Nokea
A client is distressed at body changes related to kyphosis. What response by the nurse is best?
- A. Ask the client to explain more about these feelings.
- B. Explain that these changes are irreversible.
- C. Offer to help select clothes to hide the deformity.
- D. Tell the client safety is more important than looks.
Correct Answer: A
Rationale: Assessment is the first step of the nursing process, and the nurse should begin by getting as much information about the client's feelings as possible. Explaining that the changes are irreversible discounts the client's feelings. Depending on the extent of the deformity, clothing will not hide it. While safety is more objectively important than looks, the client is worried about looks and the nurse needs to address this issue.
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The clients chart indicates genu varum. What does the nurse understand this to mean?
- A. Bow-legged
- B. Fluid accumulation
- C. Knock-kneed
- D. Spinal curvature
Correct Answer: A
Rationale: Genu varum is a bow-legged deformity. A fluid accumulation is an effusion. Genu valgum is knock-kneed. A spinal curvature could be kyphosis or scoliosis.
A student nurse learns about changes that occur to the musculoskeletal system due to aging. Which changes clearly lead to increased safety risks?
- A. Increased bone density leads to stiffness.
- B. Increased joint flexibility enhances mobility.
- C. Osteoporosis is a universal occurrence.
- D. Decreased muscle mass reduces strength.
Correct Answer: D
Rationale: Decreased muscle mass reduces strength, which increases the risk of falls and injuries in older adults. Increased bone density is not typical with aging; osteoporosis, not universal, increases fracture risk but is not guaranteed. Increased joint flexibility is not a common aging change.
The nurse is assessing four clients with musculoskeletal disorders. The nurse should assess the client with which laboratory result first?
- A. Serum alkaline phosphatase (ALP): 108 units/L.
- B. Serum aspartate aminotransferase (AST): 26 units/L.
- C. Serum calcium: 10.2 mg/dL.
- D. Serum phosphate: 2 mg/dL.
Correct Answer: D
Rationale: A serum phosphorus level of 2 mg/dL is below the normal range (2.5"?4.5 mg/dL), indicating a potential issue such as hypophosphatemia, which can affect bone health and requires immediate assessment. The other lab results are within normal ranges.
The nurse knows that hematopoiesis occurs in what part of the musculoskeletal system?
- A. Cancellous tissue
- B. Cellow tissue
- C. Red marrow
- D. Yellow marrow
Correct Answer: C
Rationale: Hematopoiesis occurs in the red marrow, which is part of the cancellous tissues containing both types of bone tissue.
A hospitalized clients strength of the upper extremities is rated at 3. What does the nurse understand about this clients ability to perform activities of daily living (ADL)?
- A. The client is able to perform ADLs but not for some items.
- B. No difficulties are expected with ADL.
- C. The client is unable to perform ADL alone.
- D. The client would need near-total assistance with ADLs.
Correct Answer: A
Rationale: This rating indicates fair muscle strength with full range of motion against gravity but not resistance. The client could complete ADLs independently unless they required lifting objects.