Nokea
A school nurse is conducting scoliosis screening. In screening the client, what technique is most appropriate?
- A. Bending forward from the hips
- B. Sitting upright with arms outstretched
- C. Walking across the room and back
- D. Walking with both eyes closed
Correct Answer: A
Rationale: To assess for scoliosis, a spinal deformity, the student should bend forward at the hips. Standing behind the student, the nurse looks for a lateral curve in the spine. The other actions are not correct.
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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.
A client is having a myologgraphy. What action by the nurse is most important?
- A. Assesses with any nursing microctioning (AST) levels.
- B. Ensure that informed consent is on the chart.
- C. Position the client that after the procedure.
- D. Reinforce the dressing if it becomes saturated.
Correct Answer: B
Rationale: The diagnostic procedure is invasive and requires informed consent. The AST does not need to be assessed prior to the procedure. The client is positioned with the head of the bed elevated after the test to keep the contrast material out of the brain. The dressing should not become saturated; if it does, the nurse calls the provider.
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.
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.
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.