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Chapter 44 notes
Care Management (Keiser University)
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Chapter 44: Assessment of the Musculoskeletal System
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is caring for an older client who has kyphosis and a widened gait. For which health
problems is the client at risk?
Osteoporosis
Contracture
Osteopenia
Falls
a.
b.
c.
d.
ANS: D
Kyphosis is caused by bone loss and causes the client to bend forward which changes the
center of gravity leading to problems with balance. Older adults who have balance issues are
at risk for falls.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Spinal deformities
MSC: Client Needs Category: Health Promotion and Maintenance
2. The nurse is teaching assistant personnel (AP) about care of an older ambulatory adult who
has osteopenia. Which statement by the AP indicates understanding of the teaching?
a. “I will tell the client to change positions frequently to prevent pressure injury.”
b. “I will remind the client to take frequent walks to strengthen bones.”
c. “I will assist the client with activities of daily living as needed.”
GRAto
DEthe
SLjoints
AB.to
COrelieve
M
d. “I will apply warm compresses
pain.”
ANS: B
The ambulatory client who has osteopenia has experienced bone loss. Therefore, taking walks
as a weight-bearing exercise helps to prevent further bone loss. The client does not have joint
pain and does not need assistance or position changes because the client is ambulatory and
probably independent.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Health promotion
MSC: Client Needs Category: Health Promotion and Maintenance
3. A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to
be pale and cool, with a 1+ pedal pulse. What action would the nurse perform first?
Assess the neurovascular status of the right leg.
Document the findings in the patient’s chart.
Elevate the left leg on at least two pillows.
Notify the primary health care provider immediately.
a.
b.
c.
d.
ANS: A
The nurse would compare findings of the two legs as these findings may be normal for the
client. If a difference is observed, the nurse would then notify the primary health care
provider. Documentation would occur after the nurse has all the data. Elevating the left leg
will not improve perfusion if there is a problem.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Diagnostic tests
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A hospitalized client’s strength of the upper extremities is rated at a 4. What does the nurse
understand about this client’s ability to perform activities of daily living (ADLs)?
a. The client is able to perform ADLs but not lift some items.
b. The client is unable to perform ADLs alone.
c. No difficulties are expected with ADLs.
d. The client would need almost total assistance with ADLs.
ANS: C
This rating indicates good muscle strength with full range of motion.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Muscle strength
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. An older client is distressed at body changes related to kyphosis. What response by the nurse
is appropriate?
Ask the client to explain more about these feelings.
Explain that these changes are irreversible.
Offer to help select clothes to hide the deformity.
Tell the client that safety is more important than looks.
a.
b.
c.
d.
ANS: A
Assessment is the first step of the nursing process, and the nurse would begin by getting as
much information about the client’s
as.possible.
GRADfeelings
ESLAB
COM Explaining that the changes are
irreversible discounts the client’s feelings. Depending on the extent of the deformity, clothing
will not hide it. While safety is more objectively important than looks, the client is worried
about looks and the nurse needs to address this issue.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Psychosocial assessment
MSC: Client Needs Category: Psychosocial Integrity
6. The nurse is taking a history from an older client who reports having frequent falls. Which
dietary habit could be contributing to the client’s problem?
Consumes high-protein foods.
Eats few concentrated sweets.
Limits fatty or greasy foods.
Avoids dairy products.
a.
b.
c.
d.
ANS: D
Falls can occur when older adults have inadequate calcium and Vitamin D because they are at
risk for osteopenia and osteoporosis. Dairy products have a high concentration of both
calcium and Vitamin D and this client avoids those foods. High-protein foods are
recommended to help prevent osteopenia and sweets and fatty/greasy foods have no impact on
bone health.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Changes associated with aging
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MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
7. The client’s electronic health record indicates genu varum. What does the nurse understand
this term to mean?
Bow-legged
Fluid accumulation
Knock-kneed
Spinal curvature
a.
b.
c.
d.
ANS: A
Genu varum is a bow-legged deformity. A fluid accumulation is an effusion. Genu valgum is
knock-kneed. A spinal curvature could be kyphosis or lordosis.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Musculoskeletal deformities
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
8. The nurse is teaching a client who had a left humeral biopsy about home care. Which
statement by the client indicates understanding of the nurse’s teaching?
“I will take my opioids only when I have severe pain.”
“I will keep my left arm elevated for 24 hours.”
“I will watch for tenderness and warmth around the biopsy site.”
“I will report any discomfort to my primary health care provider immediately.”
a.
b.
c.
d.
ANS: C
Bone biopsy is an ambulatory procedure which can cause some discomfort but not severe
pain. The client can use the affected arm soon after the procedure but should watch for
tenderness and warmth which could
GRADindicate
ESLABinfection.
.COM
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Musculoskeletal assessment, Diagnostic tests
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
9. The nurse is teaching assistive personnel (AP) about the risk for osteoporosis associated with
race or ethnicity. Which population typically has a decreased incidence of osteoporosis when
compared to Euro-Americans?
a. Irish Americans
b. African Americans
c. American Indians
d. Asian Americans
ANS: B
African Americans usually have more bone mass when compared to Euro-Americans which
makes them at a decreased risk for osteoporosis.
DIF: Remembering
TOP: Integrated Process: Culture and Spirituality
KEY: Musculoskeletal assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
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1. A female client is preparing to have open magnetic resonance imaging (MRI) of the spine.
What action(s) by the nurse is (are) most important to assess before the test? (Select all that
apply.)
a. Ask if the client has a history of kidney disease.
b. Ask the client if she could possibly be pregnant.
c. Ensure that the patient has no metal or electronic implants.
d. Assess the client for the ability to communicate.
e. Assess the client for a history of claustrophobia.
ANS: A, B, C, D
The contrast agent that is used for an MRI is gadolinium which can cause complications if the
client is pregnant or has kidney disease. The client needs to be able to communicate and
should not have any metal or electronic implants due to the magnetic nature of the machine.
For an open MRI, claustrophobia is not an issue because the client is not encased in the
device.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Diagnostic tests
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
2. The nurse is reviewing the laboratory profile for a client who has muscular dystrophy. Which
laboratory value(s) would the nurse expect to be elevated? (Select all that apply.)
Calcium (Ca)
Phosphate (PO4)
Creatine kinase (CK)
Lactic dehydrogenase (LDH)
Aspartate aminotransferase (AST)
GRADESLAB.COM
Aldolase (ALD)
a.
b.
c.
d.
e.
f.
ANS: C, D, E, F
Muscular dystrophy causes elevations in muscle enzymes and does not affect minerals like
calcium and phosphorus.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Diagnostic tests
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. An older client’s serum calcium level is 8.7 mg/dL (2.18 mmol/L). What possible
etiology(ies) does the nurse consider for this result? (Select all that apply.)
Good dietary intake of calcium and vitamin D
Normal age-related decrease in serum calcium
Possible occurrence of osteoporosis or osteopenia
Potential for metastatic cancer or Paget disease
Recent bone fracture in a healing stage
a.
b.
c.
d.
e.
ANS: B, C
This slightly low calcium level could be an age-related decrease in serum calcium or could
indicate a metabolic bone disease, such as osteoporosis or osteopenia. A good dietary intake
would be expected to produce normal values. Metastatic cancer, Paget disease, or healing
bone fractures will elevate calcium.
DIF: Applying
TOP: Integrated Process: Nursing Process: Analysis
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KEY: Musculoskeletal assessment, Diagnostic tests
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4. When assessing gait, what feature(s) would the nurse inspect? (Select all that apply.)
a. Balance
b. Ease of stride
c. Goniometer readings
d. Length of stride
e. Steadiness
ANS: A, B, D, E
To assess gait, look at balance, ease and length of stride, and steadiness. Goniometer readings
assess flexion and extension or joint range of motion.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Gait
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. The nurse takes a history on a male client reporting chronic back pain. Which factor(s) in the
client’s history may have contributed to his pain? (Select all that apply.)
Had a motor vehicle crash 10 years ago.
Played football in college and high school.
Has installed carpet and other flooring for 30 years.
Typically takes walks 3 to 4 days each week.
Eats two servings of dark, green leafy vegetables daily.
a.
b.
c.
d.
e.
ANS: A, B, C
A history of trauma caused by G
anRaccident,
ADESLAoccupation,
B.COM or contact sports can result in chronic
back pain. Regular exercise and diet helps to promote bone health.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, History
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
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