Nokea
The nurse's musculoskeletal assessment of a patient reveals involuntary twitching of muscle groups. How would the nurse document this observation in the patient's chart?
- A. Tetany
- B. Atony
- C. Clonus
- D. Fasciculations
Correct Answer: D
Rationale: Fasciculation is involuntary twitching of muscle fiber groups. Clonus is a series of involuntary, rhythmic, muscular contractions and tetany is involuntary muscle contraction, but neither is characterized as twitching. Atony is a loss of muscle strength.
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A nurse is caring for a patient who has just had an arthroscopy as an outpatient and is getting ready to go home. The nurse should teach the patient to monitor closely for what postprocedure complication?
- A. Fever
- B. Crepitus
- C. Fasciculations
- D. Synovial fluid leakage
Correct Answer: A
Rationale: Following arthroscopy, the patient and family are informed of complications to watch for, including fever. Synovial fluid leakage is unlikely and crepitus would not develop as a postprocedure complication. Fasciculations are muscle twitches and do not involve joint integrity or function.
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 caring for a patient with a diagnosis of cancer that has metastasized. What laboratory value would the nurse expect to be elevated in this patient?
- A. Bilirubin
- B. Potassium
- C. Alkaline phosphatase
- D. Creatinine
Correct Answer: C
Rationale: Alkaline phosphatase is elevated during early fracture healing and in diseases with increased osteoblastic activity (e.g., metastatic bone tumors). Elevated bilirubin, potassium, and creatinine would not be expected in a patient with metastatic bone tumors.
A patient's fracture is healing and callus is being deposited in the bone matrix. This process characterizes what phase of the bone healing process?
- A. The reparative phase
- B. The reactive phase
- C. The remodeling phase
- D. The revascularization phase
Correct Answer: A
Rationale: Callus formation takes place during the reparative phase of bone healing. The reactive phase occurs immediately after injury and the remodeling phase builds on the reparative phase. There is no discrete revascularization phase.
A nurse's assessment of a teenage girl reveals that her shoulders are not level and that she has one prominent scapula that is accentuated by bending forward. The nurse should expect to read about what health problem in the patient's electronic health record?
- A. Lordosis
- B. Kyphosis
- C. Scoliosis
- D. Muscular dystrophy
Correct Answer: C
Rationale: Scoliosis is evidenced by an abnormal lateral curve in the spine, shoulders that are not level, an asymmetric waistline, and a prominent scapula, accentuated by bending forward. Lordosis is the curvature in the lower back; kyphosis is an exaggerated curvature of the upper back. This finding is not suggestive of muscular dystrophy.