Nokea
Which of the following information in a female, older-adult patient's health history will alert the nurse to the need for a more focused assessment of the musculoskeletal system?
- A. The patient experienced a sprained ankle at age 13.
- B. The patient's mother became much shorter with aging.
- C. The patient's father died of complications of military tuberculosis.
- D. The patient reports taking ibuprofen for occasional headaches.
Correct Answer: B
Rationale: A family history of height loss with aging may indicate osteoporosis, and the nurse should perform a more thorough assessment of the patient's current height and other risk factors for osteoporosis. A sprained ankle during adolescence does not place the patient at increased current risk for musculoskeletal problems. A family history of tuberculosis is not a risk factor. Occasional nonsteroidal anti-inflammatory drug (NSAID) use does not indicate any increased musculoskeletal risk.
You may also like to solve these questions
The nurse is caring for a patient who has pain during circumduction of the shoulder when the nurse moves the arm behind the patient. Which of the following questions should the nurse ask?
- A. Do you have difficulty in putting on a jacket?
- B. Are you able to feed yourself without difficulty?
- C. Are you able to sleep through the night without waking?
- D. Do you ever have trouble lowering yourself to the toilet?
Correct Answer: A
Rationale: The patient's pain will make it more difficult to accomplish tasks like putting on a shirt or jacket. This pain should not affect the patient's ability to feed himself or herself or use the toilet because these tasks do not involve moving the arm behind the patient. The arm will not usually be positioned behind the patient during sleeping.
Which of the following assessments of synovial fluid indicates that the findings are normal?
- A. Transparent and colourless
- B. Reddish pink fluid
- C. Grey, thin fluid
- D. Whitish yellow fluid
Correct Answer: A
Rationale: Normal synovial fluid is transparent and colourless or straw-coloured. It should be scant in amount and of low viscosity. Fluid from an infected joint may be purulent and thick or grey and thin. In gout, the fluid may be whitish yellow. Blood may be aspirated.
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 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.