Question 1

The nurse is assessing the client's lateral flexion. Which commands by the nurse to the client will assess lateral flexion during the physical assessment?

Accepted Answer

Lateral flexion refers to the movement of bending sideways. Choice B, "Lean your head to the side and attempt to touch your ear to your shoulder," assesses lateral flexion of the neck. Choice C, "Bend sideways to the right and to the left while I stabilize your pelvis," assesses lateral flexion of the spine.

Question 2

The nurse is assessing a client whose chief complaint is an inability to move the fourth and fifth fingers. The nurse notes severe flexion in both of the affected fingers. Upon palpation, there are no complaints of pain from the client. Based on this data, which diagnosis does the nurse suspect?

Accepted Answer

The severe flexion of the fourth and fifth fingers is consistent with Dupuytren contracture, a condition in which the connective tissue beneath the skin of the palm becomes thick and forms into cords, which can pull the fingers down into a flexed position. The lack of pain upon palpation is also consistent with this diagnosis. Carpal tunnel syndrome typically presents with symptoms of pain, numbness, and tingling in the hand and fingers, and bursitis and osteoarthritis usually involve joint pain and inflammation, which are not present in this case.

Question 3

The nurse assesses a client and finds that a grating sound is present when a joint is bent and straightened. Which term will the nurse use when documenting this finding in the medical record?

Accepted Answer

The term used to describe the grating sound that occurs when a joint is bent and straightened is crepitation. Subluxation and joint dislocation both refer to the partial or complete displacement of a joint, while grinding is not a commonly used term to describe joint sounds.

Question 4

The nurse is caring for a client with a right femur fracture. Which type of bone does the nurse identify the femur as when discussing the fracture with the client?

Accepted Answer

The femur is classified as a long bone, along with other bones like the humerus, tibia, and fibula. Long bones are characterized by a shaft or diaphysis and two distinct ends or epiphyses. Fractures in long bones usually occur due to a significant force exerted on the bone, such as a fall, direct hit, or trauma.

Question 5

The nurse is conducting an assessment for a client whose chief complaint is numbness and tingling in the hands. This sensation is exacerbated when bending the wrist downward and pressing the backs of the hands together. Based on this data, which condition does the nurse suspect?

Accepted Answer

The symptoms described, including numbness and tingling in the hands that are worsened with wrist flexion and pressure, are indicative of carpal tunnel syndrome. Arthritis typically presents with joint pain and stiffness, while crepitus refers to a grating or crunching sound in the joints. Dupuytren contracture causes thickening and contraction of the hand's connective tissue, resulting in a claw-like deformity.

Question 6

The nurse notes an exaggerated lumbar curve while inspecting the spine of a client. Which term will the nurse use when documenting this finding in the medical record?

Accepted Answer

The term used to describe an exaggerated lumbar curve is lordosis.

Question 7

The nurse is preparing to assess a client's spine for abnormalities. Which command to the client during this assessment is most appropriate for the nurse to initiate?

Accepted Answer

This command allows the nurse to assess the spine while the client is standing and moving in different directions, providing a more complete view of any abnormalities. Sitting or bending over would not allow for the same level of observation. Dangling the arms while sitting could help to assess for nerve impingements, but it does not provide a full view of the spine. Stretching the arms overhead does not specifically assess the spine.

Question 8

The nurse notes full range of motion against gravity with moderate resistance when assessing muscle strength of the upper extremities in a client. When documenting the client's muscle strength, which term is appropriate?

Accepted Answer

"Good" is the appropriate term for muscle strength that demonstrates full range of motion against gravity with moderate resistance, typically rated as 4/5 on the muscle strength scale.

Question 9

The nurse notes swelling and tenderness of the olecranon process during palpation. The client's chief complaint is pain upon movement of the forearm and wrist. Based on this data, which condition does the nurse suspect?

Accepted Answer

The answer of The nurse notes swelling and tenderness of...

Question 10

The client is recovering from orthopedic surgery on a fractured arm. When discussing the effects of the fracture with the client, which skeletal bone functions will the nurse include in the teaching session?

Accepted Answer

The answer of The client is recovering from orthopedic surgery...

Question 11

The nurse is providing care to a client whose chief complaint is pain in the right foot. During the physical assessment, the nurse notes a deviation of the great toe from the midline and crowding of the remaining toes. There is also enlargement and inflammation noted in the area. Based on this data, which condition does the nurse suspect?

Accepted Answer

The nurse suspects a bunion, which is a deformity of the bones and joint at the base of the big toe, causing the big toe to turn inward and a bony bump to form on the outside of the foot. This also causes crowding and deviation of the remaining toes. Inflammation and enlargement of the area is also common. Flat foot and hammertoe may cause pain and deformity in the foot, but would not involve the specific presentation described. Gouty arthritis is characterized by sudden and severe pain, heat, and swelling in a joint, often the big toe, but there is no mention of sudden onset in the presented scenario.

Question 12

The nurse assesses a client whose chief complaint is tenderness and stiffness in the wrist and elbow. The client reports the discomfort is worsened with activity. Based on this data, which condition does the nurse suspect?

Accepted Answer

The client's chief complaint of tenderness and stiffness in the wrist and elbow that worsens with activity is suggestive of osteoarthritis. In contrast, carpal tunnel syndrome presents with numbness and tingling in the hands, while Dupuytren contracture presents with flexion contracture of the fingers. Crepitus of the wrists is a non-specific symptom and can be seen in various conditions.

Question 13

The nurse asks the client to pull the toes up towards the nose during an examination of the lower extremities. Which is the nurse assessing based on this description?

Accepted Answer

The nurse is assessing for dorsiflexion, which involves pulling the toes up towards the nose. Inversion, eversion, and plantar flexion are other movements of the foot, but they are not being assessed in this scenario.

Question 14

A client comes to the emergency department (ED) complaining of a painful injury to the right knee received while playing basketball. Which examination techniques will the nurse include during the physical assessment of this client?

Accepted Answer

Inspection and palpation are standard techniques for assessing injuries. Bulge sign testing and ballottement are specific tests for detecting fluid in the knee joint, which is relevant for a knee injury. Percussion is not typically used for knee injuries.

Question 15

The nurse is preparing to assess the posterior spine of a client. Which is the landmark the nurse will use to determine symmetry?

Accepted Answer

The spinous processes are the landmarks used to determine symmetry of the spine. Option C shows the spinous processes in a straight line, indicating symmetry. Options A, B, and D do not show the spinous processes and are not useful for determining symmetry.

Question 16

A young adult client is seen in the clinic complaining of a lump on the left wrist, but states it is not painful. The nurse notes a round mass on the back of the wrist. Based on this data, which condition does the nurse suspect?

Accepted Answer

A round mass on the back of the wrist that is not painful is characteristic of a ganglion cyst. Rheumatoid arthritis and osteoarthritis typically involve joint pain and swelling, while carpal tunnel syndrome results in numbness, tingling, and pain in the hand and arm.

Question 17

The school nurse is assessing adolescent females for scoliosis. Which area of the spine does the nurse plan to assess?

Accepted Answer

The answer of The school nurse is assessing adolescent females...

Question 18

The nurse is caring for a client with a knee injury. When documenting this injury in the medical record, the nurse identifies the knee as which type of joint?

Accepted Answer

The knee joint is classified as a hinge joint because it allows for movement in only one axis, like a hinge on a door. The other joint options listed, saddle, pivot, and plane, do not fit the anatomical description of the knee joint.

Question 19

The nurse is performing the bulge test on a client's left knee. Which area will the nurse assess for bulging during this test?

Accepted Answer

The answer of The nurse is performing the bulge test...

Question 20

The nurse is caring for a client with an injury to the arm. Which degree of wrist movement is appropriate when assessing extension?

Accepted Answer

The normal range of wrist extension is approximately 70 degrees.

Quiz 25: Musculoskeletal System