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A nurse is performing a nursing assessment of a patient suspected of having a musculoskeletal disorder. What is the primary focus of the nursing assessment with a patient who has a musculoskeletal disorder?
- A. Range of motion
- B. Activities of daily living
- C. Gait
- D. Strength
Correct Answer: B
Rationale: The nursing assessment is primarily a functional evaluation, focusing on the patient's ability to perform activities of daily living. The nurse also assesses strength, gait, and ROM, but these are assessed to identify their effect on functional status rather than to identify a medical diagnosis.
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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.
An older adult patient has come to the clinic for a regular check-up. The nurse's initial inspection reveals an increased thoracic curvature of the patient's spine. The nurse should document the presence of which of the following?
- A. Scoliosis
- B. Epiphyses
- C. Lordosis
- D. Kyphosis
Correct Answer: D
Rationale: Kyphosis is the increase in thoracic curvature of the spine. Scoliosis is a deviation in the lateral curvature of the spine. Epiphyses are the ends of the long bones. Lordosis is the exaggerated curvature of the lumbar spine.
A nurse on the orthopedic unit is assessing a patient's peroneal nerve. The nurse will perform this assessment by doing which of the following actions?
- A. Pricking the skin between the great and second toe
- B. Stroking the skin on the sole of the patient's foot
- C. Pinching the skin between the thumb and index finger
- D. Stroking the distal fat pad of the small finger
Correct Answer: A
Rationale: The nurse will evaluate the sensation of the peroneal nerve by pricking the skin centered between the great and second toe. None of the other listed actions elicits the function of one of the peripheral nerves.
A nurse on a patient has been experiencing significant pain in her knee and diagnostic imaging reveals an effusion in the synovial capsule. What intervention should the nurse anticipate?
- A. Arthrography
- B. Knee replacement
- C. Arthrocentesis
- D. Arthroscopy
Correct Answer: C
Rationale: Arthrocentesis (joint aspiration) is carried out to obtain synovial fluid for examination or to relieve pain due to effusion. Arthrography is used to visualize joint structures, not to remove fluid. Arthroscopy is a diagnostic visualization, and knee replacement is not indicated for effusion.
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.