Musculoskeletal Assessment Flashcards
Meet the Client: Ms. Chan Lieu
Ms. Chan Lieu is a 56-year-old Korean-American female with a history of osteoporosis. She visits the clinic, reporting the onset of low back pain.
Info
Priority Data Collection
The nurse notes the client’s history of osteoporosis and her report of low back pain. As Ms. Lieu walks to the exam room, the nurse prepares to complete a history and physical assessment, focusing on the musculoskeletal system. 1. The nurse begins the assessment as the client ambulates in the hallway. What observations should the nurse make while the client is walking to the exam room? (Select all that apply.) Fine motor function. Posture. Gait. Bone density. Balance.
Posture. Correct
Observation of the client’s posture can be completed while the client is ambulating. This assessment provides useful data related to musculoskeletal function.
Gait. Correct
Observation of the client’s gait can be completed while the client is ambulating. This assessment provides useful data related to musculoskeletal function.
Balance. Correct
Observation of the client’s balance can be completed while the client is ambulating. This assessment provides useful data related to musculoskeletal function.
2.
Once the client is settled in the exam room, which action by the nurse has the highest priority?
Obtain more in-depth information about the client’s osteoporosis management.
Review the client’s medical record for any history of bone or spinal fractures.
Gather data about the nature, location, and duration of the client’s back pain.
Compare bilateral muscle strength and tone in the client’s lower extremities.
Gather data about the nature, location, and duration of the client’s back pain.
Back pain can be a symptom of a variety of health problems. To ensure basic safety and homeostasis, it is most important for the nurse to obtain information related to the client’s report of pain.
Ms. Lieu places her hand over her lumbar area to show the nurse the location of her pain and rates it at a 7 on a scale of 1-10. The nurse consults the electronic medication administration record and notes a prescription for an anti-inflammatory medication.
3.
Indomethacin (Indocin) 50 mg capsules by mouth every 6 hours as needed for back pain is prescribed. Indomethacin 25 mg capsules are available. How many capsules should the nurse administer? (Enter the numerical value only. If rounding is required, round to the whole number.)
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4. Because of Ms. Lieu’s history of knee pain and current report of low back pain, which nursing action is most useful in developing an initial plan of care for the client? Obtain a family medical history. Complete a functional assessment. Observe for callus formation. Ask about any recent weight gain.
Complete a functional assessment.
A functional assessment provides information about the client’s ability to function and includes areas such as mobility and self-care measures. It is most important to gather this information to determine the client’s level of safety in basic functioning.
5. Ms. Lieu shares with the nurse that she often experiences knee pain. The nurse asks Ms. Lieu about other common joint symptoms. On which symptoms should the nurse focus? (Select all that apply.) Some correct choices were not selected. Stiffness. Swelling. Cramping. Numbness. Warmth.
Stiffness.
Stiffness is a common joint symptom related to acute inflammation or arthritis.
Swelling.
Swelling is a common joint symptom related to acute inflammation or arthritis.
Warmth.
Warmth is a common joint symptom related to acute inflammation or arthritis.
6.
Which information in Ms. Lieu’s history reflects a high risk for low back pain?
Frequently travels with her husband to Korea by air to visit relatives.
Traveling by air does not increase the risk for low back pain.
Spends her evenings working in her large vegetable and flower garden. Correct
Gardening activities such as bending and pulling, lifting, or moving heavy objects increases the risk for low back pain.
Often rides a bicycle to her job as a history professor at a local college.
Riding a bicycle and teaching are not activities that increase the risk for low back pain.
Volunteers on the weekend as a tour guide at a historical city mansion.
Spends her evenings working in her large vegetable and flower garden.
Gardening activities such as bending and pulling, lifting, or moving heavy objects increases the risk for low back pain.
Spinal Assessment
The nurse begins the physical assessment and prepares to assess the curvatures of the client’s spine.
7.
To check for scoliosis, the nurse provides which client instruction?
Stand with arms straight at your sides and your feet together.
Place hands on hips and lean to one side and then the other.
Twist from one side to the other with your hands on your hips.
Place feet apart and slowly raise both arms above your head.
Stand with arms straight at your sides and your feet together.
With the client standing upright, the nurse first observes for a difference in the elevation of the shoulders or scapulae before testing further for scoliosis by asking the client to touch her toes.
The client has no obvious scoliosis, and the nurse continues the spinal assessment.
8.
When observing the client from the side, the nurse observes a slightly convex thoracic curve and a slightly concave lumbar curve. What action should the nurse take in response to these findings?
Ask the client how long she has had a “Dowager’s hump.”
Record these symptoms of osteoporosis in the client’s chart.
Document the normal spinal curvature on the assessment form.
Note the client’s poor posture as a possible cause of her back pain.
Document the normal spinal curvature on the assessment form.
The curvatures observed are normal spinal curvatures, so no action is needed other than documentation of the finding.
9.
While assessing the spine, the nurse assesses Ms. Lieu’s low back pain further. Which action will help determine the cause of her pain?
Ask the client to lie supine and raise one leg, keeping it straight.
Watch the client while she stands upright and slowly squats down.
Instruct the client to balance on one foot with her arms at her sides.
Help the client to a prone position, rotating both legs inward.
Ask the client to lie supine and raise one leg, keeping it straight.
If sciatic pain occurs when raising a straight leg, the nurse should suspect the presence of a herniated disc.
10. Ms. Lieu follows the nurse’s instructions to swing her arms forward and up in a wide arc, then back. This action allows the nurse to observe what shoulder range of motion? Internal and external rotation. Abduction and adduction. Flexion and hyperextension. Forward and reverse motion.
Flexion and hyperextension.
Swinging the arms forward in a wide arc demonstrates forward flexion. Swinging the arms back behind the midline demonstrates hyperextension of the shoulder.
11.
While assessing shoulder range of motion, the nurse notes the absence of crepitation with movement. What action should the nurse take in response to this finding?
Document this normal finding in the assessment.
Ask the client about her intake of dietary calcium.
Record the degree of the range of motion limitation.
Review the client’s record for a history of arthritis.
Document this normal finding in the assessment.
Crepitation, a grating or crunching sound heard with joint movement, is an abnormal finding. An absence of crepitation is normal and should be documented in the assessment.
Upper Extremity Assessment
Ms. Lieu does not exhibit any sciatic pain. After completing the spinal assessment, the nurse assists Ms. Lieu back to a sitting position, with her legs dangling over the edge of the exam table.
The nurse begins the assessment of Ms. Lieu’s upper extremities. 12. The nurse next assesses the client’s elbows. When comparing these joints bilaterally, for what should the nurse observe? (Select all that apply.) Skin color. Tympany. Contour. Resonance. Size.
Skin color.
This is a characteristic that can be observed and provides data related to joints.
Contour.
This is a characteristic that can be observed and provides data related to joints.
Size.
This is a characteristic that can be observed and provides data related to joints.
13. The nurse observes Ms. Lieu as she rests her lower arms on a table with her hands at a 90 degree angle to the table and the thumbs up. Ms. Lieu turns her hands upward with the back of the hand flat on the table and then downward with the palm flat on the table. What action is the nurse observing? Flexion and extension of the wrist. Elbow supination and pronation. Lower arm adduction and abduction. Hand and finger hyperextension.
Elbow supination and pronation.
The client’s movements demonstrate a normal degree of elbow supination and pronation.
14.
The nurse prepares to palpate the joints in Ms. Lieu’s wrist and hands. First, the nurse supports the client’s hands. What action should the nurse take next?
Use both thumbs to apply gentle pressure.
Use the index fingers to lightly compress the pulses.
Ask the client to spread her fingers apart.
Instruct the client to make a fist with both hands.
Use both thumbs to apply gentle pressure.
Both thumbs are used to apply gentle but firm pressure over the joints to palpate for swelling, thickening, nodules, or tenderness.