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Which information in a 67-year-old woman’s health history will alert the nurse to the need for
a more focused assessment of the musculoskeletal system?
a. The patient sprained her ankle at age 13.
b. The patient’s mother became shorter with aging.
c. The patient takes ibuprofen (Advil) for occasional headaches.
d. The patient’s father died of complications of miliary tuberculosis.
ANS: B
A family history of height loss with aging may indicate osteoporosis, and the nurse should perform a more thorough assessment of the patient’s current height and other risk factors for osteoporosis. A sprained ankle during adolescence does not place the patient at increased current risk for musculoskeletal problems. A family history of tuberculosis is not a risk factor.
Occasional nonsteroidal antiinflammatory drug (NSAID) use does not indicate any increased musculoskeletal risk.
DIF: Cognitive Level: Apply (application)
REF:
1496
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
5. Which information obtained during the nurse’s assessment of a 30-year-old patient’s
nutritional-metabolic pattern may indicate the risk for musculoskeletal …show more content…
The nurse finds that a patient can flex the arms when no resistance is applied but is unable to
flex when the nurse applies light resistance. The nurse should document the patient’s muscle strength as level
a. 0.
b. 1.
c. 2.
d. 3.
ANS: D
A level 3 indicates that the patient is unable to move against resistance but can move against gravity. Level 1 indicates minimal muscle contraction, level 2 indicates that the arm can move when gravity is eliminated, and level 4 indicates active movement with some resistance.
DIF: Cognitive Level: Understand (comprehension)
REF: 1498
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
8. After completing the health history, the nurse assessing the musculoskeletal system will begin
by
a.
b.
c.
d.
having the patient move the extremities against resistance. feeling for the presence of crepitus during joint movement. observing the patient’s body build and muscle configuration. checking active and passive range of motion for the extremities.
ANS: C
The usual technique in the physical assessment is to begin with inspection. Abnormalities in muscle mass or configuration will allow the nurse to perform a more focused assessment
a more focused assessment of the musculoskeletal system?
a. The patient sprained her ankle at age 13.
b. The patient’s mother became shorter with aging.
c. The patient takes ibuprofen (Advil) for occasional headaches.
d. The patient’s father died of complications of miliary tuberculosis.
ANS: B
A family history of height loss with aging may indicate osteoporosis, and the nurse should perform a more thorough assessment of the patient’s current height and other risk factors for osteoporosis. A sprained ankle during adolescence does not place the patient at increased current risk for musculoskeletal problems. A family history of tuberculosis is not a risk factor.
Occasional nonsteroidal antiinflammatory drug (NSAID) use does not indicate any increased musculoskeletal risk.
DIF: Cognitive Level: Apply (application)
REF:
1496
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
5. Which information obtained during the nurse’s assessment of a 30-year-old patient’s
nutritional-metabolic pattern may indicate the risk for musculoskeletal …show more content…
The nurse finds that a patient can flex the arms when no resistance is applied but is unable to
flex when the nurse applies light resistance. The nurse should document the patient’s muscle strength as level
a. 0.
b. 1.
c. 2.
d. 3.
ANS: D
A level 3 indicates that the patient is unable to move against resistance but can move against gravity. Level 1 indicates minimal muscle contraction, level 2 indicates that the arm can move when gravity is eliminated, and level 4 indicates active movement with some resistance.
DIF: Cognitive Level: Understand (comprehension)
REF: 1498
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
8. After completing the health history, the nurse assessing the musculoskeletal system will begin
by
a.
b.
c.
d.
having the patient move the extremities against resistance. feeling for the presence of crepitus during joint movement. observing the patient’s body build and muscle configuration. checking active and passive range of motion for the extremities.
ANS: C
The usual technique in the physical assessment is to begin with inspection. Abnormalities in muscle mass or configuration will allow the nurse to perform a more focused assessment