Nokea
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.
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A nurse is taking a health history on a new patient who has been experiencing unexplained paresthesia. What question should guide the nurse's assessment of the patient's altered sensations?
- A. How does the strength in the affected extremity compare to the strength in the unaffected extremity?
- B. Does the color in the affected extremity match the color in the unaffected extremity?
- C. How does the feeling in the affected extremity compare with the feeling in the unaffected extremity?
- D. Does the patient have a family history of paresthesia or other forms of altered sensation?
Correct Answer: C
Rationale: Questions that the nurse should ask regarding altered sensations include How does this feeling compare to sensation in the unaffected extremity? Asking questions about strength and color are not relevant and a family history is unlikely.
The results of a nurse's musculoskeletal examination show an increase in the lumbar curvature of the spine. The nurse should recognize the presence of what health problem?
- A. Osteoporosis
- B. Kyphosis
- C. Lordosis
- D. Scoliosis
Correct Answer: C
Rationale: The nurse documents the spinal abnormality as lordosis. Lordosis is an increase in lumbar curvature of the spine. Kyphosis is an increase in the convex curvature of the spine. Scoliosis is a lateral curvature of the spine. Osteoporosis is the significant loss of bone mass and strength with an increased risk for fracture.
A patient has just had an arthroscopy performed to assess a knee injury. What nursing intervention should the nurse implement following this procedure?
- A. Wrap the joint in a compression dressing.
- B. Perform passive range of motion exercises.
- C. Maintain the knee in flexion for up to 30 minutes.
- D. Apply heat to the knee.
Correct Answer: A
Rationale: Interventions to perform following an arthroscopy include wrapping the joint in a compression dressing, extending and elevating the joint, and applying ice or cold packs. Passive ROM exercises, static flexion, and heat are not indicated.
A nurse is caring for a patient whose cancer metastasis has resulted in bone pain. Which of the following are typical characteristics of bone pain?
- A. A dull, deep ache that is boring in nature
- B. Soreness or aching that may include cramping
- C. Sharp, piercing pain that is relieved by immobilization
- D. Spastic or sharp pain that radiates
Correct Answer: A
Rationale: Bone pain is characteristically described as a dull, deep ache that is boring in nature, whereas muscular pain is described as soreness or aching and is referred to as muscle cramps. Fracture pain is sharp and piercing and is relieved by immobilization. Sharp pain may also result from bone infection with muscle spasm or pressure on a sensory nerve.
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.