Nokea
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.
You may also like to solve these questions
The nurse is performing an assessment of a patient's musculoskeletal system and is appraising the patient's bone integrity. What action should the nurse perform during this phase of assessment?
- A. Compare parts of the body symmetrically.
- B. Assess extremities when in motion rather than at rest.
- C. Percuss as many joints as accessible.
- D. Administer analgesia 30 to 60 minutes before assessment.
Correct Answer: A
Rationale: When assessing bone integrity, symmetric parts of the body, such as extremities, are compared. Analgesia should not be necessary and percussion is not a clinically useful assessment technique. Bone integrity is best assessed when the patient is not moving.
A nurse is caring for an older adult who has been diagnosed with geriatric failure to thrive. This patient's prolonged immobility creates a risk for what complication?
- A. Muscle clonus
- B. Muscle atrophy
- C. Rheumatoid arthritis
- D. Muscle fasciculations
Correct Answer: B
Rationale: If a muscle is in disuse for an extended period of time, it is at risk of developing atrophy, which is the decrease in size. Clonus is a pattern of rhythmic muscle contractions and fasciculation is the involuntary twitch of muscle fibers; neither results from immobility. Lack of exercise is a risk factor for rheumatoid arthritis.
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.
A nurse is performing a musculoskeletal assessment of a patient with arthritis. During passive range-of-motion exercises, the nurse hears an audible grating sound. The nurse should document the presence of which of the following?
- A. Fasciculations
- B. Clonus
- C. Effusion
- D. Crepitus
Correct Answer: D
Rationale: Crepitus is a grating, crackling sound or sensation that occurs as the irregular joint surfaces move across one another, as in arthritic conditions. Fasciculations are involuntary twitching of muscle fiber groups. Clonus is the rhythmic contractions of a muscle. Effusion is the collection of excessive fluid within the capsule of a joint.
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.