Nokea
A nurse is assessing a child who has a diagnosis of muscular dystrophy. Assessment reveals that the child's muscles have greater-than-normal tone. The nurse should document the presence of which of the following?
- A. Tonus
- B. Flaccidity
- C. Atony
- D. Spasticity
Correct Answer: D
Rationale: A muscle with greater-than-normal tone is described as spastic. Soft and flabby muscle tone is defined as atony. A muscle that is limp and without tone is described as being flaccid. The state of readiness known as muscle tone (tonus) is produced by the maintenance of some of the muscle fibers in a contracted state.
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The nurse's comprehensive assessment of an older adult involves the assessment of the patient's gait. How should the nurse best perform this assessment?
- A. Instruct the patient to walk heel-to-toe for 15 to 20 steps.
- B. Instruct the patient to walk in a straight line while not looking at the floor.
- C. Instruct the patient to walk away from the nurse for a short distance and then toward the nurse.
- D. Instruct the patient to balance on one foot for as long as possible and then walk in a circle around the room.
Correct Answer: C
Rationale: Gait is assessed by having the patient walk away from the examiner for a short distance. The examiner observes the patient's gait for smoothness and rhythm. Looking at the floor is not disallowed and gait is not assessed by observing balance on one leg. Heel-to-toe walking ability is not gauged during an assessment of normal gait.
A nurse is taking a health history on a patient with musculoskeletal dysfunction. What is the primary focus of this phase of the nurse's assessment?
- A. Evaluating the effects of the musculoskeletal disorder on the patient's function
- B. Evaluating the patient's adherence to the existing treatment regimen
- C. Evaluating the presence of genetic risk factors for further musculoskeletal disorders
- D. Evaluating the patient's active and passive range of motion
Correct Answer: A
Rationale: The nursing assessment of the patient with musculoskeletal dysfunction includes an evaluation of the effects of the musculoskeletal disorder on the patient. This is a vital focus of the health history and supersedes the assessment of genetic risk factors and adherence to treatment, though these are both valid inclusions to the interview. Assessment of ROM occurs during the physical assessment, not the interview.
A child is growing at a rate appropriate for his age. What cells are responsible for the secretion of bone matrix that eventually results in bone growth?
- A. Osteoblasts
- B. Osteocytes
- C. Osteoclasts
- D. Lamellae
Correct Answer: A
Rationale: Osteoblasts function in bone formation by secreting bone matrix. Osteocytes are mature bone cells and osteoclasts are multinuclear cells involved in dissolving and resorbing bone. Lamellae are circles of mineralized bone matrix.
An older adult patient has symptoms of osteoporosis and is being assessed during her annual physical examination. The assessment shows that the patient will require further testing related to a possible exacerbation of her osteoporosis. The nurse should anticipate what diagnostic test?
- A. Bone densitometry
- B. Hip bone radiography
- C. Computed tomography (CT)
- D. Magnetic resonance imaging (MRI)
Correct Answer: A
Rationale: Bone densitometry is considered the most accurate test for osteoporosis and for predicting a fracture. As such, it is more likely to be used than CT, MRI, or x-rays.
The nurse's musculoskeletal assessment of a patient reveals involuntary twitching of muscle groups. How would the nurse document this observation in the patient's chart?
- A. Tetany
- B. Atony
- C. Clonus
- D. Fasciculations
Correct Answer: D
Rationale: Fasciculation is involuntary twitching of muscle fiber groups. Clonus is a series of involuntary, rhythmic, muscular contractions and tetany is involuntary muscle contraction, but neither is characterized as twitching. Atony is a loss of muscle strength.