Chapter 62: Nursing Assessment: Musculoskeletal System Nursing School Test Banks

Chapter 62: Nursing Assessment: Musculoskeletal System

Test Bank

MULTIPLE CHOICE

1. A 42-year-old male patient complains of shoulder pain when the nurse moves his arm behind the back. Which question should the nurse ask?

a.

Are you able to feed yourself without difficulty?

b.

Do you have difficulty when you are putting on a shirt?

c.

Are you able to sleep through the night without waking?

d.

Do you ever have trouble lowering yourself to the toilet?

ANS: B

The patients pain will make it more difficult to accomplish tasks like putting on a shirt or jacket. This pain should not affect the patients ability to feed himself 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.

DIF: Cognitive Level: Apply (application) REF: 1494

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

2. A patient with left knee pain is diagnosed with bursitis. The nurse will explain that bursitis is an inflammation of

a.

the synovial membrane that lines the joint.

b.

a small, fluid-filled sac found at some joints.

c.

the fibrocartilage that acts as a shock absorber in the knee joint.

d.

any connective tissue that is found supporting the joints of the body.

ANS: B

Bursae are fluid-filled sacs that cushion joints and bony prominences. Fibrocartilage is a solid tissue that cushions some joints. Bursae are a specific type of connective tissue. The synovial membrane lines many joints but is not a bursa.

DIF: Cognitive Level: Understand (comprehension) REF: 1493

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

3. The nurse who notes that a 59-year-old female patient has lost 1 inch in height over the past 2 years will plan to teach the patient about

a.

discography studies.

b.

myelographic testing.

c.

magnetic resonance imaging (MRI).

d.

dual-energy x-ray absorptiometry (DXA).

ANS: D

The decreased height and the patients 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.

DIF: Cognitive Level: Apply (application) REF: 1494 | 1501

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

4. Which information in a 67-year-old womans health history will alert the nurse to the need for a more focused assessment of the musculoskeletal system?

a.

The patient sprained her ankle at age 13.

b.

The patients mother became shorter with aging.

c.

The patient takes ibuprofen (Advil) for occasional headaches.

d.

The patients father died of complications of miliary tuberculosis.

ANS: B

A family history of height loss with aging may indicate osteoporosis, and the nurse should perform a more thorough assessment of the patients 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 antiinflammatory drug (NSAID) use does not indicate any increased musculoskeletal risk.

DIF: Cognitive Level: Apply (application) REF: 1496

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

5. Which information obtained during the nurses assessment of a 30-year-old patients nutritional-metabolic pattern may indicate the risk for musculoskeletal problems?

a.

The patient takes a multivitamin daily.

b.

The patient dislikes fruits and vegetables.

c.

The patient is 5 ft 2 in and weighs 180 lb.

d.

The patient prefers whole milk to nonfat milk.

ANS: C

The patients 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 problems.

DIF: Cognitive Level: Apply (application) REF: 1496

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

6. Which medication information will the nurse identify as a concern for a patients musculoskeletal status?

a.

The patient takes a daily multivitamin and calcium supplement.

b.

The patient takes hormone therapy (HT) to prevent hot flashes.

c.

The patient has severe asthma and requires frequent therapy with oral corticosteroids.

d.

The patient has migraine headaches treated with nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: C

Frequent or chronic corticosteroid use may lead to skeletal problems such as avascular necrosis and osteoporosis. The use of HT and calcium supplements will help prevent osteoporosis. NSAID use does not increase the risk for musculoskeletal problems.

DIF: Cognitive Level: Apply (application) REF: 1495

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

7. The nurse finds that a 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 patients muscle strength as level

a.

0.

b.

1.

c.

2.

d.

3.

ANS: D

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.

DIF: Cognitive Level: Understand (comprehension) REF: 1498

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

8. After completing the health history, the nurse assessing the musculoskeletal system will begin by

a.

having the patient move the extremities against resistance.

b.

feeling for the presence of crepitus during joint movement.

c.

observing the patients body build and muscle configuration.

d.

checking active and passive range of motion for the extremities.

ANS: C

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 are also included in the assessment but are usually done after inspection.

DIF: Cognitive Level: Understand (comprehension) REF: 1497

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

9. Which nursing action is correct when performing the straight-leg raising test for an ambulatory patient with back pain?

a.

Raise the patients legs to a 60-degree angle from the bed.

b.

Place the patient initially in the prone position on the exam table.

c.

Have the patient dangle both legs over the edge of the exam table.

d.

Instruct the patient to elevate the legs and tense the abdominal muscles.

ANS: A

When performing the straight leg-raising test, the patient is in the supine position and the nurse passively lifts the patients legs to a 60-degree angle. The other actions would not be correct for this test.

DIF: Cognitive Level: Understand (comprehension) REF: 1498

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

10. A 72-year-old patient with kyphosis is scheduled for dual-energy x-ray absorptiometry (DXA) testing. The nurse will plan to

a.

explain the procedure.

b.

start an IV line for contrast medium injection.

c.

give an oral sedative 60 to 90 minutes before the procedure.

d.

screen the patient for allergies to shellfish or iodine products.

ANS: A

DXA 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.

DIF: Cognitive Level: Apply (application) REF: 1501

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

11. A patient has a new order for magnetic resonance imaging (MRI) to evaluate for left femur osteomyelitis after a hip replacement surgery. Which information indicates that the nurse should consult with the health care provider before scheduling the MRI?

a.

The patient has a pacemaker.

b.

The patient is claustrophobic.

c.

The patient wears a hearing aid.

d.

The patient is allergic to shellfish.

ANS: A

Patients with permanent pacemakers cannot have MRI because of the force exerted by the magnetic field on metal objects. An open MRI will not cause claustrophobia. The patient will need to be instructed to remove the hearing aid before the MRI, but this does not require consultation with the health care provider. Because contrast medium will not be used, shellfish allergy is not a contraindication to MRI.

DIF: Cognitive Level: Apply (application) REF: 1501

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

12. The nurse notes crackling sounds and a grating sensation with palpation of an older patients elbow. How will this finding be documented?

a.

Torticollis

b.

Crepitation

c.

Subluxation

d.

Epicondylitis

ANS: B

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.

DIF: Cognitive Level: Understand (comprehension) REF: 1500

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

13. Which finding is of highest priority when the nurse is planning care for a 77-year-old patient seen in the outpatient clinic?

a.

Symmetric joint swelling of fingers

b.

Decreased right knee range of motion

c.

Report of left hip aching when jogging

d.

History of recent loss of balance and fall

ANS: D

A history of falls requires further assessment and development of fall prevention strategies. The other changes are more typical of bone and joint changes associated with normal aging.

DIF: Cognitive Level: Apply (application) REF: 1494

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

14. Which finding from a patients right knee arthrocentesis will be of concern to the nurse?

a.

Cloudy fluid

b.

Scant thin fluid

c.

Pale yellow fluid

d.

Straw-colored fluid

ANS: A

The presence of purulent fluid suggests a possible joint infection. Normal synovial fluid is scant in amount and pale yellow/straw-colored.

DIF: Cognitive Level: Apply (application) REF: 1499 | 1503

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

15. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who are working in the orthopedic clinic?

a.

Grade leg muscle strength for a patient with back pain.

b.

Obtain blood sample for uric acid from a patient with gout.

c.

Perform straight-leg-raise testing for a patient with sciatica.

d.

Check for knee joint crepitation before arthroscopic surgery.

ANS: B

Drawing blood specimens is a common skill performed by UAP in clinic settings. The other actions are assessments and require registered nurse (RN)level judgment and critical thinking.

DIF: Cognitive Level: Apply (application) REF: 15-16

OBJ: Special Questions: Delegation; Multiple Patients TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

OTHER

1. Which part of the musculoskeletal assessment is the nurse doing in the video?

Click here to view the video clip

a. Passive hip range of motion

b. Inspection of the legs and feet

c. Internal and external hip rotation

d. Adduction and abduction of the hip

ANS:

D

Hip abduction and adduction is assessed by having the patient move the hip joint laterally and medially.

DIF: Cognitive Level: Understand (comprehension) REF: 1492 | 1498

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

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