Quiz 2: Musculoskeletal Assessment
A nurse conducts a physical examination of the musculoskeletal system of a client who reports upper arm pain. Which instruction should the nurse provide the client when assessing flexion of the elbow?
"Bend your elbow." Explanation: Asking the client to bend the elbow assesses for flexion. Asking the client to straighten the elbow assesses for extension. Asking the client turn the palms down assesses for pronation. Asking the client to turn the palms down and point fingers to the floor assesses flexion of the elbow.
What is an appropriate question by the nurse to ask a client about the presence of temporomandibular joint dysfunction?
"Have you noticed a popping or grating sound when you chew?" Explanation: The temporomandibular joint (TMJ) provides the stability of the jaw to open and close. Often the joint can become swollen, causing pain and decrease in range of motion of the jaw. Decreased muscle strength and range of motion, along with a popping, clicking, or grating sound may be noted with TMJ dysfunction. Swelling around the teeth and gums is seen with gingivitis. Clenching the teeth test the integrity of cranial nerve V (trigeminal nerve). Asking the client to stick out the tongue and move it from side to side tests cranial nerve XII (hypoglossal nerve).
A previously healthy 64-year-old man has been recently diagnosed with osteoarthritis. The client is motivated to maintain his quality of life and slow the progression of his new health problem. What advice can the nurse provide for the client in his efforts to minimize the effects and progression of osteoarthritis?
"It's important for you to maintain a healthy body weight." Explanation: Maintaining a healthy body weight can slow the progression of OA. The disease is not significantly affected by calcium and vitamin D intake. While it is a common accompaniment to aging, there are still tangible actions that clients can take to slow the progression.
When assessing muscle tone and strength, the nurse would document expected findings as
"upper and lower extremity muscle strength is 5/5 bilaterally" Explanation: 5/5 (100%) normal muscle strength with complete ROM against gravity and full resistance.
How many vertebrae make up the spinal column?
33 7 cervical 12 thoracic 5 lumbar 5 sacral 4 coccyx
How would the nurse document normal muscle strength?
5/5 Explanation: Scale for grading muscle strength: muscle strength is graded on a 0 to 5 scale: 0: No muscular contraction detected 1: A barely detectable flicker or trace of contraction 2: Active movement of the body part with gravity eliminated 3: Active movement against gravity 4: Active movement against gravity and some resistance 5: Active movement against full resistance without evident fatigue. This is normal muscle strength.
A client visits the clinic and tells the nurse that she has joint pain in her hands, especially in the morning. The nurse should assess the client further for signs and symptoms of
Arthritis Explanation: Pain and stiffness in the joints is associated with arthritis.
When testing muscle strength, a client has difficulty moving her right arm against resistance. What would the nurse to do next?
Ask the client to move the part against gravity. Explanation: 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. What test would the nurse perform to confirm the suspicion?
Ballottement test Explanation: 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.
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.
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?
Calcitonin Explanation: 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.
Which nutrient deficiency should a nurse recognize as placing a client at risk for osteoporosis?
Calcium Explanation: 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.
A client waiting to be seen for a clinic appointment is observed periodically shaking the left wrist. On what should the nurse focus when assessing this client?
Carpal tunnel syndrome Explanation: A motion that resembles shaking a thermometer could indicate the presence of carpal tunnel syndrome. The wrist and hand would not be mobile if the limb is paralyzed. Moving the hand and wrist would produce excruciating pain if the wrist is fractured. The inability to extend the ring and little finger is associated with a Dupuytren contracture.
A nurse is providing health education about osteoporosis to a community group. What ethnicity is considered to be an independent risk factor for osteoporosis?
Caucasian Explanation: Caucasian ethnicity is a risk factor for osteoporosis. This is not true of the other listed ethnicities.
A client presents to the health care clinic with reports of onset of neck pain 3 days ago. The nurse recognizes that the most common cause of neck pain is what condition?
Cervical strain Explanation: 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.
A client complains of chronic pain and fatigue. The nurse suspects fibromyalgia. What is a diagnosis of this condition based on?
Client's symptoms Explanation: 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 Explanation: 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.
The nurse instructs the patient to raise his arm out to the side and overhead. The nurse is asking the patient to adduct his arm.
False Explanation:
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?
Fibromyalgia Explanation: The client has pain in specific trigger point areas on the muscles with normal strength and range of motion. This is an indication for fibromyalgia.
Joints may be classified as cartilaginous, synovial, or
Fibrous Explanation: The joint (or articulation) is the place where two or more bones meet. Joints provide a variety of ranges of motion (ROM) for the body parts and may be classified as fibrous, cartilaginous, or synovial.
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. Explanation: 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.
What range of motion is the nurse testing by asking a client to stoop to pick an object off the floor?
Flexion Explanation: 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.
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 Explanation: The knee joint is capable of flexion and extension. Circumduction, abduction, and internal rotation are motions associated with the shoulder or hip joint.
Which movement should the nurse instruct the client to perform to assess range of motion for the knee?
Flexion Explanation: 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.
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?
Flexion Supination Extension Explanation: When testing the range of motion of the elbow joint, the nurse would test flexion and extension, and supination and pronation of the forearm. Abduction, rotation, and circumduction would be tested in the shoulder or the hip.
The nurse is assessing the range of motion (ROM) of a patient's joints. What would the nurse use to assess flexion and extension of a joint if the patient complains of pain on examination?
Goniometer Explanation: If ROM is limited, use a goniometer to measure the angle of the joint at its maximum flexion and extension.
A patient presents at the clinic with an enlarged, swollen, hot, and red metatarsophalangeal joint and bursa of the great toe. What medical diagnosis would the nurse suspect?
Gouty arthritis Explanation: An enlarged, swollen, hot, reddened metatarsophalangeal joint and bursa of the great toe indicates gouty arthritis.
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 Explanation: 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.
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 Explanation: Tender, painful, reddened, hot, and swollen metatarsophalangeal joint in the great (big) toe is seen in gouty arthritis. This is an inflammatory condition caused by an abnormal buildup of uric acid in the body that becomes deposited in the joints. Rheumatoid arthritis can occur in any joint but usually affects the hands first. Verruca vulgaris (warts) is a painful wart that occurs under a callus. Degenerative joint disease does not typically cause the joints to be reddened and hot because it is not an inflammatory process.
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 Explanation: 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.
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. Explanation: 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.
A nurse is preparing a program on osteoporosis for a local women's group. What would the nurse cite as a risk factor?
History of smoking Explanation: Smoking is a risk factor for osteoporosis. Obesity, multiparity, and African-American ethnicity are not noted risk factors for this disease.
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 Explanation: This client is likely experiencing carpal tunnel syndrome because of the repetitive hand movements that inflame the median nerve as it passes through the wrist. Impaired Physical Mobility related to decreased muscle strength as evidenced by a weak right hand grip meets the major criteria to confirm this nursing diagnosis. Risk for Trauma cannot be confirmed because the client already has carpal tunnel syndrome so he is not at risk. Disturbed Body Image and Activity Intolerance do not meet any major defining characteristics to confirm these nursing diagnoses.
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 the Phalen's test and Tinel's tests 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 Explanation: This client is likely experiencing carpal tunnel syndrome because of the repetitive hand movements that inflame the median nerve as it passes through the wrist. Impaired Physical Mobility related to decreased muscle strength as evidenced by a weak right hand grip meets the major criteria to confirm this nursing diagnosis. Risk for Trauma cannot be confirmed because the client already has carpal tunnel syndrome so he is not at risk. Disturbed Body Image and Activity Intolerance do not meet any major defining characteristics to confirm these nursing diagnoses.
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?
Impaired physical mobility related to osteoporosis, Activity intolerance related to osteoporosis, and Risk for injury related to osteoporosis Explanation: 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 community health nurse is providing education to help reduce musculoskeletal injuries in adults. What should the nurse include in these instructions? (Select all that apply.)
Importance of regular exercise Using proper body mechanics with lifting objects Maintaining a body weight appropriate to height and frame Maintaining a safe home environment Explanation: Health promotion topics to prevent musculoskeletal injuries include engaging in regular exercise, maintaining a body weight appropriate to height and frame, using proper body mechanics with lifting or moving objects, and maintaining a safe home environment. Clients should not be told to limit dairy intake because this is a source of dietary calcium. Having the recommended daily intake of calcium can prevent risk factors for osteoporosis, therefore, musculoskeletal injuries.
The nurse is assessing an elderly client and finds an exaggerated thoracic curve. This would be documented as what?
Kyphosis Explanation: 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.
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) Explanation: 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.
A client has suffered a suspected rotator cuff tear. Which finding would the nurse expect during assessment?
Limited abduction Explanation: 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.
Increased lumbar curvature, which compensates for the enlarging uterus in pregnant women, is called what?
Lordosis Explanation: Lordosis, increased lumbar curvature, compensates for the enlarging uterus. Kyphosis, overcurvature of the spine in the thoracic and sacral spine, can result from arthritis, osteoporosis, or trauma. Scoliosis is a side to side curvature of the spine. Keracytosis is a skin disorder and a distracter for this question.
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 Explanation: 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 Explanation: 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 Explanation: 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 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. Explanation: 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.
When providing teaching to clients in the community, a nurse is accurate in stating that the musculoskeletal system is most closely aligned with which other body system?
Neurological system Explanation: The musculoskeletal system is enervated by the neurological system. Examination of the two systems are closely aligned.
What would the nurse interpret as a positive response to the Phalen test for a client suspected of having carpal tunnel syndrome?
Numbness Explanation: With Phalen's test, the client places the backs of both hands against each other while flexing the wrists 90 degrees downward. Complaints of numbness, tingling, and pain indicate a positive response, suggesting carpal tunnel syndrome. Atrophy of the thenar prominence would be seen with carpal tunnel syndrome but not associated with Phalen's test. Hard painless Bouchard nodes suggest osteroarthritis.
A female client visits the clinic and tells the nurse that she began menarche at the age of 16 years. The nurse should instruct the client that she is at a higher risk for
Osteoporosis. Explanation: Women who begin menarche late or begin menopause early are at greater risk for development of osteoporosis because of decreased estrogen levels, which tend to decrease the density of bone mass.
The client presents at the clinic with a history of cerebral palsy. When examining the patient the nurse notes increased resistance that is rate dependent and increases with rapid movement. What would the nurse chart about this patient?
Patient demonstrates spasticity Explanation: Spasticity is increased resistance that worsens at the extremes of range. Spasticity, seen in central corticospinal tract diseases, is rate dependent, increasing with rapid movement.
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?
Phalen's Explanation: 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.
A nurse is teaching a group of children about how to grow healthy bones and to prevent osteoporosis later in life. Which of the following should the nurse mention?
Playing outside in the sun for at least 20 minutes a day and drinking plenty of vitamin D-fortified milk Explanation: Exposure to sunlight, which is necessary for the manufacture of vitamin D in the body, is recommended to prevent deficiency in this nutrient and to thus help prevent osteoporosis. Likewise, intake of calcium and vitamin D by drinking fortified milk is also recommended. Wearing sunscreen when outdoors will help prevent sunburn but will not help prevent osteoporosis. Drinking plenty of water and eating a low-fat diet, while healthy, will also not help prevent osteoporosis.
Assessment reveals that an older adult client has osteomalacia. What would be most important to include in the client's teaching plan?
Practice risk prevention for fractures. Explanation: 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.
One of the functions of a bone is to
Produce blood cells. Explanation: Bones provide structure, give protection, serve as levers, store calcium, and produce blood cells.
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 Explanation: 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.
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 Explanation: Protraction is moving forward. Retraction is moving backward. Pronation is turning or facing downward. Supination is turning or facing upward. Pronation and supination are not possible at the TMJ.
A client visits the health care facility with reports of lumbar back pain that radiates down the back. The nurse performs Lasègue's test to determine the origin of the pain. Which techniques should the nurse use to perform Lasègue's test?
Raise the leg to the point of pain and dorsiflex the foot Explanation: To perform the Lasègue's test, the nurse should raise the client's leg to the point of pain and 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 Lasègue's test.
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 Explanation: In a complete tear of the supraspinatus tendon, or a rotator cuff tear, active abduction and forward flexion at the glenohumeral joint are severely impaired, producing a characteristic shrugging of the shoulder and a positive "drop arm" test. Rotator cuff tendonitis is characterized by acute, recurrent, or chronic pain of the supraspinatus tendon. Carpal tunnel syndrome effects the wrist and not the shoulder. Anterior dislocation of the humerus is characterized by the shoulder seeming to slip out of the joint.
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 Explanation: A lateral curvature of the spine with an increase in convexity on the side that is curved is seen in scoliosis.
A client has uneven height of the shoulders and hips. What should the nurse suspect this client is demonstrating?
Scoliosis Explanation: In scoliosis the shoulders and hips will have unequal height. There is an increase in the lumbar curvature in lordosis. There is an increase in the thoracic curvature in kyphosis. Sacroiliitis is associated with tenderness over the sacroiliac joint.
The subacromial bursae are contained in the
Shoulder joint Explanation: Articulation of the head of the humerus in the glenoid cavity of the scapula. The acromioclavicular joint includes the clavicle and acromion process of the scapula. It contains the subacromial and subscapular bursae.
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 Explanation: 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.
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 Explanation: 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.
Skeletal muscles are attached to bones by
Tendons Explanation: Skeletal muscles attach to bones by way of strong, fibrous cords called tendons.
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 Explanation: 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 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. Explanation: If the client has had a total hip replacement, do not test ROM unless the physician gives permission to do so, due to the risk of dislocating the hip prosthesis. A 1-year-old arm fracture is likely to have healed fully and would not normally affect the content of the assessment. Diabetes can affect various aspects of the musculoskeletal system, but it does not likely require the nurse to modify the assessment. Antihypertensives are unlikely to affect assessment.
The nurse is performing an assessment of a client's musculoskeletal system. What would the nurse examine first?
The client's gait Explanation: 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 Explanation: 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 Explanation: 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.
A nurse is testing the range of motion of a client's wrist for supination. Which movement will this involve?
Turning the palm of the hand upward Explanation: 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.
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 Explanation: 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.
The nurse is assessing a client's ability to shrug her shoulders against resistance. The nurse is assessing which cranial nerve?
XI Explanation: Inability to shrug shoulders against resistance suggests a lesion of cranial nerve XI (spinal accessory nerve). Cranial nerve III is involved with extraocular eye movements. Cranial nerve V is involved with facial sensation. Cranial nerve VII is associated with facial muscles.
While assessing the elbow of an adult client, the client complains of pain and swelling. The nurse should further assess the client for
arthritis Explanation: Redness, heat, and swelling may be seen with bursitis of the olecranon process due to trauma or arthritis.
A client has osteoarthritis of the elbow. Which assessment approach should the nurse expect to be impacted by this health problem?
flexion Explanation: A hinge joint provides movement in one plane such as flexion and extension. A ball and socket joint provides a wide range of movement including rotation, abduction, and adduction.
An adult client tells the nurse that he eats sardines every day. The nurse should instruct the client that a diet high in purines can contribute to
gouty arthritis Explanation: A diet high in purine (e.g., liver, sardines) can trigger gouty arthritis.
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 Explanation: The client should have full range of motion.