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Terms in this set (63)How would you document normal muscle strength? 5/5 Upon examination of an elderly client, the nurse finds hard, painless nodules over the distal interphalangeal joints. What is the appropriate term the nurse should use to document this finding in the client's medical records? Heberden's nodes The nurse should document the hard, painless nodules over the distal interphalangeal joints as Heberden's nodes. Bones in synovial joints are joined together by Bones in synovial joints are joined by ligaments, which are strong, dense bands of fibrous connective tissue. Assessment of a client's ankle joint includes palpation along the Achilles tendon to look for which of the following?
Palpation of the Achilles tendon involves assessing for tenderness or nodules The nurse is going to test range of motion in a patient. To test extension of the triceps muscle, the nurse would instruct the patient to straighten the elbow While assessing muscle strength in an older adult client, the nurse determines that the client's knee joint has a rating of 3 and exhibits active motion against gravity. The nurse should document the client's muscle strength as being/having average weakness. After teaching a group of students about the bones and their functions, the instructor determines that the teaching was successful when the students state that blood cells are produced in which of the following? The red marrow of the bone is responsible for producing red blood cells The nurse is preparing an educational offering to help reduce musculoskeletal injuries for members of a community. What should the nurse include in these instructions? • Using proper body mechanics with lifting objects Assessment reveals that a client has slight weakness with active range of motion against some resistance. The nurse would document this as which of the following? 4/5 A client expresses to the nurse that he has a "giving in" or "locking" sensation in the knee. Which test should the nurse perform to elicit related findings of a possible tear in the meniscus of the client's knee? McMurray's test carpal tunnel syndrome Phalen's test test are done to detect the presence of fluid in the knee joint. The Ballottement test and the Bulge test A nurse is providing health education about osteoporosis to a community group. What ethnicity is considered to be an independent risk factor for osteoporosis? Caucasian ethnicity is a risk factor for osteoporosis. A client receives physical therapy for carpal tunnel syndrome. Which action by the nurse is appropriate to assess the efficacy of the treatment? Place the backs of both hands against each other The nurse should ask the client to place the backs of both hands against each other while flexing the wrist 90 degrees downwards for 60 seconds for the Phalen's test. The nurse is examining an older adult client. During the physical assessment, the client appears to be getting fatigued. What can the nurse do to help the client finish the assessment? Divide the assessment into portions While reviewing a client's chart before seeing the client for the first time, the nurse notes that the client has a diagnosis of Dupuytren contracture. The nurse anticipates that the client will exhibit inability to extend the ring and little finger. Which movement should the nurse instruct the client to perform to assess range of motion for the knee? The nurse should instruct the client to perform flexion to assess the range of motion for the client's knee. Circumduction Circumduction is the circular motion of the joint. Rotation Rotation involves turning the head to the right shoulder then back to midline and then turning the head to the left shoulder then back to midline Abduction Abduction refers to moving away from the midline of the body. flexion and extension. The knees are capable of performing only flexion and extension. Asking the client to move the arms forward Flexion is bending the extremity at the joint and decreasing the angle of the joint. Extension is straightening the extremity at the joint and increasing the angle of the joint. A client is brought to the health care facility with a sudden loss of movement on the right side of the body. Upon assessment, the nurse finds that the client has a slight flicker of contraction in the muscles on the right side. What should the nurse document as the muscle strength rating? The nurse should rate the muscle strength as 1. Muscle rating 4 is given when the client is able to perform active motion against some resistance. When the client is able to perform active movements against gravity, the muscle strength is graded as 3. If the client is able to perform passive ROM, the muscle strength is rated as 2 A patient presents at the clinic with a history of cerebral palsy. When examining the patient you note increased resistance that is rate dependent and increases with rapid movement. What would you chart about this patient? Patient demonstrates spasticity Spasticity is increased resistance that worsens at the extremes of range. Spasticity, seen in central corticospinal tract diseases, is rate dependent, increasing with rapid movement. The client is complaining that his lower joints are increasingly painful as the day progresses. The nurse suspects the client is experiencing what musculoskeletal disorder? Osteoarthritis is characterized by pain with motion that increases throughout the day. discomfort decreases with motion Rheumatoid arthritis Chronic pain and fatigue fibromyalgia a sharp, knife-lie pain bone fraction To assess abduction of the shoulders and arms, a nurse should ask a client to do which of the following? Bring both hands together overhead starting with the arms at the sides adduction Asking the client to move the arms to the sides starting with the arms overhead A nurse inspects a flattened lumbar curvature in a client. Which of the following conditions should the nurse most suspect in this client? A flattened lumbar curvature may be seen with a herniated lumbar disc or ankylosing spondylitis Which action by a nurse is a correct method for performing the Tinel's test to determine the presence of carpel tunnel syndrome? Percuss lightly on the inner aspect of the wrist. Sarah presents with left lateral knee pain and has some locking in full extension. There is tenderness over the medial joint line. When the knee is extended with the foot externally rotated and some valgus stress is applied, a click is noted. What is the most likely diagnosis? This maneuvre is called McMurray's test. Along with the medial joint line tenderness, the nurse should suspect a medial meniscus injury. A 50-year-old woman presents with "left hip pain" of several weeks duration. She is exquisitely tender when the nurse presses over her proximal lateral thigh. What is her most likely health problem? Bursitis is usually accompanied by tenderness on examination. This location is consistent with trochanteric bursitis. The nurse suspects carpal tunnel syndrome after examining a patient in the clinic. A test result that would suggest this diagnosis would be weak opposition of the thumb When assessing the client's upper extremities, the nurse instructs the client to put the hands behind the neck with the elbows pointed laterally. This positioning facilitates assessment of which of the following functions? External rotation of the shoulder A nurse asks a client to bring the hands together behind the head with the elbows flexed. The nurse is testing which of the following? External rotation Assessment reveals that a client has slight weakness with active range of motion against some resistance. The nurse would document this as which of the following? 4/5 Inspection of a client's knee reveals swelling, and the nurse suspects that there is significant fluid in the knee. Which of the following would the nurse use to confirm the suspicion? Ballottement test A nurse obtains an order to measure a client's leg length. How should a nurse correctly implement this order? Measure from the anterior superior iliac spine to the medial malleolus In which position should the nurse assist the patient when preparing to examine the tibiofemoral joint of the knee? To examine the tibiofemoral joint of the knee, the nurse should ask the patient to sit on the edge of the examining table with the knees flexed. is used to assess muscle strength. supine position is used to assess the integrity of the Achilles' tendon. prone position is used to assess knee alignment and contours. standing position Increased lumbar curvature, which compensates for the enlarging uterus in pregnant women, is called what? Lordosis, increased lumbar curvature, compensates for the enlarging uterus. overcurvature of the spine in the thoracic and sacral spine, can result from arthritis, osteoporosis, or trauma Kyphosis is a side to side curvature of the spine. Scoliosis When assessing muscle tone and strength, the nurse would document expected findings as upper and lower extremity muscle strength is 5/5 bilaterally" A client visits the clinic and tells the nurse that she has joint pain in her hands, especially in the morning. The nurse should assess the client further for signs and symptoms of Pain and stiffness in the joints is associated with arthritis. While assessing the elbow of an adult client, the client complains of pain and swelling. The nurse should further assess the client for Redness, heat, and swelling may be seen with bursitis of the olecranon process due to trauma or arthritis. When examining a client with a rotator cuff tear, which of the following would the nurse expect to find? Limited abduction calcified tendonitis. Chronic pain and limitation of all shoulder motion rotator cuff tendonitis Sharp catches of pain A client complains of temporomandibular joint (TMJ) pain. Which of the following would the nurse most likely assess? Difficulty
chewing After a physical assessment, the nurse determines that a patient has full range of motion of the temporomandibular joint. What did the nurse assess in this patient? (Select all that apply.) • Opened and closed the mouth Which action by a nurse is a correct method for performing Tinel's test to determine the presence of carpel tunnel syndrome? Percuss lightly on the inner aspect of the wrist The nurse should tap at the inner aspect of the wrist to percuss the median nerve because the median nerve is located at the inner aspect of the wrist where it enters the carpal canal Mrs. Fletcher presents to the office with chronic unilateral pain when chewing. She does not have facial or scalp tenderness. Which of the following is the most likely cause of her pain? Temporomandibular joint syndrome Temporomandibular joint syndrome is a very common cause of pain with chewing. Which nutrient deficiency should a nurse recognize as placing a client at risk for osteoporosis?
A calcium deficiency increases the risk osteoporosis Upon examination of an elderly client, the nurse finds hard, painless nodules over the distal interphalangeal joints. What is the appropriate term the nurse should use to document this finding in the client's medical records? Heberden's nodes Which joint movement is a nurse testing when asking a client to move an extremity towards the body? Adduction A nurse notices that a client's flexibility of the right elbow is less than the left elbow. What is an appropriate action by the nurse in regard to this finding? Measure movement with a goniometer A nurse is inspecting a client's gait. Which of the following would indicate an abnormal finding? Toes point out Abnormal findings in gait include the following: uneven weight bearing is evident; client cannot stand on heels or toes; toes point in or out; client limps, shuffles, propels forward, or has wide-based gait After assessing the client for posture and body alignment, how would the nurse document head position in relation to the spine if alignment is normal with noticeable defect? The head is midline and aligned with the spine The nurse is performing an assessment of a client's musculoskeletal system. The nurse should begin the assessment by examining which of the following? The client's gait Gait inspection provides a valuable overview of musculoskeletal function. For this reason, it is usually performed at the beginning of the objective exam and prior to more detailed assessments Sets with similar termschapter 21 CP44 terms EliMomKar Assessment Ch.24 Musculoskelatal Prep U93 terms kaylaiD27 musculoskeletal system41 terms quizlette0527 PrepU: HHA-Ch.24 Musculoskeletal System53 terms ztfang Sets found in the same folderChapter 24 Assessing Musculoskeletal system42 terms Alanderos15 Health Assessment: Assessing Musculoskeletal System27 terms painverse Assessment Ch 24 Muscoskeletal Prep U25 terms Michelle_Le73 prepu59 terms logan_katherine Other Quizlet setsPsychology 2010 Exam 1 Quiz Questions45 terms Karlee_Foster1 Skin abnormals and nutrition (Board activity defin…37 terms brooke_e_dPLUS religion test 7,8,10 commandment28 terms ritabrahamian AH Final- Ch. 21 auditory problems14 terms Jonquille Related questionsQUESTION What are the causes of traumatic amputations? 8 answers QUESTION When a person with hemiplegia is putting on a sweater what is the correct order of dressing/undressing the affected limb? 2 answers QUESTION what is included in the upper respiratory tract? 15 answers QUESTION What are the components of the subjective exam? 14 answers How will you grade an active motion against some resistance strength classification is slight weakness?When the client is able to perform the active motion against some resistance, it is classified as slight weakness. If the client has only a slight flicker of contraction, muscle strength is classified as severe weakness.
When assessing muscle tone and strength the nurse would document expected findings as?When assessing muscle tone and strength, the nurse would document expected findings a: "upper and lower extremity muscle strength is 5/5 bilaterally", 5/5 (100%) normal muscle strength with complete ROM against gravity and full resistance.
What movement from the patient does a nurse request to assess for hyperextension of the hip?Hyperextension of the hip can be checked by asking the patient to lie prone on the table and slowly lifting the leg being examined; this should be possible to 15 degrees or greater.
What is increased muscle tone in both directions that is not rate dependent quizlet?What is increased muscle tone in both directions that is not rate dependent? Rigidity. You are the school nurse in the local high school.
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Which score on the muscle strength scale will the nurse document for a patient who can perform active movement against gravity and some resistance?
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