The Point: Chapter 24 Musculoskeletal
Asking the client to touch the chin to the chest evaluates
range of motion of the cervical spine.
Abduction
refers to moving away from the midline of the body.
Osteomalacia in children is known as
rickets
A nurse is instructing a client with gouty arthritis on foods to avoid that trigger this condition. Which of the following should the nurse mention? Select all that apply.
Sardines Liver A diet high in purine (e.g., liver, sardines) can trigger gouty arthritis.
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?" 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.
Synovial joints
(e.g., shoulders, wrists, hips, knees, ankles) contain a space between the bones that is filled with synovial fluid, a lubricant that promotes a sliding movement of the ends of the bones.
Raynaud's disease.
A change in color of the fingers from red to white (pale) is seen in clients with Raynaud's disease.
Which joint movement is a nurse testing when asking a client to move an extremity towards the body?
Adduction Adduction is the movement towards the midline of the body.
A nurse inspects a flattened lumbar curvature in a client. Which of the following conditions should the nurse most suspect in this client?
Ankylosing spondylitis A flattened lumbar curvature may be seen with a herniated lumbar disc or ankylosing spondylitis.
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.
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.
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
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?
Bulge If swelling is detected in the knee, the nurse should perform the bulge test to determine if the swelling is due to an accumulation of fluid or soft-tissue swelling. The bulge test will help to detect small amounts of fluid in the knee.
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.
A nurse is working with a client who has cervical disc degenerative disease with resulting impaired range of motion and pain that radiates to the back. The nurse understands that joints between the vertebrae are which type of joint?
Cartilaginous
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 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.
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.
Which characteristics should a nurse assess during inspection of the musculoskeletal system? Select all that apply.
Contour Color Masses Swelling Inspection is the technique of observation. The nurse should inspect the client's joints for shape, color, symmetry, masses, deformities, or muscle atrophy. Bilateral joint findings should be compared for any differences between sides of the body. Pain is rated by subjective data only. Passive range of motion requires the examiner to assist the client to move a joint through the motions.
A nurse is working with an older client who has osteoporosis. The nurse understands that osteoporosis is more common in older people for which of the following reasons? Select all that apply.
Decreased osteoblast production Decreased calcium absorption Increased bone resorption Osteoporosis is more common as a person ages because that is a time when bone resorption increases, calcium absorption decreases, and production of osteoblasts decreases as well. A
A nurse inspects a child's legs with the child standing and notices that the knees turn inward. How should this finding be documented in the medical record?
Genu valgum The inward turning of the knees is called knock knees or genu valgum.
Phalen's test is performed by
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.
An African American client appears to have lumbar lordosis present upon examination of the thoracic and lumbar spine. What should the nurse do in relation to this finding?
Document this as a normal cultural variation The nurse should document this as a normal finding. African Americans often have a large gluteal prominence, making the spine appear to have lumbar Lordosis. This finding is a normal variation and doe not need surgical intervention.
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 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.
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.
Which movement should the nurse instruct the client to perform to assess range of motion for the knee?
Flexion The nurse should instruct the client to perform flexion to assess the range of motion for the client's knee. The knees are capable of performing only flexion and extension.
Upon examination of an elderly client, the nurse finds hard, painless nodules over the distal interphalangeal joints. What is the appropriate term the nurse should use to document this finding in the client's medical records?
Heberden's nodes The nurse should document the hard, painless nodules over the distal interphalangeal joints as Heberden's nodes.
Severe weakness
If the client has only a slight flicker of contraction, muscle strength is classified as severe weakness.
Muscle strength is graded as 2 when
If the client is able to perform passive ROM,
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 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.
Poor ROM
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.
Which finding in an elderly client requires additional assessment by a nurse when inspecting the musculoskeletal system?
Inability to button the jacket due to swollen finger joints With aging, the joints and muscles lose their flexibility and bones loose their density. Therefore, the elderly client is at risk for joint stiffening, muscle atrophy, and fractures. Swelling of the joints may indicate an inflammatory process is occurring and this needs to be further assessed by the nurse.
Arthritis in the joints
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 nurse tells a client that the next step in the musculoskeletal assessment is to perform range of motion of the thoracic and lumbar spine. The nurse should demonstrate which movements for the client to facilitate the examination? Select all that apply.
Lateral bending Flexion Rotation To assess the range of motion of the thoracic and lumbar spine, the client should be shown the muscle movements of flexion, lateral bending (right and left), rotation (twisting the shoulders one way then the other), and bending backwards (hyperextension).
Lateral curvature of the thoracic spine with an
Lateral curvature of the thoracic spine with an increase in the convexity on the curved side is seen in scoliosis.
A client receives physical therapy for carpal tunnel syndrome. Which action by the nurse is appropriate to assess the efficacy of the treatment?
Place the backs of both hands against each other The nurse should ask the client to place the backs of both hands against each other while flexing the wrist 90 degrees downwards for 60 seconds for the Phalen's test.
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.
A nurse obtains an order to measure a client's leg length. How should a nurse correctly implement this order?
Measure from the anterior superior iliac spine to the medial malleolus To correctly measure leg length, ask the client to lie with legs extended. With a tape measure, measure the distance between the anterior superior iliac spine and the medial malleolus, crossing the tape on the medial side of the knee.
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.
A client presents to the health care clinic with a three (3) day history of fever, chills, neck pain and stiffness, and headache. The nurse observes an elevated temperature of 102.5° F and pain with rotation of the head side to side and decrease ability to flex the head forward. The nurse recognizes these findings as most likely the onset of what infectious process?
Meningitis Impaired range of motion and neck pain associated with fever, chills, and a headache may be indicative of a serious infection such as meningitis.
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.
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? Select all that apply.
Playing outside in the sun for at least 20 minutes a day Drinking plenty of vitamin D-fortified milk 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.
The nurse is working with a client who has leukemia, which affects the red marrow of the bones. The nurse understands that which of the following is characteristic of red marrow?
Produces red blood cells Bones contain red marrow that produces blood cells and yellow marrow composed mostly of fat.
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
Asking the client to bend the wrist down and back and performing wrist movements against resistance are done to assess
ROM and muscle strength
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
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?
Rotator cuff tear Painful and limited abduction accompanied by muscle weakness and atrophy are seen with rotator cuff tears. Rotator cuff tendinitis causes the client to report sharp catches of pain when bringing the hands overhead.
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?
The nurse should rate the muscle strength as 1.
Which of these medications should a nurse ask a client if they are taking when assessing the risk for osteoporosis?
Thyroid replacement drugs Corticosteroids Medications that may increase a client's risk for osteoporosis include corticosteroids, thyroid replacement drugs, seizure medications, and some drugs for gastrointestinal disorders.
A nurse is inspecting a client's gait. Which of the following would indicate an abnormal finding?
Toes point out Abnormal findings in gait include the following: uneven weight bearing is evident; client cannot stand on heels or toes; toes point in or out;
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
Normal findings with the elderly and muscle?
When muscle loss is symmetrical it is generally due to the normal aging process. A slow and steady gait assists the elderly client to maintain balance. Kyphosis is a normal finding in the elderly client.
Muscle rating 3 is given
When the client is able to perform active movements against gravity
Slight weakness
When the client is able to perform the active motion against some resistance, it is classified as slight weakness.
Asking the client to bring both hands in front of the body elicits
adduction
Asking the client to bend forward and touch the toes facilitates
assessment of range of motion of the lumbar spine.
The client's arms is at the sides when
at rest
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 her arms around the client to prevent a fall.
Flexion is
bending the extremity at the joint and decreasing the angle of the joint.
To assess abduction of the shoulders and arms, a nurse should ask a client to:
bring both hands together overhead To elicit abduction, the nurse should ask the client to bring both hands together overhead.
Vitamin C promotes
promotes healing of tissues and bones.
Excessive consumption of alcohol or caffeine and calcium deficiency can
can increase the risk of osteoporosis.
Compression fractures of the neck may also
cause loss of sensation in the legs if the spinal cord becomes compressed.
Cervical spinal cord compression causes n
causes neck pain with loss of sensation in the legs.
itamin D deficiency
causes osteomalacia, softening of the bones due to defective bone mineralization.
Falling backward easily is seen with
cervical spondylosis and Parkinson's disease.
Spongy bone
contains numerous spaces and makes up the ends and centers of the bones.
The periosteum
covers the bones and contains osteoblasts and blood vessels that promote nourishment and formation of new bone tissues.
Asking the client to stick out the tongue and move it from side to side tests
cranial nerve XII (hypoglossal nerve).
Palpation of the hollow area on the back of the wrist is
done to examine the anatomic snuffbox.
Asking the client to move the arms backward elicits
extension
Asking the client to move the arms forward elicits
flexion
Estrogen replacement therapy is often indicated
for females at risk for osteoarthritis when approaching menopause.
Swelling around the teeth and gums is seen with
gingivitis
Rheumatoid arthritis can occur
in any joint but usually affects the hands first.
Protein functions
in muscle tone and growth
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.
Ballottement
is a knee test used to assess for the presence of large amounts of fluid in the knee.
Verruca vulgaris (warts)
is a painful wart that occurs under a callus.
Bursitis
is an inflammation in the bursa (small sacs) of synovial fluid in the body.
Spondylitis
is an inflammation of the vertebra.
Compact bone
is hard and dense and makes up the shaft and outer layers
Arthritis
is inflammation or infection within a joint.
Abduction
is moving away from the midline of the body.
An exaggerated lumbar curve (lordosis) is often seen
is often seen in pregnancy or obesity.
Extension
is straightening the extremity at the joint and increasing the angle of the joint.
Cartilaginous joints
joints between vertebrae) are joined by cartilage.
Degenerative joint disease may cause
may cause limited range of motion for all of the shoulder movements and most likely occurs symmetrically.
Pain or clicking during the test is indicative
of a torn meniscus of the knee.
Bouchard's nodes are seen over
over the proximal interphalangeal joints.
A bone fracture
presents with acute, severe pain, and often weakness of the entire extremity.
The hand grips test
strength
Unequal heights of the hips suggest
suggest unequal leg lengths.
Fibrous joints (
sutures between skull bones) are joined by fibrous connective tissue and are immovable.
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.
Phalen's test is done to
test for carpal tunnel syndrome.
Circumduction
the circular motion of the joint.
If therapy for carpal tunnel syndrome has not been successful,
the client may report tingling, numbness, and pain after holding the position for 60 seconds.
The nurse asks the client to bend the wrists down and back to test
the client's range of motion for the wrist.
Clenching the teeth test
the integrity of cranial nerve V (trigeminal nerve).
Genu varum
the outward turning or the knees or bowed legs.
Painful corns are
thickenings of the skin that occur over bony prominences and at pressure points.
The ballottement test and the bulge test are done to
to detect the presence of fluid in the knee joint.
Degenerative joint disease does not
typically cause the joints to be reddened and hot because it is not an inflammatory process.
Muscle rating 4 is given
when the client is able to perform active motion against some resistance.
Cervical disc degenerative disease is associated
with impaired range of motion and pain that radiates to the back, shoulders, or arms.