Nokea
The nurse is caring for a patient with kyphosis. Which of the following findings should the nurse expect to assess?
- A. Shortened stride
- B. Exaggerated thoracic curvature
- C. Grating sound when performing passive ROM
- D. Uncoordinated, swaying gait
Correct Answer: B
Rationale: Patients with kyphosis (dowager's hump) have a forward bending of thoracic spine, an exaggerated thoracic curvature. A shortened stride is antalgic gait. Crepitation is crackling sound or grating sensation as a result of friction between bones, broken bone, or cartilage bits in joint. An uncoordinated swaying gait is an ataxic gait.
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The nurse is conducting a musculoskeletal assessment on an older-adult patient. Which of the following are age-related changes in this body system? (Select all that apply.)
- A. Decreased bone density
- B. Decreased risk for cartilage disruption
- C. Increased glycogen stores
- D. Decreased elasticity in cartilage
- E. Increased muscle cell diameter
Correct Answer: A,D
Rationale: A decrease in both bone density and elasticity in the cartilage are age-related changes in the musculoskeletal system. Other changes include an increased risk for cartilage disruption, decreased glycogen stores, and a decrease in the diameter of muscle cells.
The nurse is preparing to assess a patient's musculoskeletal system. Which of the following actions should the nurse do first?
- A. Feel for the presence of crepitus during joint movement.
- B. Have the patient move the extremities against resistance.
- C. Observe the patient's body build and muscle configuration.
- D. Check active and passive range of motion for the extremities.
Correct Answer: C
Rationale: The usual technique in the physical assessment is to begin with inspection. Abnormalities in muscle mass or configuration will allow the nurse to perform a more focused assessment of abnormal areas. The other assessments also are included in the assessment but are usually done after inspection.
The nurse is assessing the movement of a patient's elbow and notes crackling sounds and a grating sensation with palpation. Which of the following terms should the nurse use to document these findings?
- A. Torticollis
- B. Crepitation
- C. Subluxation
- D. Epicondylitis
Correct Answer: B
Rationale: Crackling sounds and a grating sensation that accompany movement are described as crepitus or crepitation. Torticollis is a twisting of the neck to one side, subluxation is a partial dislocation of the joint, and epicondylitis is an inflammation of the elbow that causes a dull ache that increases with movement.
The nurse is caring for a patient with kyphosis who is scheduled for dual-energy x-ray absorptiometry (DEXA) testing. Which of the following actions should the nurse plan to implement?
- A. Give an oral sedative.
- B. Start an intravenous line
- C. Teach the patient about DEXA.
- D. Screen the patient for shellfish allergies.
Correct Answer: C
Rationale: DEXA testing is painless and noninvasive. No IV access is necessary. Contrast medium is not used. Because the procedure is painless, no antianxiety medications are required.
While testing the patient's muscle strength, the nurse finds that the patient can flex the arms when no resistance is applied but is unable to flex when the nurse applies light resistance. The nurse should document the patient's muscle strength as level
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: C
Rationale: A level 3 indicates that the patient is unable to move against resistance but can move against gravity. Level 1 indicates minimal muscle contraction, level 2 indicates that the arm can move when gravity is eliminated, and level 4 indicates active movement with some resistance.