Week #11: Musculoskeletal Flashcards
The nurse is developing a plan of care for a client found to have a strength problem. What would be an appropriate nursing diagnosis for this client?
a) Activity intolerance
b) Self-care deficit
c) Impaired physical mobility
d) Impaired walking
c) Impaired physical mobility
The Romberg test is one assessment that can be completed to assess balance.
a) True
b) False
a) True
What term is abbreviated “ROM”?
Range of Motion
Moving a part of the body away from the mid-line is called?
a) Abduction
b) Adduction
c) Extension
d) Flexion
a) Abduction
When assessing a client’s strength, it is necessary to:
a) Compare one side to the other
b) Assess the extremities at the same time
c) Compare upper and lower extremities
d) Assess upper and lower extremities at the same time
a) Compare one side to the other
An older adult client has been admitted to the unit. The client has problems with fine motor movement. What would be important to do for this client?
a) Open all packages and arrange the meal tray while communicating actions to the client
b) Teach the client to call for assistance when getting up to the bathroom
c) Evaluate for assistance devices
d) Assess gross motor function
a) Open all packages and arrange the meal tray while communicating actions to the client
Loss of bone density that occurs with greatest frequency in postmenopausal women is called?
a) Scoliosis
b) Lordosis
c) Osteoporosis
d) Kyphosis
c) Osteoporosis
A client presents to the ED after falling off a ladder while doing some outside painting at home. The client’s ankle appears swollen, out of alignment, and is painful to touch. What is the nurse’s first action?
a) Encourage early weight bearing and ambulation
b) Apply an ice pack to the affected extremity
c) Check for a pulse, color, temperature, and capillary refill
d) Splint and immobilize the affected extremity
c) Check for a pulse, color, temperature, and capillary refill
A client comes to the clinic and reports a sore knee. The nurse notes popping and cracking noises when the client attempts to bend the knee. The client exhibits signs of pain by facial expression. The nurse knows that the popping and cracking noises should be charted as what?
a) Crepitus
b) Grating noise
c) Tactile emphysema
d) Popping and cracking noises
a) Crepitus
Decreasing the angle between bones is called:
a) Extension
b) Eversion
c) Flexion
d) Inversion
c) Flexion
Turning the sole of the foot outward
Eversion
Movement of a part away from the center of the body
Abduction
Maneuver that decreases the angle between bones or brings bones together
Flexion
Turning the sole of the foot inward
Inversion
Movement of a part toward the center of the body
Adduction
Movement of a joint whereby one part of the body is moved away from another; increases the angle to a straight line or 0-degrees
Extension
Turning a structure to face upward
Supination
Turning a structure to face downward
Pronation
Extension beyond the neutral position
Hyperextension
The musculoskeletal system is composed of skeletal muscle and 5 types of connective tissues: bone, cartilage, ligaments, tendons, and articulations.
a) True
b) False
a) True
Nurses should compare each extremity to the other and examine painful or tender areas last.
a) True
b) False
a) True
____________ occurs in all people, but is most evident in women with small bony frames. Women experience rapid loss of bone density for the first 5-7 years after menopause.
Osteoporosis
Bone marrow cavities serves as sites of __________________, or the manufacturing of blood cells.
Hematopoiesis
_______________ is the lateral curvature of the spine, usually affecting both the thoracic and lumbar parts, with a deviation in one direction in the thoracic spine and in the other direction in the lumbar spine.
Scoliosis
_________________ is an exaggerated forward curvature of the spine that may occur in older adults.
Kyphosis
Name the type & # of each vertebrae:
Cervical (7)
Thoracic (12)
Lumbar (5)
Sacral (5)
Coccygeal (3-4)
Shortening of tendons, fascia, or muscles
Contracture
Wasting or shrinking of the muscle; can be caused by disuse such as wearing a cast
Atrophy
bending the ankles so that the toes move toward the head
dorsiflexion
moving the foot so that the toes move away from the head
plantar flexion
turning of a joint around a longitudinal axis
rotation
rotating an extremity medially along its axis
internal rotation
rotating an extremity laterally along its axis
external rotation
a circular motion that combines flexion, extension, abduction, and adduction
circumduction
moving a body part forward & parallel to the ground
protraction
moving a body part backward and parallel to the ground
retraction
moving a body part upward
elevation
moving a body part downward
depression
moving the thumb to touch the little finger
opposition
Describe the grading scale of muscle strength:
5/5 (100%), Normal: complete ROM against gravity & full resistance
4/5 (75%), Good: complete ROM against gravity & moderate resistance
3/5 (50%), Fair: complete ROM against gravity
2/5 (25%), Poor: complete ROM with the joint supported; cannot perform ROM against gravity
1/5 (10%), Trace: muscle contraction detectable, but no movement of the joint
0/5 (0%), Zero: no visible muscle contraction
episode of pain that lasts from seconds to less than 6 MOS
acute pain
temporary flare-up of moderate to severe pain that occurs when the Pt is taking around-the-clock meds for persistent pain
breakthrough pain
episode of pain that lasts for 6 MOS or longer; may be intermittent or continuous
chronic pain
superficial pain usually involving the skin or subcutaneous tissue
cutaneous pain
severe pain that is extremely resistant to relief measures
intractable pain
pain that result from a normal process that results in noxious stimuli being perceived as painful
nociceptive pain
pain that results as a direct consequence of a lesion or disease affecting abnormal functioning of the PNS or CNS
neuropathic pain
sensation of pain without demonstratable physiologic or pathologic substance; commonly observed after the amputation of a limb
phantom pain
pain in an area removed from that in which stimulation has its origin
referred pain
pain originating in structures in the body’s external wall
somatic pain
pain originating in the internal organs in the thorax, cranium, or abdomen
visceral pain
