Chapter 23 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 23

Question 1

Type: MCSA

The nurse is caring for a client with a right femur fracture. The nurse would correctly identify the femur as which of the following bone types?

1. Short

2. Long

3. Flat

4. Irregular

Correct Answer: 2

Rationale 1: Bones are classified according to shape and composition. Short bones include the carpals and tarsals.

Rationale 2: Bones are classified according to shape and composition. Long bones include the femur and humerus.

Rationale 3: Bones are classified according to shape and composition. Flat bones include the parietal skull bone and sternum.

Rationale 4: Bones are classified according to shape and composition. Irregular bonea include the vertebrae and hips.

Global Rationale: Bones are classified according to shape and composition. Long bones include the femur and humerus; short bones include the carpals and tarsals; flat bones include the parietal skull bone and sternum; and irregular bones include the vertebrae and hips.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23.1: Describe the anatomy and physiology of the bones, muscles, and joints.

Question 2

Type: MCMA

The client is recovering from orthopedic surgery on a fractured arm. The nurse realizes that skeletal muscles provide which of the following functions?

Standard Text: Select all that apply.

1. Provide a body framework

2. Provide movement

3. Maintain posture

4. Generate heat

5. Calcium storage

Correct Answer: 2,3,4

Rationale 1: Provide a body framework. Skeletal muscles provide movement, maintain posture, and generate heat. Skeletal muscles do not provide a framework for the body. The bones of the skeleton provide a framework and store minerals such as calcium and phosphorus.

Rationale 2: Provide movement. Skeletal muscles provide movement, maintain posture, and generate heat.

Rationale 3: Maintain posture. Skeletal muscles provide movement, maintain posture, and generate heat.

Rationale 4: Generate heat. Skeletal muscles provide movement, maintain posture, and generate heat.

Rationale 5: Calcium storage. Skeletal muscles do not provide a framework for the body nor do they store minerals such as calcium. The bones of the skeleton provide a framework and store minerals such as calcium and phosphorus.

Global Rationale: Skeletal muscles provide movement, maintain posture, and generate heat. Skeletal muscles do not provide a framework for the body nor do they store minerals such as calcium. The bones of the skeleton provide a framework and store minerals such as calcium and phosphorus.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23.1: Describe the anatomy and physiology of the bones, muscles, and joints.

Question 3

Type: MCSA

The clients chief complaint is pain in the foot. The nurse notes a deviation of the great toe from the midline and crowding of the remaining toes. There is enlargement and inflammation noted in the area. The nurse would suspect which of the following conditions in this situation?

1. Flat foot

2. Gouty arthritis

3. Hammertoe

4. Bunion

Correct Answer: 4

Rationale 1: In pes planus, or flat foot, the arch of the foot is flattened, sometimes coming in contact with the floor.

Rationale 2: The toes are common sites for gouty arthritis. In this condition the metarsolphlangeal joint of the toe is swollen, hot, red, and extremely painful. There is no deviation of the toes.

Rationale 3: Hammertoe produces flexion of the proximal interphalangeal joint of a toe. The distal metarsophalalgeal joint hyperextends.

Rationale 4: A hallux valgus, or bunion, causes a deviation of the great toe from the midline, and crowding of the remaining toes. This crowding results in deviation. The metatarsophalangeal joint and bursa become enlarged and inflamed.

Global Rationale: A hallux valgus, or bunion, causes a deviation of the great toe from the midline, and crowding of the remaining toes. The metatarsophalangeal joint and bursa become enlarged and inflamed. In pes planus, or flat foot, the arch of the foot is flattened, sometimes coming in contact with the floor. Hammertoe produces flexion of the proximal interphalangeal joint of a toe, while the distal metatarsophalalgeal joint hyperextends. In gouty arthritis the metatarsophalangeal joint of the great toe is swollen, hot, red, and extremely painful.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 23.2: Discuss the directional movements of the joints.

Question 4

Type: MCSA

The nurse asks the client to pull the toes up towards the nose during an examination of the lower extremities. The nurse is assessing which of the following movements?

1. Inversion

2. Plantar flexion

3. Eversion

4. Dorsiflexion

Correct Answer: 4

Rationale 1: Inversion is the movement of pointing the sole of the foot inward.

Rationale 2: Plantar flexion is the movement of pointing the toes toward the floor.

Rationale 3: Eversion is the movement of pointing the sold of the food outward.

Rationale 4: Dorsiflexion is the moement of pulling the toes upward toward the nose.

Global Rationale: Dorsiflexion is the movement of pulling the toes upward toward the nose. Plantar flexion is the movement of pointing the toes toward the floor. Eversion is the movement of pointing the sole of the foot outward. Inversion is the movement of pointing the sole of the foot inward.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23.2: Discuss the directional movements of the joints.

Question 5

Type: MCMA

The student nurse is assessing the clients lateral flexion. Which of the following instructions by the student to the client indicates the need for further instruction?

Standard Text: Select all that apply.

1. Tilt your head back and look at the ceiling.

2. Lean your head to the side and attempt to touch your ear to your shoulder.

3. Touch your chin to your chest.

4. Attempt to raise your shoulders up toward your ears.

5. Attempt to rotate your head in a circular manner.

Correct Answer: 1,3,4,5

Rationale 1: Tile your head back and look at the ceiling. Tilting the head back and looking toward the ceiling is an example of hyperflexion.

Rationale 2: Lean your head to the side and attempt to touch your ear to your shoulder. Lateral flexion can be assessed by tilting the head to each shoulder with the ear from the same side.

Rationale 3: Touch your chin to your chest. Flexion refers to movements that reduce the angle. Touching the chin to the chest would be an example of flexion.

Rationale 4: Attempt to raise your shoulders up toward your ears. Flexibility and mobility may be assessed by asking the client to raise and lower the shoulders but are not examples of methods to assess lateral flexion.

Rationale 5: Attempt to rotate your head in a circular manner. Flexibility and mobility may be assessed by asking the client to rotate the head but it is not an example of methods of lateral flexion.

Global Rationale: Lateral flexion of the head is attempted by touching each shoulder of the ear on the same side. Tilting the head back to look at the ceiling would be an example of hyperflexion. Touching the chin to the chest would assess flexion. Raising the shoulders toward the ears and rotating the head are methods to assess mobility and flexibility of the client but do not demonstrate lateral flexion.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 23.2: Discuss the directional movements of the joints.

Question 6

Type: MCSA

The nurse is caring for a client with a knee injury. The nurse would correctly identify the knee as which of the following joint types?

1. Saddle

2. Hinge

3. Pivot

4. Plane

Correct Answer: 2

Rationale 1: Saddle joints consist of an articulating bone having both concave and convex areas (resembling a saddle). The opposing surfaces fit together. The carpometacarpal joints of the thumbs are an example.

Rationale 2: In hinge joints, a convex projection of one bone fits into a concave depression in another. Motion is similar to that of a mechanical hinge. These joints permit flexion and extension only. Examples include the elbow and knee joints.

Rationale 3: In pivot joints, the rounded end of one bone protrudes into a ring of bone (and possibly ligaments). The only movement allowed is rotation of the bone around its own long axis or against the other bone. An example is the joint between the atlas and axis of the neck.

Rationale 4: In plane joints, the articular surfaces are flat, allowing only slipping or gliding movements. Examples include the intercarpal and intertarsal joints, and the joints between the articular processes of the ribs.

Global Rationale: The knee and elbows are hinge joints; the thumbs are saddle joints; the neck is a pivot joint; the intercarpals and intertarsals are plane joints.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23.2: Discuss the directional movements of the joints.

Question 7

Type: MCHS

The nurse is preparing to assess the posterior spine of a client. The nurse prepares to identify the iliac crest to determine symmetry. Identify the location of the iliac crest.

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Screen Shot 2015-09-24 at 12.43.51 PM

Correct Answer:

Rationale : The iliac crests are used as landmarks on the posterior spine. They are used to assess for symmetry.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23.4: Describe the techniques required for assessment of the musculoskeletal system.

Question 8

Type: HOTSPOT

The nurse is caring for a client with an injury to the arm. To check the client ability to move the nurse directs the client to pronate the hand. Indicate the side of the table that arm should be rotated towards.

Screen Shot 2015-09-24 at 12.44.23 PM

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : Pronation is a rotational movement of the radius around the ulna. It will result in the rotation of the hand and forearm so that the palm surface is facing downward to a posterior or inferior position.

Global Rationale:

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23.4: Describe the techniques required for assessment of the musculoskeletal system.

Question 9

Type: HOTSPOT

The school nurse is providing an educational meeting with a group of teenaged girls. The nurse is discussing the assessment for scoliosis. Use the diagram below to shade the area of the spine that will be assessed for the condition.

Screen Shot 2015-09-24 at 12.45.10 PM

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : Scoliosis is a screening frequently completed on teenaged girls. Scoliosis is the abnormal curvature of the thoracic spine.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23.4: Describe the techniques required for assessment of the musculoskeletal system.

Question 10

Type: HOTSPOT

The nurse is performing the bulge test on a clients left knee. Circle the area in which the nurse will need to assess for bulges when applying pressure.

Screen Shot 2015-09-24 at 12.45.50 PM

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The bulge sign can be assessed to check for the presence of fluid. If fluid is present there will be a bulging on the medial side. To perform the test, assist the client to a supine position. Use firm pressure to stroke the medial aspect of the knee upward several times displacing any fluid. Next apply pressure to the lateral side of the knee while observing the medial side. In a normal test no fluid is present.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23.4: Describe the techniques required for assessment of the musculoskeletal system.

Question 11

Type: MCMA

A client comes to the emergency department complaining of a painful injury to the right knee received while playing basketball. The nurse would include which of the following in the examination of this client?

Standard Text: Select all that apply.

1. Inspection

2. Palpation

3. Bulge sign testing

4. Ballottement

5. Percussion

Correct Answer: 1,2,3,4

Rationale 1: Inspection. The nurse would visually inspect the knees general appearance including the presence or redness, swelling and dislocation. The knees appearance would be contrasted with the unaffected knee.

Rationale 2: Palpation. The area would be palpated for tenderness and warmth.

Rationale 3: Bulge sign testing. The bulge sign test is used to detect the presence of small amounts of fluid (4 to 8 ml) in the suprapatellar bursa. The test involves placing the client in the supine position and then using firm pressure to stroke the medial aspect of the knee upward several times, displacing any fluid. As the pressure is applied to the lateral side of the knee the medial side is observed for bulging.

Rationale 4: Ballottement. Ballottement is a technique used to detect fluid, or to examine or detect floating body structures. The nurse displaces body fluid and then palpates the return impact of the body structure.

Rationale 5: Percussion. Percussion is the use of tapping actions by the examiner. This tapping elicits sounds that can be evaluated for tone and depth to detect the presence of abnormalities. Percussion is normally utilized to assess the lungs and abdominal cavity. It is not used to assess for knee injuries.

Global Rationale: The assessment of a client presenting with an injury to the knee would include inspection, palpation, bulge sign testing, and ballottement. The nurse would visually inspect the knees general appearance, including the presence or redness, swelling and dislocation. The knees appearance would be contrasted with the unaffected knee. The area would be palpated for tenderness and warmth. Ballottement is a technique used to detect fluid, or to examine or detect floating body structures. The nurse displaces body fluid and then palpates the return impact of the body structure. The bulge sign test is used to detect the presence of small amounts of fluid (4 to 8 ml) in the suprapatellar bursa. The test involves placing the client in the supine position and then using firm pressure to stroke the medial aspect of the knee upward several times, displacing any fluid. As the pressure is applied to the lateral side of the knee the medial side is observed for bulging. Percussion is the use of tapping actions by the examiner. This tapping elicits sounds that can be evaluated for tone and depth to detect the presence of abnormalities. Percussion is normally utilized to assess the lungs and abdominal cavity. It is not used to assess for knee injuries.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 23.4: Describe the techniques required for assessment of the musculoskeletal system.

Question 12

Type: MCSA

The nurse is preparing to assess a clients spine for abnormalities. The nurse would ask the client to do which of the following steps to gather the most information with this assessment?

1. Sit down, then stand as the nurse looks from the front of the client.

2. Stand, bend back slowly, then to the right and left while the nurse looks from the back.

3. Bend over, stand tall, and stretch arms over the head.

4. Sit down, then lean forward and dangle the arms at the sides of the body.

Correct Answer: 2

Rationale 1: The client should be asked to stand during this assessment. This will allow the nurse to assess for symmetry.

Rationale 2: The spine should be visually inspected by viewing the back of the client. The client should be asked to stand during this assessment. This will allow the nurse to assess for symmetry. The spine should appear straight when viewed from the back.

Rationale 3: Bending and stretching will not illicit the needed information about the spine. Range of motion and flexibility may be assessed by asking the client to bend over or stretch.

Rationale 4: The spine is assessed by asking the client to stand. The nurse will then visually assess the client from the back.

Global Rationale: The spine should be visually inspected by viewing the back of the client. The client should be asked to stand during this assessment. This will allow the nurse to assess for symmetry. The spine should appear straight when viewed from the back. The cervical and lumbar spine should appear concave, and the thoracic spine should appear convex. Range of motion and flexibility may be assessed by asking the client to bend over or stretch.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23.4: Describe the techniques required for assessment of the musculoskeletal system.

Question 13

Type: MCSA

The clients chief complaint is numbness and tingling in the hands when interviewed by the nurse. The client complains of numbness and tingling in the arms when bending the wrist downward and pressing the backs of the hands together. The nurse would suspect which of the following conditions in this situation?

1. Arthritis of the wrists

2. Carpal tunnel syndrome

3. Crepitus of the wrists

4. Dupuytrens contracture

Correct Answer: 2

Rationale 1: Arthritis typically causes pain and limitations in movement but not numbness and tingling.

Rationale 2: Carpal tunnel is a condition caused by compression of the median nerve. The test described is called Phalens test, and when used on individuals with carpal tunnel syndrome, 80 percent experience pain, tingling, and numbness that radiates to the arm, shoulder, neck, or chest within 60 seconds. Another assessment for carpal tunnel syndrome is called Tinels sign, and is elicited by percussing lightly over the median nerve in each wrist. The test is positive if the client feels numbness, tingling, and pain along the median nerve.

Rationale 3: Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative disease, trauma, or inflammatory conditions.

Rationale 4: Dupuytrens contracture involves inability to extend the fourth and fifth fingers but is a painless, inherited disorder.

Global Rationale: Carpal tunnel is a condition caused by compression of the median nerve. The test described is called Phalens test, and when used on individuals with carpal tunnel syndrome, 80 percent experience pain, tingling, and numbness that radiates to the arm, shoulder, neck, or chest within 60 seconds. Another assessment for carpal tunnel syndrome is called Tinels sign, and is elicited by percussing lightly over the median nerve in each wrist. The test is positive if the client feels numbness, tingling, and pain along the median nerve. Arthritis typically causes pain and limitations in movement but not numbness and tingling. Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative disease, trauma, or inflammatory conditions. Dupuytrens contracture involves inability to extend the fourth and fifth fingers but is a painless, inherited disorder.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 23.4: Describe the techniques required for assessment of the musculoskeletal system.

Question 14

Type: MCSA

The clients chief complaint is inability to move the fourth and fifth fingers during the nurses interview. The nurse notes severe flexion in both of the affected fingers and upon palpation, but there are no complaints of pain from the client. The nurse would suspect which of the following conditions in this situation?

1. Dupuytrens contracture

2. Carpal tunnel syndrome

3. Bursitis

4. Osteoarthritis

Correct Answer: 1

Rationale 1: Dupuytrens contracture involves inability to extend the fourth and fifth fingers, but is a painless, inherited disorder.

Rationale 2: Carpal tunnel is a condition caused by compression of the median nerve. In carpal tunnel syndrome the client feels numbness, tingling, and pain in the hands and wrists.

Rationale 3: Bursitis involves inflammation of the bursae. The condition is manifested by redness, warmth, swelling, and tenderness.

Rationale 4: Osteoarthritis is the degeneration of the joints. The condition typically causes pain and limitations in movement, but not numbness and tingling.

Global Rationale: Dupuytrens contracture involves inability to extend the fourth and fifth fingers, but is a painless, inherited disorder. Carpal tunnel is a condition caused by compression of the median nerve. In carpal tunnel syndrome the client feels numbness, tingling, and pain in the hands and wrists. Bursitis involves inflammation of the bursae. The condition is manifested by redness, warmth, swelling, and tenderness. Osteoarthritis is the degeneration of the joints. The condition typically causes pain and limitations in movement, but not numbness and tingling.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system.

Question 15

Type: MCSA

A young adult is seen in the clinic complaining of a lump the left wrist, but states it is not painful. The nurse notes a round mass on the back of the wrist. The nurse would suspect which of the following?

1. Rheumatoid arthritis

2. Osteoarthritis

3. Ganglion

4. Carpal tunnel syndrome

Correct Answer: 3

Rationale 1: Rheumatoid arthritis is an autoimmune disorder that presents with pain and tenderness in the joints. The condition may affect numerous joints. It is a systematic condition in which other body parts may be impacted in varying degrees.

Rationale 2: Osteoarthritis is a condition in which the joints degenerate. The potential causes may include obesity, trauma, and occupational stressors. Joint pain with use/exercise is the chief symptom of osteoarthritis. It is commonly seen in the hips, knees, and hands.

Rationale 3: A ganglion is a painless, round, fluid-filled mass. It arises from the tendon sheaths on the dorsum of the wrist and hand. It may be painful.

Rationale 4: Carpal tunnel syndrome results from compression of the median nerve. It may be associated with occupations requiring repetitive tasks and pregnancy. It may begin with numbness and tingling in the hands and fingers. Over time the condition may advance toward an inability to grasp objects.

Global Rationale: The findings describe a ganglion, a painless, round, fluid-filled mass that arises from the tendon sheaths on the dorsum of the wrist and hand. Rheumatoid arthritis is an autoimmune disorder that presents with joint pain and tenderness. The joint regions may exhibit warmth and swelling. Osteoarthritis is a condition in which the joints degenerate. The condition manifests with joint pain and stiffness. Carpal tunnel syndrome results from compression of the median nerve. It manifests with discomfort in the wrist and potentially the reduction in the ability to grasp objects.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system.

Question 16

Type: MCSA

The nurse assesses a client and finds that a grating sound is present when a joint is bent and straightened. The nurse would correctly document this finding as which of the following?

1. Subluxation

2. Grinding

3. Crepitation

4. Joint dislocation

Correct Answer: 3

Rationale 1: Subluxation refers to a partial joint location.

Rationale 2: Grinding sounds may be heard or felt with musculoskeletal disorders but it is not appropriate medical terminology.

Rationale 3: Crepitation is the medical term used to describe the grating sounds a joint makes when the articulating surfaces have lost their cushioning cartilage.

Rationale 4: There is inadequate information to determine the joint is indeed dislocated.

Global Rationale: It is important to use proper terminology when reporting findings. Crepitation is the proper term when a grating sound is present in a joint. Crepitation results when the joint articulating surfaces have lost their cartilage. Subluxation refers to a partial joint dislocation. There is inadequate information to determine if the joint is dislocated.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system.

Question 17

Type: MCSA

The clients chief complaint is tenderness and stiffness in the wrist and elbow when interviewed by the nurse. The client reports the discomfort is worsened with activity. The nurse would suspect which of the following conditions in this situation?

1. Carpal tunnel syndrome

2. Osteoarthritis

3. Crepitus of the wrists

4. Dupuytrens contracture

Correct Answer: 2

Rationale 1: Carpal tunnel syndrome is caused by compression of the median nerve.

Rationale 2: Arthritis typically causes pain and limitations in movement, but not numbness and tingling.

Rationale 3: Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative joint disease, trauma, or inflammatory conditions.

Rationale 4: Dupuytrens contracture involves inability to extend the fourth and fifth fingers, but is a painless, inherited disorder.

Global Rationale: Osteoarthritis is also known as degenerative joint disease. It is associated with pain and stiffness of the joints. Carpal tunnel syndrome is caused by compression of the median nerve. Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative joint disease, trauma, or inflammatory conditions. Dupuytrens contracture involves inability to extend the fourth and fifth fingers, but is a painless, inherited disorder.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system.

Question 18

Type: MCSA

The nurse notes full range of motion against gravity with moderate resistance when assessing muscle strength of the upper extremities in a client. The nurse would correctly document which of the following choices?

1. Poor

2. Normal

3. Fair

4. Good

Correct Answer: 4

Rationale 1: Full range of motion against gravity with full resistance is considered normal muscle strength, also rated a 5. A rating of poor, or a 1, would be the presence of palpable muscle contraction with no movement.

Rationale 2: Full range of motion against gravity with full resistance is considered normal muscle strength, also rated a 5.

Rationale 3: Full range of motion against gravity with full resistance is considered normal muscle strength, also rated a 5. A rating of fair, or a 3, would be full range of motion with gravity.

Rationale 4: Full range of motion against gravity with full resistance is considered normal muscle strength, also rated a 5. A rating of good, or a 4, would be full range of motion against gravity with moderate resistance.

Global Rationale: Full range of motion against gravity with full resistance is considered normal muscle strength, also rated a 5. A rating of poor, or a 1, would be the presence of palpable muscle contraction with no movement. A rating of good, or a 4, would be full range of motion against gravity with moderate resistance. A rating of fair, or a 3, would be full range of motion with gravity. A rating of poor, or a 2, would be full range of motion without gravity, or passive motion.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system.

Question 19

Type: MCSA

The nurse notes swelling and tenderness of the olecranon process during palpation. The clients chief complaint is pain upon movement of the forearm and wrist. The nurse would correctly suspect which of the following conditions in this situation?

1. Arthritis

2. Bursitis

3. Epicondylitis

4. Crepitus

Correct Answer: 3

Rationale 1: Rheumatoid arthritis may result in nodules in the olecranon bursa or along the extensor surface of the ulna. Nodules are firm, nontender, and not attached to the overlying skin.

Rationale 2: Bursitis is characterized by a painful, inflamed warm area.

Rationale 3: Lateral epicondylitis, also called tennis elbow, results from constant, repetitive movements of the wrist and/or forearm. Pain occurs when the client attempts to extend the wrist against resistance. Medial epicondylitis, also called pitchers or golfers elbow, results from constant, repetitive flexion of wrist. Pain occurs when the client attempts to flex the wrist against resistance.

Rationale 4: Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative disease, trauma, or inflammatory conditions.

Global Rationale: Lateral epicondylitis, also called tennis elbow, results from constant, repetitive movements of the wrist and/or forearm. Pain occurs when the client attempts to extend the wrist against resistance. Medial epicondylitis, also called pitchers or golfers elbow, results from constant, repetitive flexion of wrist. Pain occurs when the client attempts to flex the wrist against resistance. Rheumatoid arthritis will typically produce nontender nodules along the extensor surface of the ulna. Bursitis is characterized by a painful area of inflammation. Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative disease, trauma, or inflammatory conditions.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system.

Question 20

Type: MCSA

The nurse notes an exaggerated lumbar curve while inspecting the spine of a client. The nurse would correctly document which of the following choices?

1. Lordosis

2. Scoliosis

3. Kyphosis

4. Flattened curve

Correct Answer: 1

Rationale 1: Lordosis is an exaggerated lumbar curve and is often present in pregnancy, obesity, or other skeletal changes. The spine leans to the left or right in a list, and a line drawn from the thoracic one vertebrae does not fall between the gluteal cleft.

Rationale 2: Scoliosis results when the spine curves to the right or left. It is noted in the thoracic region.

Rationale 3: Kyphosis is an exaggerated thoracic dorsal curve resulting in asymmetry between the sides of the posterior thorax.

Rationale 4: A flattened lumbar curve is a concave curvature of the lumbar areas and occurs when lumbar muscles spasm.

Global Rationale: Lordosis is an exaggerated lumbar curve and is often present in pregnancy, obesity, or other skeletal changes. The spine leans to the left or right in a list, and a line drawn from the thoracic one vertebrae does not fall between the gluteal cleft. Scoliosis results when the spine curves to the right or left. It is noted in the thoracic region. Kyphosis is an exaggerated thoracic dorsal curve that causes asymmetry between the sides of the posterior thorax. A flattened lumbar curve is a concave curvature of the lumbar areas and occurs when lumbar muscles spasm.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system.

Question 21

Type: MCSA

The nurse notes asymmetry of the iliac crests and gluteal folds while inspecting the spine of a client. The clients spine has a slight curvature to the right, but denies complaints of pain. The nurse would correctly document which of the following choices?

1. Kyphosis

2. Scoliosis

3. Spinal list

4. Lordosis

Correct Answer: 2

Rationale 1: Kyphosis results in an exaggerated thoracic dorsal curve that causes asymmetry between the sides of the posterior thorax.

Rationale 2: Scoliosis results when the spine curves to the right or left, causing an exaggerated thoracic convexity on that side.

Rationale 3: A spinal list occurs when the spine leans to the left or right. The condition may be noted in conditions with paravertebral muscle spasms or herniated disks.

Rationale 4: Lordosis is an exaggerated curve of the lumbar spine. It is noted most in condition such as pregnancy and obesity.

Global Rationale: In scoliosis the spine curves to the right or left, causing an exaggerated thoracic convexity on that side. Kyphosis results in an exaggerated thoracic dorsal curve that causes asymmetry between the sides of the posterior thorax. The spine leans to the left or right in a spinal list. A plumb line drawn from T1 does not fall between the gluteal cleft. This condition may occur with spasms in the paravertebral muscles or a herniated disk. Lordosis refers to an exaggerated curve of the lumbar spine. It is seen most commonly in conditions such as pregnancy and obesity.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system.

Question 22

Type: MCSA

The nurse is examining a client with a chief complaint of pain in the right great toe. The nurse notes hardened nodules on the lateral aspect of the toe, as well as redness and swelling. The nurse would suspect which of the following?

1. Bunion

2. Synovitis

3. Hammertoe

4. Gout

Correct Answer: 4

Rationale 1: The manifestations are consistent with a diagnosis of gout. Gout is a form of arthritis. It results from an excess of uric acid. The uric acid crystals deposit in the affected joints. The findings describe tophi, which are the hardened nodules associated with the altered purine metabolism of gout. Bunions are thickening and inflammation of the bursa of the joint of the great toe.

Rationale 2: The manifestations are consistent with a diagnosis of gout. Gout is a form of arthritis. It results from an excess of uric acid. The uric acid crystals deposit in the affected joints. The findings describe tophi, which are the hardened nodules associated with the altered purine metabolism of gout. Synovitis refers to an inflammation of the synovial membrane. It may be present with pain and swelling but is typically seen more in the knee.

Rationale 3: The manifestations are consistent with a diagnosis of gout. Gout is a form of arthritis. It results from an excess of uric acid. The uric acid crystals deposit in the affected joints. The findings describe tophi, which are the hardened nodules associated with the altered purine metabolism of gout. In hammertoe the metatarsophalangeal joint of the toe hyperextends with flexion of the interphalangeal joint of the toe.

Rationale 4: The manifestations are consistent with a diagnosis of gout. Gout is a form of arthritis. It results from an excess of uric acid. The uric acid crystals deposit in the affected joints. The findings describe tophi, which are the hardened nodules associated with the altered purine metabolism of gout.

Global Rationale: The manifestations are consistent with a diagnosis of gout. Gout is a form of arthritis. It results from an excess of uric acid. The uric acid crystals deposit in the affected joints. The findings describe tophi, which are the hardened nodules associated with the altered purine metabolism of gout. Bunions are thickening and inflammation of the bursa of the joint of the great toe. Synovitis occurs in the knee. In hammertoe the metatarsophalangeal joint of the toe hyperextends with flexion of the interphalangeal joint of the toe.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system.

Question 23

Type: MCMA

The nurse is assessing a client with suspected rheumatoid arthritis. Which of the following musculoskeletal changes would contribute to a positive diagnosis?

Standard Text: Select all that apply.

1. Ulnar deviation

2. Bouchards nodes

3. Heberdens nodes

4. Swan-neck deformity

5. Symmetrical loss of function in extremities

Correct Answer: 1,4,5

Rationale 1: Ulnar deviation. In rheumatoid arthritis there is chronic inflammation of the metacarpophalangeal and interphalangeal joints leading to ulnar deviation.

Rationale 2: Bouchards nodes. The nodes that may appear on the fingers such as Bouchards and Heberdens nodes are associated with osteoarthritis. Bouchards nodes are located on the proximal interphalangeal joints.

Rationale 3: Heberdens nodes. The nodes that may appear on the fingers such as Bouchards and Heberdens nodes are associated with osteoarthritis. Heberdens nodes are hard, typically painless, bony enlargements associated with osteoarthritis that may occur in the distal interphalangeal joints.

Rationale 4: Swan-neck deformity. Another manifestation of rheumatoid arthritis involves what are known as swan-neck contractures. These result when the proximal interphalangeal joints are hyperextended while the distal interphalangeal joints are fixed in flexion.

Rationale 5: Symmetrical loss of function in extremities. Rheumatoid arthritis impacts the extremities symmetrically.

Global Rationale: Rheumatoid arthritis is an autoimmune condition. The disease may impact multiple body systems. Symptoms of the condition include pain and inflammation. In rheumatoid arthritis there is chronic inflammation of the metacarpophalangeal and interphalangeal joints leading to ulnar deviation. Another manifestation of rheumatoid arthritis involves what are known as swan-neck contractures. These result when the proximal interphalangeal joints are hyperextended while the distal interphalangeal joints are fixed in flexion. The impact on the extremities is typically symmetrical in rheumatoid arthritis. The nodes that may appear on the fingers such as Bouchards and Heberdens nodes are associated with osteoarthritis. Osteoarthritis is a condition of joint degeneration.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system.

Question 24

Type: MCSA

The nurse is assessing a client with a suspected femur fracture. Which of the following findings would most support this diagnosis?

1. External rotation of the lower leg and foot

2. Internal rotation of the lower leg and foot

3. Limited hip internal rotation

4. Limited hip external rotation

Correct Answer: 1

Rationale 1: External rotation, not internal rotation, of the lower leg and foot is a classic sign of a fractured femur.

Rationale 2: External rotation, not internal rotation, of the lower leg and foot is a classic sign of a fractured femur.

Rationale 3: Limitations of internal and external rotation in the hip signify inflammatory or degenerative joint diseases.

Rationale 4: Limitations of internal and external rotation in the hip signify inflammatory or degenerative joint diseases.

Global Rationale: External rotation, not internal rotation, of the lower leg and foot is a classic sign of a fractured femur. Limitations of internal and external rotation in the hip signify inflammatory or degenerative joint diseases.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 23.5: Differentiate normal from abnormal findings of the musculoskeletal system.

Question 25

Type: MCSA

The nurse notes a child sitting in reverse tailor position during a well-child examination. The nurse would correctly choose which of the following actions in this situation?

1. Notify the healthcare provider so that X-rays can be obtained.

2. Explain to the parent that this can cause joint stress.

3. Continue with the examination.

4. Assess the child for back problems.

Correct Answer: 2

Rationale 1: The reverse tailor position should be discouraged as a result of the stresses it places on the joints of a growing child. The preferred sitting position of the child does not, however, indicate the presence of deformities that would require diagnostic testing.

Rationale 2: The reverse tailor position stresses the hip, knee, and ankle joints of the growing child. Children should be encouraged to try other sitting positions to prevent these problems, and teaching the parent and the child regarding this is best done at the time the position is noted.

Rationale 3: The reverse tailor position places stress on the joints of the growing child. The best time for the nurse to provide education is at the time of discovery. This education should be performed prior to completing of the full assessment.

Rationale 4: The reverse tailor position stresses the hip, knee, and ankle joints of the growing child. Back problems are not directly associated with the reverse tailor position.

Global Rationale: The reverse tailor position stresses the hip, knee, and ankle joints of the growing child. The position has the individual sitting flat on the floor with the legs bent back similar to an upside down W. Children should be encouraged to try other sitting positions to prevent these problems, and teaching the parent and the child regarding this is best done at the time the position is noted. There is no need for the nurse to anticipate that X-rays will be needed as this position does not indicate deformities requiring diagnostic tests. The examination is a period of time in which the nurse can provide teaching to the patient. It would be remiss to discuss this potential problem with the parents at the time noted. Thus, continuation of the examination should not be done before the education has taken place. The reverse tailor position does not promote back problems for the child.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23.6: Describe developmental, cultural, psychosocial, and environmental related variations in assessment and findings.

Question 26

Type: MCSA

A 38-week pregnant client is complaining of lower back pain. The nurse notes a slight lordosis and waddling gait in the client. The nurse would correctly choose which of the following actions in this situation?

1. Suggest the client begin bed rest.

2. Notify the healthcare provider of the findings.

3. Document the findings as normal.

4. Ask the client if she has been lifting.

Correct Answer: 3

Rationale 1: Lordosis, exaggeration of the lumbar spinal curve, and a waddling gait are the result of compensation for the enlarging fetus. The womans center of gravity shifts forward, and her weight shifts farther back on the lower extremities, causing lower back pain. These are all normal findings during the later stages of pregnancy and do not require bed rest.

Rationale 2: Lordosis, exaggeration of the lumbar spinal curve, and a waddling gait are the result of compensation for the enlarging fetus. The womans center of gravity shifts forward, and her weight shifts farther back on the lower extremities, causing lower back pain. These are all normal findings during the later stages of pregnancy and do not require notification of the healthcare provider.

Rationale 3: Lordosis, exaggeration of the lumbar spinal curve, and a waddling gait are the result of compensation for the enlarging fetus. The womans center of gravity shifts forward, and her weight shifts farther back on the lower extremities, causing lower back pain. These are all normal findings during the later stages of pregnancy. The nurse should document these findings as normal.

Rationale 4: Lordosis, exaggeration of the lumbar spinal curve, and a waddling gait are the result of compensation for the enlarging fetus. The womans center of gravity shifts forward, and her weight shifts farther back on the lower extremities, causing lower back pain. These are all normal findings during the late stages of pregnancy and are not the result of lifting.

Global Rationale: During pregnancy estrogen and other hormones soften the cartilage in the pelvis and increase the mobility of the joints. Lordosis, exaggeration of the lumbar spinal curve, and a waddling gait are the result of compensation for the enlarging fetus. The womans center of gravity shifts forward, and her weight shifts farther back on the lower extremities, causing lower back pain. These are all normal findings during the late stages of pregnancy and do not require bed rest or notification of the healthcare provider. Lordosis and waddling gait in the later stages of pregnancy are not the result of lifting.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23.6: Describe developmental, cultural, psychosocial, and environmental related variations in assessment and findings.

Question 27

Type: MCSA

The nurse is caring for an elderly client. The nurse would expect which of the following in the musculoskeletal system of an older adult?

1. Difficulty with dexterity

2. Increased bone production

3. Risk for fractures

4. Pain when ambulating

Correct Answer: 3

Rationale 1: Difficulty with dexterity is a direct change associated with aging. Older clients may have chronic conditions that may indirectly cause changes in this skill.

Rationale 2: The rate of bone production does not increase with aging.

Rationale 3: Elderly clients are at risk for fracture as a result of decreased calcium absorption and loss of bone density.

Rationale 4: Pain with ambulation is not a direct result of aging. Some chronic conditions seen with greater frequency in the older adult may be associated with painful ambulation.

Global Rationale: Elderly clients are at risk for fractures due to decreased calcium absorption and loss of bone density. Difficulty with dexterity is not a normal age related change. The rate of bone production is not increased but decreased with aging. Pain with ambulation is not a direct result of aging; however, some chronic conditions of aging may be associated with varying levels and types of discomfort.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23.6: Describe developmental, cultural, psychosocial, and environmental related variations in assessment and findings.

Question 28

Type: MCSA

The nurse is caring for an elderly client. The nurse would expect which of the following bone to occur with aging?

1. No bone changes are associated with aging

2. Increased osteoblastic activity

3. Decreased calcium absorption

4. Increase in bone density

Correct Answer: 3

Rationale 1: As individuals age, physiologic changes take place in the bones, muscles, connective tissue, and joints. These changes may affect the older clients mobility and endurance. Bone changes include decreased calcium absorption and reduced osteoblast production.

Rationale 2: Bone changes associated with aging include reduced osteoblast production. Osteoblasts are the cells responsible for bone production.

Rationale 3: The rate of calcium absorption is reduced with aging.

Rationale 4: Reductions in calcium absorption and reduced osteoblast production will result in a reduction of bone density. These changes are associated with aging.

Global Rationale: As individuals age, physiologic changes take place in the bones, muscles, connective tissue, and joints. These changes may affect the older clients mobility and endurance. Bone changes include decreased calcium absorption and reduced osteoblast production. Elderly persons who are housebound and immobile or whose dietary intake of calcium and vitamin D is low may also experience reduced bone mass and strength. During aging, bone resorption occurs more rapidly than new bone growth, resulting in the loss of bone density typical of osteoporosis. The entire skeleton is affected, but the vertebrae and long bones are especially impacted. The elderly client will experience decreased calcium absorption. Osteoblasts are the cells responsible for bone production. Osteoblast activity is reduced, not increased, with aging. Bone density decreases, not increases, in the elderly.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23.6: Describe developmental, cultural, psychosocial, and environmental related variations in assessment and findings.

Question 29

Type: MCSA

The nurse is planning a program to promote Healthy People 2020 focus areas relating to osteoporosis. Which of the following would appropriately serve as a primary prevention program?

1. The development of a program to address available medication therapies for the individual with osteoporosis.

2. Community screening programs to identify individuals who have early onset osteoporosis.

3. Community education programs to discuss methods that can be implemented to reduce the chance of developing osteoporosis.

4. The development of community support programs for individuals who have been diagnosed with osteoporosis.

Correct Answer: 3

Rationale 1: Primary prevention seeks to provide education and reduce the incidence of disease. Secondary prevention seeks to promote early diagnosis of conditions. Tertiary preventions goal is to manage existing conditions while seeking to prevent related complications. Programs seeking to discuss treatment options or to offer support for clients with the disorder are examples of tertiary prevention.

Rationale 2: Primary prevention seeks to provide education and reduce the incidence of disease. Secondary prevention seeks to promote early diagnosis of conditions. Tertiary preventions goal is to manage existing conditions while seeking to prevent related complications. Secondary prevention seeks to promote early diagnosis of conditions.

Rationale 3: Primary prevention seeks to provide education and reduce the incidence of disease. Secondary prevention seeks to promote early diagnosis of conditions. Tertiary preventions goal is to manage existing conditions while seeking to prevent related complications. Programs to reduce the incidence of osteoporosis are an example of primary prevention.

Rationale 4: Primary prevention seeks to provide education and reduce the incidence of disease. Secondary prevention seeks to promote early diagnosis of conditions. Tertiary preventions goal is to manage existing conditions while seeking to prevent related complications. Programs seeking to discuss treatment options or to offer support for clients with the disorder are examples of tertiary prevention.

Global Rationale: Primary prevention seeks to provide education and reduce the incidence of disease. Secondary prevention seeks to promote early diagnosis of conditions. Tertiary preventions goal is to manage existing conditions while seeking to prevent related complications. Programs to reduce the incidence of osteoporosis are an example of primary prevention. Secondary prevention activities would include screening programs to identify individuals with early onset osteoporosis. Programs seeking to discuss treatment options or to offer support for clients with the disorder are examples of tertiary prevention.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 23.7: Discuss objectives related to overall health of the musculoskeletal system as presented in Healthy People 2020.

Question 30

Type: MCSA

The nurse is admitting a client with a shoulder dislocation. The client tells the nurse that the healthcare provider has told her she has a dislocated shoulder. The client asks the nurse what this diagnosis means. The nurse would respond with which of the following statements?

1. I cannot tell you without your healthcare providers permission.

2. You have a muscle tear at the shoulder.

3. Your shoulder bone has come apart from the shoulder joint.

4. Your shoulder is fractured and separated from the joint.

Correct Answer: 3

Rationale 1: The client has voiced a concern and asked a question of the nurse. It is within the scope of practice and responsibility of the nurse to respond to this inquiry.

Rationale 2: A dislocation is a displacement of the bone from its usual anatomical location in the joint. A muscle tear is not the same thing as a dislocation.

Rationale 3: A dislocation is a displacement of the bone from its usual anatomical location in the joint.

Rationale 4: A dislocation is displacement of the bone from its usual anatomical location. This condition does not include a fracture.

Global Rationale: Dislocation is a displacement of the bone from its usual anatomical location in the joint. A dislocation is not the same as a muscle tear, or a fracture of the shoulder. The client has a concern and the nurse has the obligation to attempt to answer the questions presented within the nurses scope of practice and responsibility.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 23.8: Apply critical thinking in selected simulations related to physical assessment of the musculoskeletal system.

Question 31

Type: MCMA

The nurse is discharging a client with osteoarthritis. Which of the following would the nurse include in the teaching plan?

Standard Text: Select all that apply.

1. Obesity increases the risks of bone, muscle, and joint disorders.

2. Musculoskeletal health is influenced by the diet.

3. Exercise is important in the prevention of osteoarthritis.

4. Smoking and alcohol contribute to the development of osteoarthritis.

5. As the condition progresses the hands may develop contractures that resemble swan necks

Correct Answer: 1,2,3

Rationale 1: Obesity increases the risks of bone, muscle, and joint disorders. Obesity places an increase in stress on the bones and joints. Obesity is viewed as a risk factor for the development of osteoarthritis.

Rationale 2: Musculoskeletal health is influenced by the diet. Dietary intake has an impact on musculoskeletal health. Vitamin D and calcium are associated with bone health. Protein intake is associated with healthy muscles.

Rationale 3: Exercise is important in the prevention of osteoarthritis. Exercise increases muscle strength and flexibility.

Rationale 4: Smoking and alcohol contribute to the development of osteoarthritis. Smoking and alcohol are risk factors for the development of osteoporosis not osteoarthritis.

Rationale 5: As the condition progresses the hands may develop contractures that resemble swan necks. Swan-neck contractures are a deformity noted in the hand of an individual diagnosed with rheumatoid arthritis. Rheumatoid arthritis is a systemic disorder of autoimmune origin.

Global Rationale: Osteoarthritis is a condition that results from degeneration of the joints. Risk factors include aging, obesity, congenital abnormalities, and occupations that place excessive stress on the joints. Dietary intake has an impact on musculoskeletal health. Calcium and vitamin D both promote strong bones. Regular exercise will promote healthful musculoskeletal functioning. Exercise increases muscle strength and flexibility. Smoking and alcohol contribute to the development of osteoporosis, not osteoarthritis.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 23.8: Apply critical thinking in selected simulations related to physical assessment of the musculoskeletal system.

Question 32

Type: MCSA

The nursing student is planning to observe the registered nurse complete a focused interview on a client being admitted to the facility with complaints of leg pain. Which of the following statements by the student nurse indicates the need for further education?

1. The focused interview will be guided by the physical assessment that was completed by the healthcare provider prior to admission.

2. Subjective information is contained in the focused assessment.

3. The age, gender, and past medical history of the client are used to guide the questions in the focused assessment.

4. A focus interview on the musculoskeletal system is individualized for each client.

Correct Answer: 1

Rationale 1: The focused interview will be guided by the physical assessment that was completed by the healthcare provider prior to admission. The focused interview is used to guide the physical assessment on the client.

Rationale 2: Subjective information is contained in the focused assessment. The information obtained by the focused interview is subjective. Subjective data refers to that information that is obtained from the client and family.

Rationale 3: The age, gender, and past medical history of the client are used to guide the questions in the focused assessment. The nurse will consider the clients age, gender, race, culture, past and current medical history to guide the interview questions thus making the interview individualized.

Rationale 4: A focus interview on the musculoskeletal system is individualized for each client. The nurse will consider the clients age, gender, race, culture, past and current medical history to guide the interview questions thus making the interview individualized.

Global Rationale: The focused interview is used to guide the physical assessment on the client. The information obtained in the focused interview is subjective. The nurse will consider the clients age, gender, race, culture, past and current medical history to guide the interview questions thus making the interview individualized.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23.3: Develop questions to be used when completing the focused interview.

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