Nokea
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.
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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.
The nurse is assessing an older female patient and notes that the patient has lost 2 cm in height since the previous visit 2 years ago. Which of the following diagnostic tests should the nurse include in the teaching plan?
- A. Discography studies
- B. Myelographic testing
- C. Magnetic resonance imaging (MRI)
- D. Dual-energy x-ray absorptiometry (DEXA)
Correct Answer: D
Rationale: The decreased height and the patient's age suggest that the patient may have osteoporosis and that bone density testing is needed. Discography, MRI, and myelography are typically done for patients with current symptoms caused by musculoskeletal dysfunction and are not the initial diagnostic tests for osteoporosis.
Which of the following information obtained during the nurse's assessment of the patient's nutritional-metabolic pattern may indicate the risk for musculoskeletal condition?
- A. The patient takes a multivitamin daily.
- B. The patient dislikes fruits and vegetables.
- C. The patient is 158 cm and weighs 81 kg.
- D. The patient prefers whole milk to nonfat milk.
Correct Answer: C
Rationale: The patient's height and weight indicate obesity, which places stress on weight-bearing joints. The use of whole milk, avoiding fruits and vegetables, and use of a daily multivitamin are not risk factors for musculoskeletal condition.
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.
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.