Chapter 49: Assessment of the Musculoskeletal System

Chapter 49: Assessment of the Musculoskeletal System

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. A client is having a myelography. What action by the nurse is most important?
   1. Assess serum aspartate aminotransferase (AST) levels.
   2. Ensure that informed consent is on the chart.
   3. Position the client flat after the procedure.
   4. Reinforce the dressing if it becomes saturated.

ANS:   B

This diagnostic procedure is invasive and requires informed consent. The AST does not need to be assessed prior to the procedure. The client is positioned with the head of the bed elevated after the test to keep the contrast material out of the brain. The dressing should not become saturated; if it does, the nurse calls the provider.

DIF:     Applying/Application                         REF: 1025                   KEY: Musculoskeletal system| musculoskeletal assessment| musculoskeletal disorders MSC:         Integrated Process: Nursing Process: Implementation                                 NOT:                          Client Needs Category: Safe and Effective Care Environment: Management of Care

2. A client is undergoing computed tomography (CT) of a joint. What action by the nurse is most important before the test?
   1. Administer sedation as prescribed.
   2. Assess for seafood or iodine allergy.
   3. Ensure that the client has no metal on the body.
   4. Provide preprocedure pain medication.

ANS:   B

Because CT uses iodine-based contrast material, the nurse assesses the client for allergies to iodine or seafood (which often contains iodine). The other actions are not needed.

DIF:     Applying/Application                         REF: 1028                   KEY: Musculoskeletal system| musculoskeletal assessment| musculoskeletal disorders| diagnostic testing             MSC: Integrated Process: Nursing Process: Assessment NOT:                                   Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

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 1+/4+ pedal pulses. What action by the nurse is best?
   1. Assess the neurovascular status of the right leg.
   2. Document the findings in the client’s chart.
   3. Elevate the left leg on at least two pillows.
   4. Notify the provider of the findings immediately.

ANS:   A

The nurse should compare findings of the two legs as these findings may be normal for the client. If a difference is observed, the nurse notifies the provider. Documentation should occur after the nurse has all the data. Elevating the left leg will not improve perfusion if there is a problem.

DIF:            Applying/Application                         REF:    1027                 KEY: Musculoskeletal system| musculoskeletal assessment| musculoskeletal disorders| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT:                     Client Needs Category: Safe and Effective Care Environment: Management of Care

4. A hospitalized client’s strength of the upper extremities is rated at 3. What does the nurse understand about this client’s ability to perform activities of daily living (ADLs)?
   1. The client is able to perform ADLs but not lift some items.
   2. No difficulties are expected with ADLs.
   3. The client is unable to perform ADLs alone.
   4. The client would need near-total assistance with ADLs.

ANS:           A

This rating indicates fair muscle strength with full range of motion against gravity but not resistance. The client could complete ADLs independently unless they required lifting objects.

DIF:            Understanding/Comprehension         REF:    1024                 KEY: Musculoskeletal system| musculoskeletal assessment| musculoskeletal disorders| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT:                     Client Needs Category: Physiological Integrity: Physiological Adaptation

5. A client is distressed at body changes related to kyphosis. What response by the nurse is best?
   1. Ask the client to explain more about these feelings.
   2. Explain that these changes are irreversible.
   3. Offer to help select clothes to hide the deformity.
   4. Tell the client safety is more important than looks.

ANS:           A

Assessment is the first step of the nursing process, and the nurse should begin by getting as much information about the client’s feelings as possible. 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/Application                         REF:    1021

KEY:          Musculoskeletal system| musculoskeletal assessment| musculoskeletal disorders|

psychosocial response| coping| therapeutic communication

MSC:          Integrated Process: Nursing Process: Assessment

NOT:   Client Needs Category: Psychosocial Integrity