Download 22-1 Jarvis: Physical Examination and Health Assessment, 5th

Jarvis: Physical Examination and Health Assessment, 5th edition
Chapter 22: Musculoskeletal System
Test Bank
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. This movement is called:
1. flexion.
2. abduction.
3. adduction.
4. extension.
ANS: 3
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: Application REF: Page: 599
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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 the following movement:
1. flexion.
2. abduction.
3. adduction.
4. extension.
ANS: 1
Flexion, or bending a limb at a joint, would be required to move your hand to
your mouth.
DIF: Application REF: Page: 599
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. The functional units of the musculoskeletal system are the:
1. joints.
2. bones.
3. muscles.
4. tendons.
22-2
ANS: 1
Joints are the functional units of the musculoskeletal system because they
permit the mobility needed for activities of daily living.
DIF:
Knowledge
REF: Page: 598
MSC: NCLEX: General
4. Hematopoiesis takes place in the:
1. liver.
2. spleen.
3. kidneys.
4. bone marrow.
ANS: 4
The musculoskeletal system functions to encase and protect inner vital organs,
support the body, produce red blood cells in the bone marrow, and store
minerals.
DIF:
Application
REF: Page: 598
MSC: NCLEX: General
5. Fibrous bands running directly from one bone to another that strengthen the joint and
help prevent movement in undesirable directions are called:
1. bursa.
2. tendons.
3. cartilage.
4. ligaments.
ANS: 4
Fibrous bands running directly from one bone to another that strengthen the
joint and help prevent movement in undesirable directions are called ligaments.
DIF:
Knowledge
REF: Page: 598
MSC: NCLEX: General
6. The nurse notices that a woman in an exercise class is unable to jump rope. The
nurse knows that to jump rope, one’s shoulder has to be capable of:
1. inversion.
2. supination.
3. protraction.
4. circumduction.
ANS: 4
Circumduction is defined as moving the arm in a circle around the shoulder.
DIF: Application REF: Page: 599
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
22-3
7.The articulation of the mandible and the temporal bone is known as the:
1. intervertebral foramen.
2. condyle of the mandible.
3. temporomandibular joint.
4. zygomatic arch of the temporal bone.
ANS: 3
The articulation of the mandible and the temporal bone is the
temporomandibular joint.
DIF:
Knowledge
REF: Page: 600
MSC: NCLEX: General
8. To palpate the temporomandibular joint, the nurse’s fingers should be placed in the
depression:
1. distal to the helix of the ear.
2. proximal to the helix of the ear.
3. anterior to the tragus of the ear.
4. posterior to the tragus of the ear.
ANS: 3
The temporomandibular joint can be felt in the depression anterior to the
tragus of the ear.
DIF:
Application
REF: Page: 600
MSC: NCLEX: General
9. Of the 33 vertebrae in the spinal column, there are:
1. 5 lumbar.
2. 5 thoracic.
3. 7 sacral.
4. 12 cervical.
ANS: 1
There are 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3 to 4 coccygeal
vertebrae.
DIF: Comprehension
General
REF: Page: 600
MSC: NCLEX:
10. An imaginary line connecting the highest point on each iliac crest would cross:
1. the first sacral vertebra.
2. the fourth lumbar vertebra.
3. the seventh cervical vertebra.
4. the twelfth thoracic vertebra.
ANS: 2
An imaginary line connecting the highest point on each iliac crest crosses the
fourth lumbar vertebra.
22-4
DIF: Comprehension
General
REF: Page: 600
MSC: NCLEX:
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. The nurse is referring to his:
1. costal facets.
2. nucleus pulposus.
3. vertebral foramen.
4. intervertebral discs.
ANS: 4
Intervertebral discs are elastic fibrocartilaginous plates that cushion the spine
like shock absorbers and help it move.
DIF: Comprehension
REF: Page: 601
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12. The nurse is providing patient education for a man who has been diagnosed with a
rotator cuff injury. The nurse knows that a rotator cuff injury involves:
1. nucleus pulposus.
2. the articular process.
3. the medial epicondyle.
4. the glenohumeral joint.
ANS: 4
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.
DIF: Application REF: Page: 602
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
13. During an interview, a 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.” The nurse
should tell her:
1. “That is your subacromial bursa.”
2. “That is your acromion process.”
3. “That is your glenohumeral joint.”
4. “That is the greater tubercle of your humerus.”
ANS: 2
The bump of the scapula’s acromion process is felt at the very top of the
shoulder.
DIF: Application REF: Page: 602
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
22-5
14. The nurse is checking the range of motion in a patient’s knee and knows that the
knee is capable of the following movements:
1. flexion and extension.
2. supination and pronation.
3. circumduction.
4. inversion and eversion.
ANS: 1
The knee is a hinge joint, permitting flexion and extension of the lower leg on a
single plane.
DIF: Comprehension
MSC: NCLEX: General
REF: Pages: 603, 605
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 he is
unable to remove his wedding ring. This joint is called the:
1. interphalangeal joint.
2. tarsometatarsal joint.
3. metacarpophalangeal joint.
4. talocalcaneonavicular joint.
ANS: 3
See Figure 22-10 for a diagram of the bones and joints of the hand and fingers.
DIF:
Application
REF: Page: 603
MSC: NCLEX: General
16. The nurse is assessing a patient’s ischial tuberosity. To palpate the ischial tuberosity,
the nurse knows that it is best to have the patient:
1. stand.
2. flex his hip.
3. flex his knee.
4. in the supine position.
ANS: 2
The ischial tuberosity lies under the gluteus maximus muscle and is palpable
when the hip is flexed.
DIF: Application REF: Page: 604
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
17. The knee joint is the articulation of the femur, the tibia, and the:
1. fibula.
2. radius.
3. patella.
4. humerus.
22-6
ANS: 3
The knee joint is the articulation of three bones, including the femur, the tibia,
and the patella (kneecap) in one common articular cavity.
DIF:
Knowledge
REF: Page: 605
MSC: NCLEX: General
18. The ankle joint is the articulation of the tibia, the fibula, and the:
1. talus.
2. cuboid.
3. calcaneus.
4. talocalcaneonavicular joint.
ANS: 1
The ankle or tibiotalar joint is the articulation of the tibia, fibula, and talus.
DIF:
Knowledge
REF: Page: 605
MSC: NCLEX: General
19. The nurse is explaining the mechanism of the growth of long bones to a mother of a
toddler. The nurse knows that bones increase in width or diameter by deposition of
new bony tissue around the shafts. The nurse also knows that lengthening occurs at
the:
1. bursa.
2. calcaneus.
3. epiphyses.
4. tuberosities.
ANS: 3
Long bones grow in two dimensions: first in width or diameter by deposition of
new bony tissue around the shafts. Lengthening occurs at the epiphyses, or
growth plates.
DIF: Comprehension
REF: Page: 606
MSC: NCLEX: Health Promotion and Maintenance
20. A woman who is 8 months pregnant comments that she has noticed a change in
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. This shift in
posture is known as:
1. lordosis.
2. scoliosis.
3. ankylosis.
4. kyphosis.
ANS: 1
Lordosis compensates for the enlarging fetus, which would shift the center of
balance forward. This shift in balance in turn creates strain on the low back
muscles, felt as low back pain during late pregnancy by some women.
22-7
DIF: Application REF: Page: 606
MSC: NCLEX: Health Promotion and Maintenance
21. An 85-year-old patient comments during his annual physical that he seems to be
getting shorter as he ages. The nurse should explain that decreased height occurs
with aging because:
1. long bones tend to shorten with age.
2. of the shortening of the vertebral column.
3. there is a significant loss of subcutaneous fat.
4. there is a thickening of the intervertebral discs.
ANS: 2
Postural changes are evident with aging; decreased height is most noticeable
and is due to shortening of the vertebral column. Long bones do not shorten
with age.
DIF: Application REF: Page: 606
MSC: NCLEX: Health Promotion and Maintenance
22. A patient has been diagnosed with osteoporosis and asks the nurse, “What is
osteoporosis?” The nurse knows that osteoporosis can be defined as:
1. loss of bone matrix.
2. loss of bone density.
3. new, weaker bone growth.
4. increased phagocytic activity.
ANS: 2
Osteoporosis is the loss of bone density.
DIF: Knowledge REF: Page: 606
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
23. A 28-year-old jogger comes to the sports clinic complaining of increased foot
problems while running. The nurse knows that a possible cause of this could be:
1. twenty-four vertebrae.
2. a missing peroneus teritus.
3. convex anterior curvature of the femur.
4. a second toe that is longer than the great toe.
ANS: 4
Joggers and athletes report increased foot problems when a second toe is longer
than the great toe. See Table 22-1.
DIF: Application REF: Page: 607
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
22-8
24. The nurse knows that the incidence of osteoporosis is greatest in which group?
1. Black men
2. Black women
3. White women
4. American Indian men
ANS: 3
The incidence of osteoporosis is lowest in black men and highest in white
women. See Table 22-1.
DIF: Comprehension
REF: Page: 606
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
25. A teenage girl has arrived complaining of pain in her left wrist. She had been playing
basketball and fell, landing on her left hand. The nurse examines her hand and would
expect a fracture if the girl complains:
1. of a dull ache.
2. that the pain in her wrist is deep.
3. of sharp pain that increases with movement.
4. of dull throbbing pain that increases with rest.
ANS: 3
A fracture causes sharp pain that increases with movement.
DIF: Analysis
REF: Page: 608
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
26. A patient is complaining of pain in his joints that is worse in the morning, is better
after he has moved around for awhile, and then gets worse again if he sits for long
periods of time. The nurse suspects that he may have:
1. tendinitis.
2. osteoarthritis.
3. rheumatoid arthritis.
4. intermittent claudication.
ANS: 3
Rheumatoid arthritis is worse in the morning when arising. Movement
increases most joint pain, except in rheumatoid arthritis, in which movement
decreases pain.
DIF: Analysis
REF: Page: 608
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
22-9
27. A patient states, “I can hear a crunching or grating sound when I kneel.” She also
states “it is very difficult to get out of bed in the morning because of stiffness and
pain in my joints.” The nurse suspects that the sound she hears is:
1. crepitation.
2. a bone spur.
3. a loose tendon.
4. fluid in the knee joint.
ANS: 1
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: Analysis
REF: Page: 612
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
28. 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; the nurse suspects:
1. crepitation.
2. rotator cuff lesions.
3. dislocated shoulder.
4. rheumatoid arthritis.
ANS: 2
Rotator cuff lesions may cause limited range of motion and pain and muscle
spasm during abduction, whereas forward flexion stays fairly normal.
DIF: Analysis
REF: Page: 615
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
29. A professional tennis player comes into the clinic complaining of a sore elbow. The
nurse suspects that he has tenderness at the:
1. olecranon bursa.
2. annular ligament.
3. base of the radius.
4. medial and lateral epicondyle.
ANS: 4
Epicondyle, head of radius, and tendons are common sites of inflammation and
local tenderness, or “tennis elbow.”
DIF: Analysis
REF: Page: 616
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
22-10
30. The nurse suspects that a patient has carpal tunnel syndrome and wants to perform
the Phalen’s test. To perform this test, the nurse will instruct the patient to:
1. dorsiflex the foot.
2. plantarflex the foot.
3. hold both hands back to back while flexing the wrists 90 degrees for 60 seconds.
4. hyperextend the wrists with the palmar surface of both hands touching and wait
for 60 seconds.
ANS: 3
For the Phalen’s test, 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’s test reproduces numbness and
burning in a person with carpal tunnel syndrome
DIF: Application REF: Page: 621
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
31. An 80-year-old woman is visiting the clinic for a checkup. The nurse is observing
for motor dysfunction in her hip and would have her:
1. internally rotate her hip while she is sitting.
2. abduct her hip while she is lying on her back.
3. adduct her hip while she is lying on her back.
4. externally rotate her hip while she is standing.
ANS: 2
Limitation of abduction of the hip while supine is the most common motion
dysfunction found in hip disease.
DIF: Analysis
REF: Page: 623
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
32. The nurse has completed the musculoskeletal examination of a patient’s knee and
has found a positive bulge sign. The nurse suspects:
1. irregular bony margins.
2. soft tissue swelling in the joint.
3. swelling from fluid in the epicondyle.
4. swelling from fluid in the suprapatellar pouch.
ANS: 4
For swelling in the suprapatellar pouch, the bulge sign confirms the presence of
fluid.
DIF: Analysis
REF: Page: 624
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
22-11
33. During an examination, the nurse asks a patient to bend forward from the waist and
notes that the patient has lateral tilting. When his leg is raised straight up, he
complains of a pain going down his buttock into his leg. The nurse suspects:
1. scoliosis.
2. meniscus tear.
3. herniated nucleus pulposus.
4. spasm of paravertebral muscles.
ANS: 3
Lateral tilting and sciatic pain with straight leg raising are findings that occur
with a herniated nucleus pulposus.
DIF: Analysis
REF: Page: 631
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
34. The nurse is examining a 3-month-old infant. While holding the thumbs on the
infant’s inner mid thighs and the fingers outside on the hips, touching the greater
trochanter, the nurse adducts the legs until the nurse’s thumbs touch and then
abducts the legs until the infant’s knees touch the table. The nurse does not note any
“clunking” sounds and is confident to record a:
1. positive Allis.
2. negative Allis.
3. positive Ortolani.
4. negative Ortolani.
ANS: 4
Normally this maneuver feels smooth and has no sound. With a positive
Ortolani sign, you will feel and hear a “clunk” as the head of the femur pops
back into place.
DIF: Analysis
REF: Page: 633
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
35. During a neonatal examination, the nurse notes that the newborn infant has six toes.
This finding is documented as:
1. unidactyly.
2. syndactyly.
3. polydactyly.
4. multidactyly.
ANS: 3
Polydactyly is the presence of extra fingers or toes.
DIF: Comprehension
REF: Page: 634
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
22-12
36. A mother brings her newborn baby boy in for a checkup; she tells the nurse that he
doesn’t 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 and would observe for:
1. a negative Allis sign.
2. a positive Ortolani sign.
3. limited range of motion during the Moro reflex.
4. limited range of motion during LaSegue’s reflex.
ANS: 3
For a fractured clavicle, observe for limited arm range of motion and unilateral
response to the Moro reflex.
DIF: Analysis
REF: Page: 634
MSC: NCLEX: Health Promotion and Maintenance
37. A 40-year-old man has come into the clinic with complaints of “extreme tenderness
in my toes.” The nurse notes that his toes are slightly swollen, reddened, and warm
to the touch. His complaints would suggest:
1. osteoporosis.
2. acute gout.
3. ankylosing spondylitis.
4. degenerative joint disease.
ANS: 2
Acute gout occurs primarily in men over 40 years of age. Clinical findings
consist of redness, swelling, heat, and extreme tenderness. Gout is a metabolic
disorder of disturbed purine metabolism, associated with elevated serum uric
acid.
DIF: Analysis
REF: Page: 650
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
38. 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. The nurse suspects:
1. joint effusion.
2. tear of rotator cuff.
3. adhesive capsulitis.
4. dislocated shoulder.
ANS: 4
Dislocated shoulder occurs with trauma involving abduction, extension, and
external rotation (e.g., falling on an outstretched arm or diving into a pool).
DIF: Analysis
REF: Page: 644
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
22-13
39. A 68-year-old woman has come in for an assessment of her rheumatoid arthritis, and
the nurse notes raised, firm, nontender nodules at the olecranon bursa and along the
ulna. These nodules are most commonly diagnosed as:
1. epicondylitis.
2. gouty arthritis.
3. olecranon bursitis.
4. subcutaneous nodules.
ANS: 3
Subcutaneous nodules that are raised, firm, and nontender occur with
rheumatoid arthritis in the olecranon bursa and along the extensor surface of
the ulna.
DIF: Analysis
REF: Page: 645
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
40. A woman who has had rheumatoid arthritis for years is starting to notice that her
fingers are drifting to the side. The nurse knows that this condition is commonly
referred to as:
1. radial drift.
2. ulnar deviation.
3. swan neck deformity.
4. Dupuytren’s contracture.
ANS: 2
Fingers drift to the ulnar side because of stretching of the articular capsule and
muscle imbalance caused by chronic rheumatoid arthritis.
DIF: Application REF: Page: 647
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
41. A patient who has had rheumatoid arthritis for years comes to the clinic to ask about
changes in her hands. The nurse knows that changes associated with rheumatoid
arthritis include:
1. Heberden’s nodes.
2. Bouchard’s nodules.
3. swan-neck deformities.
4. Dupuytren’s contractures.
ANS: 3
Changes in the hands caused by chronic rheumatoid arthritis include swanneck and boutonniere deformities. Heberden’s nodes and Bouchard’s nodules
are associated with osteoarthritis.
DIF: Application REF: Page: 647
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
22-14
42. 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. The nurse knows that this abnormality of the spine would be called:
1. structural scoliosis.
2. functional scoliosis.
3. herniated nucleus pulposus.
4. dislocated nucleus pulposus.
ANS: 2
Functional scoliosis is flexible; it is apparent with standing and disappears with
forward bending.
DIF: Analysis
REF: Page: 652
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
43. 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?
1. “If these symptoms persist, you may need arthroscopic surgery.”
2. “You are experiencing degeneration of your knee, which may not resolve.”
3. “Your disease is due to repeated stress on the patellar tendon. It is usually selflimited, and your symptoms should resolve with rest.”
4. “Increasing your activity and performing knee-strengthening exercises will help
to decrease the inflammation and maintain mobility in the knee.”
ANS: 3
Osgood-Schlatter disease is painful swelling of the tibial tubercle just below the
knee. It is most likely due to repeated stress on the patellar tendon. It is usually
self-limited, occurring during rapid growth and most often in males. The
symptoms resolve with rest.
DIF: Application REF: Page: 649
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
44. When assessing muscle strength, the nurse observes that a patient has complete
range of motion against gravity with full resistance. What should the nurse record
using a 0 to 5+ scale?
1. 2+
2. 3+
3. 4+
4. 5+
ANS: 4
Complete range of motion against gravity is normal muscle strength and is
recorded as 5+ muscle strength.
DIF: Application REF: Page: 612
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
22-15
45. The nurse is examining a 6-month-old baby and places the baby’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 the following is true of this finding?
1. This is a positive Allis sign and suggests hip dislocation.
2. The infant probably has a dislocated patella on the right.
3. This is a normal finding for the Allis test for an infant of this age.
4. The infant should return to the clinic in 2 weeks to see if this has changed.
ANS: 1
Finding one knee significantly lower than the other is a positive Allis sign and
suggests hip dislocation.
DIF: Analysis
REF: Page: 634
MSC: NCLEX: Health Promotion and Maintenance
46. The nurse is assessing a 1-week-old infant and testing his muscle strength. The nurse
lifts the infant with hands under the axillae and notes that the infant starts to “slip”
between the hands. The nurse should:
1. suspect a fractured clavicle.
2. consider that the infant may have a deformity of the spine.
3. suspect that the infant may have weakness of the shoulder muscles.
4. consider this a normal finding because the musculature of an infant this age is
undeveloped.
ANS: 3
A baby who starts to “slip” between your hands shows weakness of the shoulder
muscles.
DIF: Analysis
REF: Page: 635
MSC: NCLEX: Health Promotion and Maintenance
47. The nurse is planning to measure a patient’s angles of joint flexion and will use
which instrument?
1. Caliper
2. Protracter
3. Goniometer
4. Measuring tape
ANS: 3
A goniometer is used to measure the angles of joint flexion accurately.
DIF: Comprehension
REF: Page: 611
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
22-16
48. The nurse should use which test to check for large amounts of fluid around the
patella?
1. Ballottement
2. Tinel’s sign
3. Phalen’s test
4. McMurray’s test
ANS: 1
Balottement of the patella is reliable when larger amounts of fluid are present.
DIF: Comprehension
REF: Page: 625
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
49. The nurse knows that another term for “knock knees” is:
1. genu varum.
2. genu valgum.
3. pes planus.
4. metatarsus adductus.
ANS: 2
Genu valgum is also known as “knock knees” and is present when there is more
than 2.5 cm between the medial malleoli when the knees are together.
DIF: Comprehension
REF: Page: 636
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
50. A patient has been diagnosed with a ganglion cyst over the dorsum of his left wrist.
He asks the nurse, “What is this thing?” The nurse’s best answer would be:
1. “It is a common benign tumor.”
2. “It is a tumor that will have to be watched because it may turn malignant.”
3. “It is caused by chronic repetitive motion injury.”
4. “It is a skin infection that will need to be drained.”
ANS: 1
A ganglionic cyst is a common benign tumor; it does not become malignant.
DIF: Analysis
REF: Page: 646
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
51. A man who has had gout for several years comes to the clinic with a “problem with
my toe.” On examination, the nurse notes the presence of hard, painless nodules over
the great toe; one had burst open with a chalky discharge. This finding is known as:
1. a callus.
2. a plantar wart.
3. tenosynovitis.
4. tophi.
22-17
ANS: 4
Tophi are collections of sodium 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.
DIF: Application REF: Page: 650
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
52. When performing a musculoskeletal assessment, the nurse knows that the correct
approach for the examination should be:
1. proximal to distal.
2. distal to proximal.
3. posterior to anterior.
4. anterior to posterior.
ANS: 1
The musculoskeletal assessment should be done in an orderly approach, head to
toe, proximal to distal.
DIF: Application REF: Page: 610
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
22-18
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 the following are symptoms of osteoarthritis? Select all that
apply.
1. Symmetric
2. Asymmetric
3. Pain with motion of affected joints
4. Affected joints swollen with hard, bony protuberances
5. Affected joints may have heat, redness, and swelling.
ANS: 2, 3, 4
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.
DIF: Comprehension
REF: Page: 643
MSC: NCLEX: Physiological Integrity: Physiological Adaptation