Health Assessment: Assessing Musculoskeletal System – Flashcards
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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? a) McMurray's b) Ballottement c) Phalen's d) Bulge
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Correct response: 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 carpal tunnel syndrome. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 24: Assessing Musculoskeletal System, p. 534.
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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? a) Trigeminal neuralgia b) Temporal arteritis c) Tumour of the mandible d) Temporomandibular joint syndrome
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Correct response: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 24: Assessing Musculoskeletal System, p. 513.
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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? a) Effusion in the knee joint b) Crepitus uteri flexion c) Osteoarthritis d) Ligament trauma
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Correct response: Effusion in the knee joint Explanation: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 24: Assessing Musculoskeletal System, p. 533.
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A school age client has been diagnosed with genu valgum. What is the other name for this disease? a) Clubfoot b) Flatfeet c) Knock kneed d) Bowlegs
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Correct response: Knock kneed Explanation: Many children have a temporary period of genu valgum, but persistent knock knee may be genetic or the result of metabolic bone disease. The client may need to swing each leg outward while walking to prevent striking the planted limb with the moving limb. The strain on the knee frequently causes anterior and medial knee pain. Physical therapy and surgical intervention may be required. Bowlegs, also known as genu varum, the knees do not touch when the child stands with the feet together. Bowlegs is consider normal up to the age of 2 to 3 years, but may persist until age 6. Clubfoot, also known as congenital talipes equinovarus (CTEV), is a congenital deformity that rotates the foot internally at the ankle. Flatfeet, a deformity of the foot where the arch collapses or never properly forms. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 24: Assessing Musculoskeletal System, p. 533.
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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? a) Rheumatoid arthritis b) Verruca vulgaris (warts) c) Gouty arthritis d) Degenerative joint disease
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Correct response: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 24: Assessing Musculoskeletal System, p. 535.
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Which action by a nurse is a correct method for performing Tinel's test to determine the presence of carpel tunnel syndrome? a) Ask the client to bend the wrist down and back b) Palpate the hollow area on the back of the wrist c) Percuss lightly on the inner aspect of the wrist d) Perform wrist movements against resistance
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Correct response: Percuss lightly on the inner aspect of the wrist Explanation: 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. Palpation of the hollow area on the back of the wrist is done to examine the anatomic snuffbox. Asking the client to bend the wrist down and back and performing wrist movements against resistance are done to assess range of motion and muscle strength. (less) Reference: Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 24: Assessing Musculoskeletal System, p. 528.
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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. a) Increased incidence of arthritis b) Increased bone resorption c) Increased sun exposure d) Decreased osteoblast production e) Decreased calcium absorption f) Decreased intake of vitamin K
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Correct response: • Increased bone resorption • Decreased calcium absorption • Decreased osteoblast production Explanation: 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. Arthritis is not a risk factor for osteoporosis. It is not established that decreased intake of vitamin K or increased sun exposure are associated with advancing age, and even if it were, these are not risk factors associated with osteoporosis. (less) Reference: Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 24: Assessing Musculoskeletal System, p. 514.
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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? a) Pronation b) Retraction c) Supination d) Protraction
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Correct response: 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. (less) Reference: Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 24: Assessing Musculoskeletal System, p. 507.
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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? a) Tinel's b) Ballottement c) McMurray's d) Phalen's
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Correct response: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 24: Assessing Musculoskeletal System, p. 528.
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When assessing a client's strength, it is necessary to a) Compare upper and lower extremities b) Assess the extremities at the same time c) Assess upper and lower extremities at the same time d) Compare one side to the other
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Correct response: Compare one side to the other Explanation: When assessing muscle tone and strength, it is necessary to compare one side to the other. It is not necessary to compare the upper extremities to the lower extremities or to assess the upper and lower extremities. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 24: Assessing Musculoskeletal System, p. 518.
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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? a) Cervical disc degenerative disease b) Cervical strain c) Compression fractures d) Cervical spinal cord compression
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Correct response: 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. (less) Reference: Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 24: Assessing Musculoskeletal System, p. 521.
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A nurse is inspecting a client's gait. Which of the following would indicate an abnormal finding? a) Weight is evenly distributed b) Toes point out c) Arms swing in opposition d) Posture is erect
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Correct response: Toes point out Explanation: Abnormal findings in gait include the following: uneven weight bearing is evident; client cannot stand on heels or toes; toes point in or out; client limps, shuffles, propels forward, or has wide-based gait. Posture being erect, arms swinging in opposition, and weight being evenly distributed are all normal findings. (less) Reference: Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 24: Assessing Musculoskeletal System, p. 519.
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The nurse is assessing a client with joint pain and is trying to decide whether it is inflammatory or non-inflammatory. Which of the following symptoms is consistent with an inflammatory process? a) Cool temperature b) Ecchymosis c) Nodules d) Tenderness
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Correct response: Tenderness Explanation: Tenderness implies an inflammatory process along with increased temperature. Nodules and ecchymosis are not typically associated with inflammatory processes. (less) Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 26: Musculoskeletal System, pp. 542-543.
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A college age athlete presents to the clinic with pain in the tibiotalar joint. It is a hinge joint limited to flexion and extension. The terms used to describe these movements are what? a) Supination and pronation b) Adducting and abducting c) Dorsiflexion and plantar flexion d) Rotation and supination
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Correct response: Dorsiflexion and plantar flexion Explanation: The terms used to describe the movements of the tibiotalar joint are dorsiflexion and plantar flexion. Adducting means to move a part of the body toward the midline. Abducting is moving a part of the body away from the midline. Supination is a motion where the foot or palm of the hand is moved to a surface up position. Pronation is a motion where the foot or palm of the hand is moved to a surface down position. Rotation is simply the movement of the joint. Rotation could be either internal or external in nature. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 24: Assessing Musculoskeletal System, p. 513.
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On inspection of the spine of a 79-year-old man, the nurse might expect to find a(n) a) increased thoracic curve b) decreased lumbar curve c) decreased cervical curve d) increased cervical curve
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Correct response: increased thoracic curve Explanation: An exaggerated thoracic curve (kyphosis)is common with aging. Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 24: Assessing Musculoskeletal System, p. 520.
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Which nutrient deficiency should a nurse recognize as placing a client at risk for osteoporosis? a) Calcium b) Protein c) Vitamin D d) Vitamin C
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Correct response: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 24: Assessing Musculoskeletal System, p. 517
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What range of motion is the nurse testing by asking a client to stoop to pick an object off the floor? a) Flexion b) Abduction c) Extension d) Rotation
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Correct response: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 24: Assessing Musculoskeletal System, p. 534.
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What is an appropriate question by the nurse to ask a client about the presence of temporomandibular joint dysfunction? a) "Do you notice any swelling around the teeth or gums?" b) "Have you noticed a popping or grating sound when you chew?" c) "Can you fully clench your teeth and feel the muscles in your jaw tense?" d) "Please stick out your tongue sand move it from side to side"
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Correct response: "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). (less) Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 26: Musculoskeletal System, p. 532.
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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? a) Ask the client to raise the leg to the point of pain and then dorsiflex the foot b) Instruct the client to bend forward and touch the toes c) Instruct the client to touch the chin to the chest d) Palpate the spinous processes and the paravertebral muscles
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Correct response: Ask the client to raise the leg to the point of pain and then dorsiflex the foot Explanation: 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. (less) Reference: Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 24: Assessing Musculoskeletal System, p. 523.
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Assessment of a client's ankle joint includes palpation along the Achilles tendon to look for which of the following? a) Tenderness and nodules b) Tension and strength c) Bogginess and calluses d) Atrophy and flexibility
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Correct response: Tenderness and nodules Explanation: Palpation of the Achilles tendon involves assessing for tenderness or nodules. Strength and flexibility are not assessed during palpation, and calluses and bogginess are not typically associated with the Achilles tendon. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 24: Assessing Musculoskeletal System, p. 519.
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A 50-year-old man has sought care because of the intense shoulder pain that resulted when he threw a baseball to home plate from the outfield the previous evening. The client states that he has never had problems with his shoulder previously. The nurse has asked to client to slowly abduct his affected arm to shoulder level and maintain the position. Which of the following shoulder problems does the nurse suspect? a) Bicipital tendinitis b) Rotator cuff tear c) Calcific tendinitis d) Adhesive capsulitis
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Correct response: Rotator cuff tear Explanation: A rotator cuff tear is often the result of a strong, single throwing motion and is assessed for using the drop arm test. Calcific tendinitis, adhesive capsulitis, and bicipital tendinitis are degenerative diseases that typically have a more gradual onset. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 24: Assessing Musculoskeletal System, p. 524.
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Risk factors in which of the following areas are most readily changed to reduce the potential risk for falls? a) Environmental b) Cognitive c) Social d) Physiological
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Correct response: Environmental Explanation: While adapting individuals' social, cognitive, and physiological circumstances can present challenges, modifications to address environmental threats to safety can often be made mo... (more) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 24: Assessing Musculoskeletal System, p. 515.
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A nurse is testing the range of motion of a client's wrist for supination. Which movement will this involve? a) Moving the tips of the fingers away from the forearm b) Turning the palm of the hand downward c) Moving the tips of the fingers toward the forearm d) Turning the palm of the hand upward
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Correct response: 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. (less) Reference: Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 24: Assessing Musculoskeletal System, p. 507.
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Which movement should the nurse instruct the client to perform to assess range of motion for the knee? a) Flexion b) Circumduction c) Rotation d) Abduction
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Correct response: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 24: Assessing Musculoskeletal System, p. 535.
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Which joint movement is a nurse testing when asking a client to move an extremity towards the body? a) Extension b) Abduction c) Flexion d) Adduction
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Correct response: Adduction Explanation: Adduction is the movement towards the midline of the body. Flexion is bending the extremity at the joint and decreasing the angle of the joint. 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 24: Assessing Musculoskeletal System, p. 507.
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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? a) Cervical disc degenerative disease b) Cervical spinal cord compression c) Cervical strain d) Compression fractures
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Correct response: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 24: Assessing Musculoskeletal System, p. 521
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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 a) turn the palm down b) straighten the elbow c) turn the palm up d) bend the elbow
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Correct response: straighten the elbow Explanation: The client should have full range of motion. Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 24: Assessing Musculoskeletal System, p. 526.
