Chapter 62: Nursing Assessment: Musculoskeletal System My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 62: Nursing Assessment: Musculoskeletal System

Test Bank

MULTIPLE CHOICE

1. A patient complains of pain during circumduction of the shoulder when the nurse moves the arm behind the patient. Which question should the nurse ask?

a.

Do you have difficulty in putting on a jacket?

b.

Are you able to feed yourself without difficulty?

c.

Are you able to sleep through the night without waking?

d.

Do you ever have trouble lowering yourself to the toilet?

ANS: A

The patients pain will make it more difficult to accomplish tasks like putting on a shirt or jacket. This pain should not affect the patients ability to feed himself or herself or use the toilet because these tasks do not involve moving the arm behind the patient. The arm will not usually be positioned behind the patient during sleeping.

DIF: Cognitive Level: Application REF: 1577-1578

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

2. A patient with knee pain who is diagnosed with bursitis asks the nurse to explain just what bursitis is. The nurse will respond that bursitis is an inflammation of

a.

a small, fluid-filled sac found at many joints.

b.

the synovial membrane that lines the joint area.

c.

the fibrocartilage that acts as a shock absorber in the knee joint.

d.

any connective tissue that is found supporting the joints of the body.

ANS: A

Bursae are fluid-filled sacs that cushion joints and bony prominences. Fibrocartilage is a solid tissue that cushions some joints. Bursae are a specific type of connective tissue. The synovial membrane lines many joints but is not a bursa.

DIF: Cognitive Level: Comprehension REF: 1574

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

3. When assessing a 64-year-old woman, the nurse notes that the patient has lost 1 inch in height since the previous visit 2 years ago. The nurse will plan to teach the patient about

a.

discography studies.

b.

myelographic testing.

c.

magnetic resonance imaging (MRI).

d.

dual-energy x-ray absorptiometry (DEXA).

ANS: D

The decreased height and the patients age suggest that the patient may have osteoporosis and that bone density testing is needed. Discography, MRI, and myelography are typically done for patients with current symptoms caused by musculoskeletal dysfunction and are not the initial diagnostic tests for osteoporosis.

DIF: Cognitive Level: Application REF: 1580-1582 TOP: Nursing Process: Planning

MSC: NCLEX: Health Promotion and Maintenance

4. Which information in a 60-year-old womans health history will alert the nurse to the need for a more focused assessment of the musculoskeletal system?

a.

The patient experienced a sprained ankle at age 13.

b.

The patients mother became much shorter with aging.

c.

The patients father died of complications of miliary tuberculosis.

d.

The patient reports taking ibuprofen (Advil) for occasional headaches.

ANS: B

A family history of height loss with aging may indicate osteoporosis, and the nurse should perform a more thorough assessment of the patients current height and other risk factors for osteoporosis. A sprained ankle during adolescence does not place the patient at increased current risk for musculoskeletal problems. A family history of tuberculosis is not a risk factor. Occasional nonsteroidal anti-inflammatory drug (NSAID) use does not indicate any increased musculoskeletal risk.

DIF: Cognitive Level: Application REF: 1575-1576

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

5. Which information obtained during the nurses assessment of the patients nutritional-metabolic pattern may indicate the risk for musculoskeletal problems?

a.

The patient takes a multivitamin daily.

b.

The patient dislikes fruits and vegetables.

c.

The patient is 5 ft 2 in and weighs 180 lb.

d.

The patient prefers whole milk to nonfat milk.

ANS: C

The patients height and weight indicate obesity, which places stress on weight-bearing joints. The use of whole milk, avoiding fruits and vegetables, and use of a daily multivitamin are not risk factors for musculoskeletal problems.

DIF: Cognitive Level: Application REF: 1575-1576

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

6. When the nurse is assessing a new patient in the clinic, which information about the patients medications will be of most concern?

a.

The patient takes a daily multivitamin and calcium supplement.

b.

The patient has migraine headaches that are treated with nonsteroidal anti-inflammatory drugs (NSAIDs).

c.

The patient has severe asthma and requires frequent therapy with oral steroids.

d.

The patient takes hormone replacement therapy (HRT) to prevent hot flashes.

ANS: C

Corticosteroid use may lead to skeletal problems such as avascular necrosis and osteoporosis. The use of HRT and calcium supplements will help prevent osteoporosis. NSAID use does not increase the risk for musculoskeletal problems.

DIF: Cognitive Level: Application REF: 1574-1575

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

7. While testing the patients muscle strength, the nurse finds that the patient can flex the arms when no resistance is applied but is unable to flex when the nurse applies light resistance. The nurse should document the patients muscle strength as level

a.

1.

b.

2.

c.

3.

d.

4.

ANS: C

A level 3 indicates that the patient is unable to move against resistance but can move against gravity. Level 1 indicates minimal muscle contraction, level 2 indicates that the arm can move when gravity is eliminated, and level 4 indicates active movement with some resistance.

DIF: Cognitive Level: Comprehension REF: 1578

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

8. When assessing the musculoskeletal system, the nurses initial action will usually be to

a.

feel for the presence of crepitus during joint movement.

b.

have the patient move the extremities against resistance.

c.

observe the patients body build and muscle configuration.

d.

check active and passive range of motion for the extremities.

ANS: C

The usual technique in the physical assessment is to begin with inspection. Abnormalities in muscle mass or configuration will allow the nurse to perform a more focused assessment of abnormal areas. The other assessments also are included in the assessment but are usually done after inspection.

DIF: Cognitive Level: Comprehension REF: 1577

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

9. Which nursing action is correct when the nurse is assessing the straight-leg raising test for a patient with back pain?

a.

Raise the patients legs to a 60-degree angle from the bed.

b.

Have the patient dangle the legs over the edge of the exam table.

c.

Place the patient initially in the prone position on the bed or exam table.

d.

Instruct the patient to elevate the legs while tightening the abdominal muscles.

ANS: A

When performing the straight leg-raising test, the patient is in the supine position and the nurse passively lifts the patients legs to a 60-degree angle. The other actions would not be correct for this test.

DIF: Cognitive Level: Comprehension REF: 1578 | 1580

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

10. A patient with kyphosis is scheduled for dual-energy x-ray absorptiometry (DEXA) testing. The nurse will plan to

a.

give an oral sedative.

b.

start an intravenous line.

c.

teach the patient about DEXA.

d.

screen the patient for shellfish allergies.

ANS: C

DEXA testing is painless and noninvasive. No IV access is necessary. Contrast medium is not used. Because the procedure is painless, no antianxiety medications are required.

DIF: Cognitive Level: Application REF: 1580-1582

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

11. A patient has a new order for magnetic resonance imaging (MRI) to evaluate for right femur osteomyelitis. Which patient information indicates that the nurse should consult with the health care provider before scheduling the MRI?

a.

The patient has a pacemaker.

b.

The patient is claustrophobic.

c.

The patient wears a hearing aid.

d.

The patient is allergic to shellfish.

ANS: A

Patients with permanent pacemakers cannot have MRI because of the force exerted by the magnetic field on metal objects. An open MRI will not cause claustrophobia. The patient will need to be instructed to remove the hearing aid before the MRI, but this does not require consultation with the health care provider. Since contrast medium will not be used, shellfish allergy is not a contraindication to MRI.

DIF: Cognitive Level: Application REF: 1580-1582

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

12. When assessing the movement of a patients elbow, the nurse notes crackling sounds and a grating sensation with palpation. How will this be documented?

a.

Torticollis

b.

Crepitation

c.

Subluxation

d.

Epicondylitis

ANS: B

Crackling sounds and a grating sensation that accompany movement are described as crepitus or crepitation. Torticollis is a twisting of the neck to one side, subluxation is a partial dislocation of the joint, and epicondylitis is an inflammation of the elbow that causes a dull ache that increases with movement.

DIF: Cognitive Level: Comprehension REF: 1579

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

13. The nurse obtains this information when assessing a 74-year-old patient in the outpatient clinic. Which finding is of highest priority when the nurse is planning care for the patient?

a.

Symmetrical joint swelling of fingers

b.

Decreased right knee range of motion

c.

History of recent loss of balance and fall

d.

Complaint of left hip aching when jogging

ANS: C

A history of falls requires further assessment and development of fall prevention strategies. The other changes are more typical of bone and joint changes associated with normal aging.

DIF: Cognitive Level: Application REF: 1574 | 1575

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

14. A patient is seen in the clinic complaining of knee pain following an arthroscopic procedure 7 days previously and the health care provider performs arthrocentesis. Which finding will be of most concern to the nurse?

a.

Scant thin fluid

b.

Sanguineous fluid

c.

Straw-colored fluid

d.

Purulent appearing fluid

ANS: D

The presence of purulent fluid suggests a possible joint infection. Bloody fluid might be expected after an arthroscopic procedure. Normal synovial fluid is scant in amount and straw-colored.

DIF: Cognitive Level: Application REF: 1580 | 1583

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

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