Chapter 23: Musculoskeletal System

Jarvis: Physical Examination and Health Assessment, 8th Edition

Multiple Choice

1. A patient is being assessed for range-of-joint movement. The nurse asks him to move his arm in toward the center of his body. What is this movement called?

a. Flexion b. Abduction c. Adduction d. Extension

ANS: C

Moving a limb toward the midline of the body is called adduction; moving a limb away from the midline of the body is called abduction. Flexion is bending a limb at a joint; and extension is straightening a limb at a joint.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care a. Flexion b. Abduction c. Adduction d. Extension

2. A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement?

ANS: A

Flexion, or bending a limb at a joint, is required to move the hand to the mouth. Extension is straightening a limb at a joint. Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. Bones b. Joints c. Muscles d. Tendons

3. What are the functional units of the musculoskeletal system?

ANS: B

Joints are the functional units of the musculoskeletal system because they permit the mobility needed to perform the activities of daily living. The skeleton (bones) is the framework of the body. There are three types of muscles: skeletal, smooth, and cardiac and they produce movement when they contract. Tendons are strong fibrous cords that attach skeletal muscles to the bones. The other options are not correct.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. Liver b. Spleen c. Kidneys d. Bone marrow

4. When reviewing the musculoskeletal system, the nurse should recall that hematopoiesis takes place where?

ANS: D

The musculoskeletal system functions to encase and protect the inner vital organs, to support the body, to produce red blood cells (hematopoiesis) in the bone marrow, and to store minerals. The other options are not correct. The liver has many functions such as detoxifying the blood, production of bile, and synthesis of proteins needed for blood to clot, but hematopoiesis is not one of its functions. The spleen has many functions such as filtering the blood as part of the immune system, recycling old red blood cells, and storing platelets and white bloods cells but it is not the location of hematopoiesis. The kidney also has many functions such as maintaining fluid balance, filtering minerals, and production of hormones that help stimulate red blood cells production; however, it is not the location of hematopoiesis.

DIF: Cognitive Level: Remembering (Knowledge)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. Bursa b. Tendons c. Cartilage d. Ligaments

5. What are the fibrous bands that run directly from one bone to another, strengthen the joint, and help prevent movement in undesirable directions called?

ANS: D

Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called ligaments. The other options are not correct.

DIF: Cognitive Level: Remembering (Knowledge)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care a. Inversion b. Supination c. Protraction d. Circumduction

6. The nurse notices that a woman in an exercise class is unable to do one-person jump rope. What does the nurse know that the shoulder must be able to do in order for one to be able to do one-person jump rope?

ANS: D

Circumduction is defined as moving the arm in a circle around the shoulder. This movement is necessary to perform one-person jump rope. Inversion is the moving of the sole of the foot inward at the ankle. Supination is turning the forearm so the palm is down. Protraction is moving a body part forward and parallel to the ground.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. Intervertebral foramen b. Condyle of the mandible c. Temporomandibular joint d. Zygomatic arch of the temporal bone

7. What is the articulation of the mandible and the temporal bone called?

ANS: C

The articulation of the mandible and the temporal bone is the temporomandibular joint. The other responses are not correct.

DIF: Cognitive Level: Remembering (Knowledge)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care a. The depression inferior to the tragus of the ear b. The depression superior to the tragus of the ear c. The depression anterior to the tragus of the ear d. The depression posterior to the tragus of the ear

8. To palpate the temporomandibular joint, where should the nurse place his or her fingers?

ANS: C

The temporomandibular joint can be felt in the depression anterior to the tragus of the ear. The other locations are not correct.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. 5 lumbar b. 5 thoracic c. 7 sacral d. 12 cervical

9. Of the 33 vertebrae in the spinal column, which is correct?

ANS: A

There are 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3 to 4 coccygeal vertebrae in the spinal column.

DIF: Cognitive Level: Remembering (Knowledge)

MSC: Client Needs: Health Promotion and Maintenance a. First sacral b. Fourth lumbar c. Seventh cervical d. Twelfth thoracic

10. If an imaginary line were drawn connecting the highest point on each iliac crest. What vertebra would that line cross?

ANS: B

An imaginary line connecting the highest point on each iliac crest crosses the fourth lumbar vertebra. The other options are not correct.

DIF: Cognitive Level: Remembering (Knowledge)

MSC: Client Needs: Health Promotion and Maintenance a. Vertebral column b. Nucleus pulposus c. Vertebral foramen d. Intervertebral disks

11. The nurse is explaining to a patient that there are shock absorbers in his back to cushion the spine and to help it move. What is the nurse referring to as shock absorbers ?

ANS: D

Intervertebral disks are elastic fibrocartilaginous plates that cushion the spine similar to shock absorbers and help it move. The vertebral column is the spinal column itself. The nucleus pulposus is located in the center of each disk. The vertebral foramen is the channel, or opening, for the spinal cord in the vertebrae.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. Nucleus pulposus b. Medial epicondyle c. Glenohumeral joint d. Articular processes

12. The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. When explaining the structures involved in his injury, what should the nurse include?

ANS: C

A rotator cuff injury involves the glenohumeral joint, which is enclosed by a group of four powerful muscles and tendons that support and stabilize it. The other options are not in or near the rotator cuff or shoulder. The nucleus pulposus is located in the center of each intervertebral disk. The articular processes are projections in each vertebral disk that lock onto the next vertebra, thereby stabilizing the spinal column. The medial epicondyle is located at the elbow.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. “That is the subacromial bursa.” b. “That is the acromion process.” c. “That is the glenohumeral joint.” d. “That is the greater tubercle of the humerus.”

13. During an interview the patient states, “I can feel this bump on the top of both of my shoulders—it doesn’t hurt but I am curious about what it might be.” What should the nurse tell this patient?

ANS: B

The bump of the scapula’s acromion process is felt at the very top of the shoulder. The other options are not correct.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Health Promotion and Maintenance a. Circumduction b. Flexion and extension c. Inversion and eversion d. Supination and pronation

14. The nurse is checking the range of motion in a patient’s knee and knows that the knee is capable of which movement(s)?

ANS: B

The knee is a hinge joint, permitting flexion and extension of the lower leg on a single plane. The knee is not capable of circumduction, inversion, eversion, supination, or pronation.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. Tibiotalar b. Interphalangeal c. Tarsometatarsal d. Metacarpophalangeal

15. A patient is visiting the clinic for an evaluation of a swollen, painful knuckle. The nurse notices that the knuckle above his ring on the left hand is swollen and that he is unable to remove his wedding ring. What is the name of this patient’s affected joint?

ANS: D

The joint located just above the ring on the finger is the metacarpophalangeal joint. The interphalangeal joint is located distal to the metacarpophalangeal joint. The tarsometatarsal and tibiotalar joints are found in the foot and ankle.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. Standing b. Flexing the hip c. Flexing the knee d. Lying in the supine position

16. The nurse is assessing a patient’s ischial tuberosity. How should the nurse position the patient to palpate the ischial tuberosity?

ANS: B

The ischial tuberosity lies under the gluteus maximus muscle and is palpable when the hip is flexed. The other options are not correct.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Health Promotion and Maintenance a. Iliac crest b. Ischial tuberosity c. Greater trochanter d. Gluteus maximus muscle

17. The nurse is examining the hip area of a patient and palpates a flat depression on the upper, lateral side of the thigh when the patient is standing. What is the nurse palpating?

ANS: C

The greater trochanter of the femur is palpated when the person is standing, and it appears as a flat depression on the upper lateral side of the thigh. The iliac crest is the upper part of the hip bone; the ischial tuberosity lies under the gluteus maximus muscle and is palpable when the hip is flexed; and the gluteus muscle is part of the buttocks. The iliac crest is the upper part of the hip bone (not lateral); the ischial tuberosity lies under the gluteus maximus muscle and is palpable when the hip is flexed (not standing); and the gluteus muscle is part of the buttocks. The flat depression in the upper lateral side of the thigh that the nurse is palpating is the greater trochanter.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. Talus b. Cuboid c. Calcaneus d. Cuneiform bones

18. What is articulated with the tibia and fibula in the ankle joint?

ANS: A

The ankle or tibiotalar joint is the articulation of the tibia, fibula, and talus. The other bones listed are foot bones and not part of the ankle joint.

DIF: Cognitive Level: Remembering (Knowledge)

MSC: Client Needs: Health Promotion and Maintenance a. Lordosis b. Scoliosis c. Ankylosis d. Kyphosis

19. A woman who is 8 months pregnant comments that she has noticed a change in her posture and is having lower back pain. The nurse tells her that during pregnancy, women have a posture shift to compensate for the enlarging fetus. What is the term for this shift in posture?

ANS: A

Lordosis compensates for the enlarging fetus, which would shift the center of balance forward. This shift in balance, in turn, creates a strain on the low back muscles, felt as low back pain during late pregnancy by some women. Scoliosis is lateral curvature of portions of the spine; ankylosis is extreme flexion of the wrist, as observed with severe rheumatoid arthritis; and kyphosis is an enhanced thoracic curvature of the spine. Scoliosis is lateral curvature of portions of the spine; ankylosis is extreme flexion of the wrist, as observed with severe rheumatoid arthritis; and kyphosis is an enhanced thoracic curvature of the spine. The symptoms this patient is experiencing are lordosis.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care a. The vertebral column shortens. b. Long bones tend to shorten with age. c. A significant loss of subcutaneous fat occurs. d. A thickening of the intervertebral disks develops.

20. An 85-year-old patient comments during his annual physical examination that he seems to be getting shorter as he ages. Why does height decrease with aging?

ANS: A

Postural changes are evident with aging and decreased height is most noticeable due to shortening of the vertebral column. Long bones do not shorten with age. Intervertebral disks actually get thinner with age. Subcutaneous fat is not lost but is redistributed to the abdomen and hips.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. “It is the loss of bone density.” b. “It is an increase in bone matrix.” c. “It is new bone growth that is weaker.” d. “There is a decrease in phagocytic activity.”

21. A patient has been diagnosed with osteoporosis and asks the nurse, “What is osteoporosis?” What is the best explanation by the nurse?

ANS: A

After age 40 years, a loss of bone matrix (resorption) occurs more rapidly than new bone formation. The net effect is a gradual loss of bone density, or osteoporosis. The other options are not correct. There is a decrease, not increase, in bone matrix with aging; new bone growth is slower than the loss of bone matrix (not weaker bone growth); and phagocytic activity has nothing to do with bones.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. Assessing bone density annually b. Taking medications to prevent osteoporosis c. Performing physical activity, such as fast walking d. Taking 800 mg calcium and 200 IU vitamin D supplements daily

22. The nurse is teaching a class on preventing osteoporosis to a group of perimenopausal women. Which of these actions is the best way to prevent or delay bone loss in this group?

ANS: C

Physical activity, such as fast walking, delays or prevents bone loss in perimenopausal women. The faster the pace of walking, the higher the preventive effect is on the risk for hip fracture. The other options are not correct. Annually assessing bone density does not prevent or delay bone loss, it just monitors it. There are no medications to prevent osteoporosis, but to treat it. Taking 800 mg calcium and 200 IU vitamin D supplements daily is not enough to meet the recommended daily doses for a perimenopausal woman. The best way to prevent or delay bone loss is exercise.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Health Promotion and Maintenance a. Dull ache b. Deep pain in her wrist c. Sharp pain that increases with movement d. Dull throbbing pain that increases with rest

23. A teenage girl has arrived reporting pain in her left wrist. She was playing basketball when she fell and landed on her left hand. The nurse examines her hand. Which finding would lead the nurse to expect a fracture?

ANS: C

A fracture causes sharp pain that increases with movement. The other types of pain do not occur with a fracture.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. Tendinitis b. Osteoarthritis c. Rheumatoid arthritis d. Intermittent claudication

24. A patient is reporting pain in his joints that is worse in the morning, better after he moves around for a while, and then gets worse again if he sits for long periods. The nurse should assess for other signs of what problem?

ANS: C

Rheumatoid arthritis pain is worse in the morning when a person arises and then improves with movement. Movement increases most other types of joint pain.

DIF: Cognitive Level: Analyzing (Analysis)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. Bone spur b. Tendonitis c. Crepitation d. Fluid in the knee joint

25. A patient states, “I can hear a crunching or grating sound when I kneel.” She also states that “it is very difficult to get out of bed in the morning because of stiffness and pain in my joints.” The nurse should assess for signs of what problem?

ANS: C

Crepitation is an audible and palpable crunching or grating that accompanies movement and occurs when articular surfaces in the joints are roughened, as with rheumatoid arthritis. A bone spur is a bony projection (osteophyte) that develops along a bone edge, usually where bones meet at a joint. They often do not cause pain, but when they do, it is usually pain with movement in the specific joint with the bone spur. Tendonitis is an inflammation of a tendon and produces a swelling and tenderness to that one spot in the joint and affects only certain planes of ROM, especially during active ROM. Excess fluid in the knee can cause swelling and difficulty moving the knee, but usually does not cause pain, although the disease process causing the fluid (e.g. rheumatoid arthritis, osteoarthritis) may cause pain. The symptoms this patient is experiencing (audible and palpable crunching when kneeling indicates crepitation. Crepitation is an audible and palpable crunching or grating that accompanies movement and occurs when articular surfaces in the joints are roughened, as with rheumatoid arthritis.

DIF: Cognitive Level: Analyzing (Analysis)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. Crepitation b. Rheumatoid arthritis c. Rotator cuff lesions d. A dislocated shoulder

26. A patient is able to flex his right arm forward without difficulty or pain but is unable to abduct his arm because of pain and muscle spasms. What does the nurse suspect?

ANS: C

Rotator cuff lesions may limit range of motion and cause pain and muscle spasms during abduction, whereas forward flexion remains fairly normal. Crepitation is an audible and palpable crunching or grating that accompanies movement and occurs when articular surfaces in the joints are roughened, as with rheumatoid arthritis. Rheumatoid arthritis is a chronic inflammatory pain condition in the joints. Joint involvement is symmetric and bilateral, with heat, redness, swelling, and painful motion of affected joints. A dislocated shoulder shows an obvious deformity and severe pain with movement. Crepitation is an audible and palpable crunching or grating that accompanies movement and occurs when articular surfaces in the joints are roughened, as with rheumatoid arthritis. Rheumatoid arthritis is a chronic inflammatory pain condition in the joints. Joint involvement is symmetric and bilateral (not just one side as in this patient), with heat, redness, swelling, and painful motion of affected joints. A dislocated shoulder shows an obvious deformity and severe pain with movement (not just with certain movements as with this patient). The symptoms this patient is experiencing are that of rotator cuff lesions.

DIF: Cognitive Level: Analyzing (Analysis)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. Olecranon bursa b. Annular ligament c. Base of the radius d. Medial and lateral epicondyle

27. A professional tennis player comes into the clinic complaining of a sore elbow. Where should the nurse assess for tenderness?

ANS: D

The epicondyles, the head of the radius, and the tendons are common sites of inflammation and local tenderness, commonly referred to as tennis elbow. The other locations are not affected.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. Dorsiflex the foot. b. Plantarflex the foot. c. Hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. d. Hyperextend the wrists with the palmar surface of both hands touching, and wait for 60 seconds.

28. The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen test. What instructions should the nurse give the patient to perform this test?

ANS: C

For the Phalen test, the nurse should ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. The Phalen test reproduces numbness and burning in a person with carpal tunnel syndrome. The other actions are not correct when testing for carpal tunnel syndrome.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Health Promotion and Maintenance a. Internally rotate her hip while she is sitting. b. Abduct her hip while she is lying on her back. c. Adduct her hip while she is lying on her back. d. Externally rotate her hip while she is standing.

29. An 80-year-old woman is visiting the clinic for a checkup. She states, “I can’t walk as much as I used to.” What should the nurse have the patient do to observe for motor dysfunction in her hip?

ANS: B

Limited abduction of the hip while supine is the most common motion dysfunction found in hip disease. The other options are not correct.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Health Promotion and Maintenance a. Irregular bony margins b. Soft-tissue swelling in the joint c. Swelling from fluid in the epicondyle d. Swelling from fluid in the suprapatellar pouch

30. The nurse has completed the musculoskeletal examination of a patient’s knee and has found a positive bulge sign. How does the nurse interpret this finding?

ANS: D

A positive bulge sign confirms the presence of swelling caused by fluid in the suprapatellar pouch. The other options are not correct.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a Scoliosis b. Meniscus tear c. Herniated nucleus pulposus d. Spasm of paravertebral muscles

31. During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, the patient states pain going down his buttock into his leg. What does the nurse suspect?

ANS: C

Lateral tilting and sciatic pain with straight leg raising are findings that occur with a herniated nucleus pulposus. The other options are not correct.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. Positive Allis test b. Negative Allis test c. Positive Ortolani sign d. Negative Ortolani sign

32. The nurse is examining a 3-month-old infant. While the nurse holds his or her thumbs on the infant’s inner mid thighs and the fingers on the outside of the infant’s hips, touching the greater trochanter, the nurse adducts the legs until the his or her thumbs touch and then abducts the legs until the infant’s knees touch the table. The nurse does not notice any “clunking” sounds. How should the nurse document this finding?

ANS: D

This maneuver is the Ortolani sign. Normally this maneuver feels smooth and has no sound (negative Ortolani sign). However, with a positive Ortolani sign the nurse will feel and hear a “clunk,” as the head of the femur pops back into place. A positive Ortolani sign also reflects hip instability. The Allis test also tests for hip dislocation but is performed by comparing leg lengths. The Allis test is a test that assesses for hip dislocation but comparing leg lengths. The maneuver described in this question is the Ortolani sign. Normally this maneuver feels smooth and has no sound (negative Ortolani sign). However, with a positive Ortolani sign the nurse will feel and hear a “clunk,” as the head of the femur pops back into place. A positive Ortolani sign also reflects hip instability.

DIF: Cognitive Level: Analyzing (Analysis)

MSC: Client Needs: Health Promotion and Maintenance a. Unidactyly b. Syndactyly c. Polydactyly d. Multidactyly

33. During a neonatal examination, the nurse notices that the newborn infant has six toes. How should the nurse document this finding?

ANS: C

Polydactyly is the presence of extra fingers or toes. Syndactyly is webbing between adjacent fingers or toes. The other terms are not correct.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care a. Negative Allis test b. Positive Ortolani sign c. Limited range of motion during Lasègue test d. Limited range of motion during the Moro reflex

34. A mother brings her newborn baby boy in for a checkup; she tells the nurse that he does not seem to be moving his right arm as much as his left and that he seems to have pain when she lifts him up under the arms. The nurse suspects a fractured clavicle. What finding would support this suspicion?

ANS: D

For a fractured clavicle, the nurse should observe for limited arm range of motion and unilateral response to the Moro reflex. The Allis test and Ortolani sign are performed to assess for hip dislocations, not fractured clavicle. The Lasègue test is performed to assess for sciatica or herniated nucleus pulposus. For a fractured clavicle, the nurse should observe for limited arm range of motion and unilateral response to the Moro reflex. The other tests are not appropriate for this type of fracture.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Health Promotion and Maintenance a. Acute gout b. Osteoporosis c. Ankylosing spondylitis d. Degenerative joint disease

35. A 40-year-old man has come into the clinic reporting extreme pain in his toes. The nurse notices that his toes are slightly swollen, reddened, and warm to the touch. What does the nurse suspect?

ANS: A

Clinical findings for acute gout consist of redness, swelling, heat, and extreme pain like a continuous throbbing. Gout is a metabolic disorder of disturbed purine metabolism, associated with elevated serum uric acid. Osteoporosis is a decrease in skeletal bone mass leading to low bone mineral density and impaired bone density which increases the risk for fractures. It occurs primarily in postmenopausal white women. Ankylosing spondylitis is chronic inflamed vertebrae and is characterized by inflammatory back pain that is dull and deep in lower back or buttocks. Degenerative joint disease (osteoarthritis) is a localized, progressive disorder involving deterioration of articular cartilages and subchondral bone remodeling, synovial inflammation, and formation of new bone at joint surfaces. Asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. This patient’s symptoms are consistent with acute gout.

DIF: Cognitive Level: Analyzing (Analysis)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. Joint effusion b. Tear of rotator cuff c. Adhesive capsulitis d. Dislocated shoulder

36. A young swimmer comes to the sports clinic complaining of a very sore shoulder. He was running at the pool, slipped on some wet concrete, and tried to catch himself with his outstretched hand. He landed on his outstretched hand and has not been able to move his shoulder since. What does the nurse suspect?

ANS: D

A dislocated shoulder occurs with trauma involving abduction, extension, and external rotation (e.g., falling on an outstretched arm or diving into a pool). Joint effusion is swelling from excess fluid in the joint capsule. Tear of rotator cuff typically presents in a “hunched” position and limited abduction of arm. Adhesive capsulitis (frozen shoulder) presents with stiffness; progressive limitation of motion in abduction and external rotation, and unable to reach overhead; and pain caused by the formation of fibrous tissues in the joint capsule. Joint effusion is swelling from excess fluid in the joint capsule. Tear of rotator cuff typically presents in a “hunched” position and limited abduction of arm. Adhesive capsulitis (frozen shoulder) presents with stiffness; progressive limitation of motion in abduction and external rotation, and unable to reach overhead; and pain caused by the formation of fibrous tissues in the joint capsule. This patient appears to have a dislocated shoulder.

DIF: Cognitive Level: Analyzing (Analysis)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. Epicondylitis b. Gouty arthritis c. Olecranon bursitis d. Subcutaneous nodules.

37. A 68-year-old woman has come in for an assessment of her rheumatoid arthritis, and the nurse notices raised, firm, nontender nodules at the olecranon bursa and along the ulna. What is the appropriate term for these nodules?

ANS: D

Subcutaneous nodules are raised, firm, and nontender and occur with rheumatoid arthritis in the olecranon bursa and along the extensor surface of the ulna. Epicondylitis (Tennis elbow) is pain at the lateral epicondyle of the humerus. Gout is a painful inflammatory arthritis characterized by excess uric acid in the blood and deposits of urate crystals in the joint space. Symptoms include redness, swelling, heat and extreme pain. Olecranon bursitis is a large, soft knob or “goose egg” and redness from swelling and inflammation of olecranon bursa.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care a. Radial drift b. Ulnar deviation c. Swan-neck deformity d. Dupuytren contracture

38. A woman who has had rheumatoid arthritis for years is starting to notice that her fingers are drifting to the side. What is term commonly used for this condition?

ANS: B

Fingers drift to the ulnar side because of stretching of the articular capsule and muscle imbalance caused by chronic rheumatoid arthritis. A radial drift is not observed. Swan-neck deformity is a flexion contracture in the metacarpophalangeal joint, then hyperextension of the PIP joint, and flexion of the DIP joint which resembles the curve of a swan’s neck. Dupuytren contracture is a flexion contracture of the digits. It first affects the fourth digit, then the fifth digit, and then third digit.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care a. Heberden nodes b. Bouchard nodules c. Swan-neck deformities d. Dupuytren contractures

39. A patient who has had rheumatoid arthritis for years comes to the clinic to ask about changes in her fingers. The nurse will assess for signs of what problems?

ANS: C

Changes in the fingers caused by chronic rheumatoid arthritis include swan-neck and boutonniere deformities. Heberden nodes and Bouchard nodules are associated with osteoarthritis. Dupuytren contractures of the digits occur because of chronic hyperplasia of the palmar fascia.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. Dislocated hip b. Structural scoliosis c. Functional scoliosis d. Herniated nucleus pulposus

40. A patient’s annual physical examination reveals a lateral curvature of the thoracic and lumbar segments of his spine; however, this curvature disappears with forward bending. What is this abnormality called?

ANS: C

Functional scoliosis is flexible and apparent with standing but disappears with forward bending. Structural scoliosis is fixed; the curvature shows both when standing and when bending forward. These findings are not indicative of a herniated nucleus pulposus or dislocated hip.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care a. “If these symptoms persist, you may need arthroscopic surgery.” b. “You are experiencing degeneration of your knee, which may not resolve.” c. “Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest.” d. “Increasing your activity and performing knee-strengthening exercises will help decrease the inflammation and maintain mobility in the knee.”

41. A 14-year-old boy who has been diagnosed with Osgood-Schlatter disease reports painful swelling just below the knee for the past 5 months. Which response by the nurse is appropriate?

ANS: C

Osgood-Schlatter disease is a painful swelling of the tibial tubercle just below the knee and most likely due to repeated stress on the patellar tendon. It is usually self-limited, occurring during rapid growth and most often in boys. The symptoms resolve with rest. The other responses are not appropriate.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. 2 b. 3 c. 4 d. 5

42. When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What grade of muscle strength should the nurse record using a 0- to 5-point scale?

ANS: D

Complete range of motion against gravity is normal muscle strength and is recorded as grade 5 muscle strength. The other options are not correct.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. This finding is a positive Allis sign and suggests hip dislocation. b. The infant probably has a dislocated patella on the right knee. c. This finding is a negative Allis sign and normal for an infant of this age. d. The infant should return to the clinic in 2 weeks to see if his condition has changed.

43. The nurse is examining a 6-month-old infant and places the infant’s feet flat on the table and flexes his knees up. The nurse notes that the right knee is significantly lower than the left. Which of these statements is true of this finding?

ANS: A

Finding one knee significantly lower than the other is a positive Allis sign and suggests hip dislocation. Normally the tops of the knees are at the same elevation. The other statements are not correct.

DIF: Cognitive Level: Analyzing (Analysis)

MSC: Client Needs: Health Promotion and Maintenance a. A fractured clavicle b. Possible deformity of the spine c. Weakness of the shoulder muscles d. This is a normal finding for an infant at this age

44. The nurse is assessing a 1-week-old infant and is testing his muscle strength. The nurse lifts the infant with hands under the axillae and notices that the infant starts to “slip” between the hands. What does the nurse suspect?

ANS: C

An infant who starts to “slip” between the nurse’s hands shows weakness of the shoulder muscles. An infant with normal muscle strength wedges securely between the nurse’s hands. The other responses are not correct.

DIF: Cognitive Level: Analyzing (Analysis)

MSC: Client Needs: Health Promotion and Maintenance a. Spina bifida b. Down syndrome c. Hip dislocation d. Fractured clavicle

45. The nurse is examining a 2-month-old infant and notices asymmetry of the infant’s gluteal folds. The nurse should assess for other signs of what disorder?

ANS: C

Unequal gluteal folds may accompany hip dislocation after 2 to 3 months of age, but some asymmetry may occur in healthy children. Further assessment is needed. The other responses are not correct.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care a. Tinel sign b. Phalen test c. McMurray test d. Ballottement

46. The nurse should use which test to check for large amounts of fluid around the patella?

ANS: D

Ballottement of the patella is reliable when large amounts of fluid are present. The Tinel sign and the Phalen test are used to check for carpal tunnel syndrome. The McMurray test is used to test the knee for a torn meniscus.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. Genu varum b. Pes planus c. Genu valgum d. Metatarsus adductus

47. A patient tells the nurse that, “All my life I’ve been called ‘knock knees’.” What is medical term for this condition?

ANS: C

Genu valgum is also known as knock knees and is present when more than 2.5 cm is between the medial malleoli when the knees are together. Pes planus, or flat foot, is pronation, or turning in, of the medial side of the foot. Metatarsus adductus is adduction, or turning inward, of the front half of the foot. The term used to describe knock knees is genu valgum. Genu valgum is present when more than 2.5 cm is between the medial malleoli when the knees are together.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care a. Tophi b. Callus c. Bunion d. Plantar wart

48. A man who has had gout for several years comes to the clinic with a problem with his toe. On examination, the nurse notices the presence of hard, painless nodules over the great toe; one has burst open with a chalky discharge. What is this called?

ANS: A

Tophi are collections of monosodium urate crystals resulting from chronic gout in and around the joint that cause extreme swelling and joint deformity. They appear as hard, painless nodules (tophi) over the metatarsophalangeal joint of the first toe and they sometimes burst with a chalky discharge. A callus is a hard, thickened area of skin that forms as a result of friction or pressure. A bunion is a bony bump that forms on the joint at the base of your big toe (metatarsophalangeal joint). A plantar wart is vascular papillomatous growth that occurs on the sole of the foot, commonly at the ball and has small dark spots and is painful. A callus is a hard, thickened area of skin that forms as a result of friction or pressure. A bunion is a bony bump that forms on the joint at the base of your big toe (metatarsophalangeal joint). A plantar wart is vascular papillomatous growth that occurs on the sole of the foot, commonly at the ball and has small dark spots and is painful.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care a. Proximal to distal b. Distal to proximal c. Posterior to anterior d. Anterior to posterior

49. When performing a musculoskeletal assessment, what is the correct approach?

ANS: A

The musculoskeletal assessment should be performed in an orderly approach, head to toe, proximal to distal, from the midline outward. The other options are not correct.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance

Multiple Response

1. The nurse is assessing the joints of a woman who has stated, “I have a long family history of arthritis, and my joints hurt.” The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? (Select all that apply.)

a. Symmetric joint involvement b. Asymmetric joint involvement c. Pain with motion of affected joints d. Affected joints may have heat, redness, and swelling e. Affected joints are swollen with hard, bony protuberances

ANS: B, C, E

In osteoarthritis, asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness, swelling with hard bony protuberances, pain with motion, and limitation of motion. The other options reflect the signs of rheumatoid arthritis.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation