has difficulty moving each extremity against resistance. Which of the following would the nurse do next? Compare bilateral findings. Ask the client to move the part against gravity. Inspect by touch for a palpable contraction of the muscle. Move the part passively through its range of motion.

Ask the client to move the part against gravity.

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? Palpate the spinous processes and the paravertebral muscles Instruct the client to touch the chin to the chest Ask the client to raise the leg to the point of pain and then dorsiflex the foot 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

The nurse is assessing a client who presents with shoulder pain. No signs of inflammation are present. What is the nurse's priority action? Administer prescribed pain medication. Check for passive range of motion. Assess for shortness of breath. Notify the healthcare provider immediately.

Assess for shortness of breath.

A nurse performs inspection and palpation of a client's knee and detects swelling. What is the appropriate test the nurse should perform next to determine the cause of the swelling? Ballottement Range of motion Bulge McMurray's

Bulge

A client presents to the emergency department after falling off a ladder while doing some outside painting at home. The client's ankle appears swollen, out of alignment, and is painful to touch. What is the nurse's first action? Encourage early weight bearing and ambulation. Apply an ice pack to the affected extremity. Check for a pulse, color, temperature, and capillary refill. Splint and immobilize the affected extremity.

Check for a pulse, color, temperature, and capillary refill.

A nurse asks a client to bring the hands together behind the head with the elbows flexed. The nurse is testing which of the following? Internal rotation Abduction External rotation Adduction

External rotation

A 28-year-old graduate student comes to the clinic for evaluation of pain "all over." With further questioning, she can relate that the pain is worse in the neck, shoulders, hands, low back, and knees. She denies swelling in her joints; she states that the pain is worse in the morning; there is no limitation in her range of motion. On physical examination, she has several points on the muscles of the neck, shoulders, and back that are tender to palpation; muscle strength and range of motion are normal. Which of the following is likely the cause of her pain? Polymyalgia rheumatica Osteoarthritis Rheumatoid arthritis Fibromyalgia

Fibromyalgia

A client is experiencing left elbow pain. When assessing this joint, in which direction should the nurse move the extremity? Select all that apply. Supination Circumduction Flexion Pronation Extension

Flexion Supination Pronation Extension

The nurse notes when the client enters the room for the physical examination, there is unsteadiness during the weight-bearing stance phase of walking. Which of the following areas should the nurse focus the assessment? Ankles Feet Hips Knees

Hips

A nurse is testing the range of motion of the thoracic and lumbar spine. Which of the following would the nurse document as an abnormal finding? Flexion of 80 degrees Lateral bending of 35 degrees Rotation of 30 degrees Hyperextension of 20 degrees

Hyperextension of 20 degrees

The nurse is developing a plan of care for a client found to have a strength problem. What would be an appropriate nursing diagnosis for this client? Self-care deficit Impaired walking Impaired physical mobility Activity intolerance

Impaired physical mobility

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 Impaired physical mobility related to osteoporosis Risk for injury related to osteoporosis Activity intolerance related to osteoporosis Disturbed sensory perception related to osteoporosis

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

Which finding in an elderly client requires additional assessment by a nurse when inspecting the musculoskeletal system? An exaggerated thoracic curve (kyphosis) Inability to button the jacket due to swollen finger joints Slow and steady gait with a wide base of support Symmetrical atrophy of the biceps muscles

Inability to button the jacket due to swollen finger joints

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. Make sure house hallways are well lit Install grab bars in the bathroom Correct environmental hazards in the home Have the client go to a physical therapy three times a week Place colorful throw rugs near the exits

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

The nurse notes limitation in active range of motion of a client's right shoulder. What would the nurse to do next? Ask the client which is the dominant side. Test muscle strength. Perform passive range of motion test. Measure range of motion with a goniometer.

Measure range of motion with a goniometer.

A client receives physical therapy for carpal tunnel syndrome. Which action by the nurse is appropriate to assess the efficacy of the treatment? Flex the wrists 90 degrees upward Place the backs of both hands against each other Maintain flexed wrists for 90 seconds Bend the wrists down and back

Place the backs of both hands against each other

A client is unable to perform abduction with the right arm and reports pain when attempting to do so. The nurse notices that the muscles surrounding the right shoulder are smaller than those on the left shoulder. The nurse recognizes this finding as the possibility of what condition? Fracture Rotator cuff tear Degenerative joint disease Tendinitis

Rotator cuff tear

The nurse assesses a client's musculoskeletal system as shown. What is the nurse assessing? (picture of doctor holding client's arms and bring them out) Tennis elbow Carpal tunnel syndrome Supraspinatus strength Hand grasp strength

Supraspinatus strength

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 Torn anterior cruciate ligament Torn lateral meniscus Torn posterior cruciate ligament

Torn medial meniscus

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 bend forward while trying to touch the toes. move from a standing to a squatting position. raise his leg while in a supine position. flex the knee and hip while in a supine position.

flex the knee and hip while in a supine position.