Musculoskeletal Assessment

Question 1

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.

Answer 1

Info

Question 2

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.

Answer 2

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.

Question 3

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.

Answer 3

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.

Question 4

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.)

Answer 4

2

Question 5

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.

Answer 5

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.

Question 6

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.

Answer 6

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.

Question 7

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.

Answer 7

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.

Question 8

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.

Answer 8

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.

Question 9

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.

Answer 9

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.

Question 10

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.

Answer 10

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.

Question 11

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.

Answer 11

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.

Question 12

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.

Answer 12

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.

Question 13

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.

Answer 13

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.

Question 14

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.

Answer 14

Elbow supination and pronation.

The client’s movements demonstrate a normal degree of elbow supination and pronation.

Question 15

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.

Answer 15

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.

Question 16

Recording and Reporting Assessment Data
15.
While palpating the client’s hands, the nurse asks Ms. Lieu if she has any tenderness in her fingers. Ms. Lieu reports that sometimes her fingers get stiff after several hours of computer work but states she is not currently experiencing any tenderness. When using the SOAP format of charting, how should the nurse document this finding?
O: Client reports fingers are stiff.
S: History of finger discomfort.
S: Fingers get stiff after computer work.
O: Denies finger tenderness at present.

Answer 16

S: Fingers get stiff after computer work.
This notation correctly identifies the client’s report of finger stiffness as a subjective (S) finding and accurately and concisely describes what the client reported.

Question 17

16.
Ms. Lieu is able to move her upper extremities through complete range of motion. In documenting full range of motion of the upper extremities, the nurse is able to note the absence of which abnormality?
  Arthritis.
  Kyphosis.
  Flaccidity.
  Contracture.

Answer 17

Contracture.
A contracture is a shortening of a muscle resulting in limited range of motion. Full range of motion indicates that no contractures are present.

Question 18

Related Assessment: Developmental Stage

While the nurse documents the findings related to the upper extremity assessment, the nurse and Ms. Lieu continue the conversation about the stiffness in her fingers after using the computer. Ms. Lieu laughs quietly and states, “Getting older is not much fun. I often wonder how much longer I can keep working before my body gives out on me.”
17.
In responding to Ms. Lieu, the nurse recognizes that the client is dealing with issues related to which of Erikson’s developmental stages?
Initiative vs. guilt.
Identity vs. inferiority.
Generativity vs. stagnation.
Integrity vs. despair.

Answer 18

Generativity vs. stagnation.
According to Erikson’s developmental framework, this is the central task of the adult and is supported by the client’s expressed concern about continuing to work as she gets older.

Question 19

18.
Ms. Lieu continues the conversation, stating, “I guess I may have to change the way I do certain things in order to continue to do the things I love.” How should the nurse respond to this statement?
Recognize that the client has regressed to an earlier developmental stage because of her worry about her current physical problems.
Offer encouragement to the client as she struggles to find meaning in her life despite her current physical problems.
Document on the assessment form that the client seems to be overly fixated on her current physical problems.
Support the client as she considers strategies to adapt to the physiologic changes contributing to her current physical problems.

Answer 19

Support the client as she considers strategies to adapt to the physiologic changes contributing to her current physical problems.
Changing and adapting behavior to maintain control is emphasized by Erikson. A positive resolution to the client’s developmental task of generativity vs. stagnation is the ability to be creative and productive, and the nurse should support the client in her efforts to adapt creatively to the physiologic changes causing her current physical problems.

Question 20

19.
Ms. Lieu lies down on the exam table in a supine position. The nurse assesses adduction and abduction of the hip by instructing the client to take what action?
Bend the knee so the foot is flat on the table and allow the knee to drop inward then outward.
Swing the entire leg laterally and then medially, keeping the knee straight while moving.
Lift each leg straight above the body to a 90-degree angle.
Turn both legs so the toes are pointed inward and then outward.

Answer 20

Swing the entire leg laterally and then medially, keeping the knee straight while moving.
Lateral movement demonstrates abduction, and medial movement demonstrates adduction.

Question 21

Ms. Lieu demonstrates full range of motion of her hips.
20.
While Ms. Lieu moves her legs through the various forms of range of motion, the nurse grades her muscle strength. To indicate 100% muscle strength, the nurse assesses for movement against which? (Select all that apply.)
  gravity.
  rest.
  light touch.
  pain.
  resistance.

Answer 21

gravity.
When assessing muscle strength, the nurse assesses for movement against gravity.

resistance.
When assessing muscle strength, the nurse assesses for movement against resistance.

Grade 5, or 100% muscle strength, is present when the client demonstrates full range of motion against gravity and resistance.

Question 22

21.
To assess muscle strength in the foot, the nurse next asks the client to dorsiflex her foot. The client points her toes downward. What action should the nurse take next?
Apply gentle pressure over the client’s toes.
Place one hand on the bottom of the client’s foot.
Ask the client to flex her foot upward.
Help the client evert and then invert her foot.

Answer 22

Ask the client to flex her foot upward.
Dorsiflexion involves pointing the toes upward, so the nurse should use language the client can understand to first position the foot correctly.

Question 23

22.
Ms. Lieu states she is uncomfortable lying on the exam table, so the nurse assists her to a sitting position before completing the assessment of her knees. The nurse begins by observing the anterior thighs and knees. How should the nurse assess for the presence of muscle atrophy?
Gently apply pressure around the patella.
Observe the size of the muscle.
Palpate the tissues for edema.
Measure the muscle with a goniometer.

Answer 23

Observe the size of the muscle. Correct
Atrophy, decrease in size, may first be observed in the medial portion of the anterior thigh muscle and is a sign of muscle disuse.

Question 24

23.
Earlier, Ms. Lieu reported that she often experiences unilateral left knee pain. The nurse palpates her left knee and notes the presence of a small amount of swelling. Which sign should the nurse attempt to elicit?
  Bulge sign.
  Battle sign.
  Allis sign.
  Tinel’s sign.

Answer 24

Bulge sign. Correct
A positive Bulge sign is found when very small amounts of fluid move across the joint. When swelling is palpated, the nurse may attempt to elicit this sign.

Question 25

A Change in Condition

Following the completion of the assessment, Ms. Lieu stands up next to the exam table. She grabs hold of the table and lurches forward, indicating that her knee suddenly “gave way.” The nurse assists her back to a sitting position on the exam table.
24.
Upon further questioning by the nurse, Ms. Lieu reports that this buckling of her knee has occurred several times previously. What additional information is most important for the nurse to obtain?
Whether she takes any pain medication for her knee pain.
The date she last had her bone density measured.
Any recent history of trauma or injury to the affected knee.
How frequently she performs weight-bearing exercises.

Answer 25

Any recent history of trauma or injury to the affected knee.
When the knee gives way suddenly, the nurse should determine if the client has experienced trauma to the area. This information is important in determining the cause of the symptom.

Question 26

25.
The nurse performs McMurray’s test and hears an audible click while maneuvering Ms. Lieu’s left leg. In response to this finding, what action should the nurse implement?
Observe the client’s gait as she walks across the room.
Explain to the client that her knee dislocation has resolved.
Plan to instruct the client about knee strengthening exercises.
Report the assessment to the clinic healthcare provider.

Answer 26

Report the assessment to the clinic healthcare provider. Correct
An audible click during McMurray’s test indicates that the client may have a torn meniscus. This finding should be reported promptly to the healthcare provider for further evaluation and treatment.