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Questions and Answers
Question 1 of 4
Which question would the nurse ask a patient to determine symptom-related issues with the musculoskeletal system?
Question 1 of 4
Which question would the nurse ask a patient to determine symptom-related issues with the musculoskeletal system?
- “Do any of your family members have osteoporosis?”
- “Have you noticed any differences in your gait?” (correct)
- “Do you have an active lifestyle or sedentary lifestyle?”
- “Have you ever found yourself on the floor and don’t know how you got there?”
Question 2 of 4
Which patient finding is expected in a musculoskeletal assessment?
Question 2 of 4
Which patient finding is expected in a musculoskeletal assessment?
- Morse Fall Scale score of 20 (correct)
- Asymmetry of joints
- Slumped posture
- Hendrich II Fall Risk Model score of 7
Question 3 of 4
Which movement is the nurse assessing in this image?
Question 3 of 4
Which movement is the nurse assessing in this image?
- Rotation
- Extension
- Hyperextension
- Lateral flexion (correct)
Question 4 of 4
Which finding is unexpected when assessing effects of immobility?
Question 4 of 4
Which finding is unexpected when assessing effects of immobility?
Which cue is relevant to alterations in the musculoskeletal system?
Which cue is relevant to alterations in the musculoskeletal system?
Match the musculoskeletal system alteration to its cause.
Match the musculoskeletal system alteration to its cause.
Which patient would likely be prone to reduced bone density?
Which patient would likely be prone to reduced bone density?
Which cues are relevant for weakness?
(Select all that apply)
Which cues are relevant for weakness? (Select all that apply)
Which patient is prone to paralysis?
Which patient is prone to paralysis?
Which cues are relevant for activity intolerance?
(Select all that apply.)
Which cues are relevant for activity intolerance?
(Select all that apply.)
Which graphic record cue indicates the patient has anorexia?
Which graphic record cue indicates the patient has anorexia?
Which finding is a psychological consequence of bed rest and manifests in the patient becoming lonely or depressed?
Which finding is a psychological consequence of bed rest and manifests in the patient becoming lonely or depressed?
Tissue ischemia related to immobility can directly lead to the development of which complication?
Tissue ischemia related to immobility can directly lead to the development of which complication?
Which patient situation is a medical emergency?
Which patient situation is a medical emergency?
Which cues are relevant for a deep vein thrombosis (DVT)?
(Select all that apply.)
Which cues are relevant for a deep vein thrombosis (DVT)? (Select all that apply.)
Which complication from immobility causes the alveoli to collapse?
Which complication from immobility causes the alveoli to collapse?
In which areas would the patient experience pain if a urinary tract infection is present?
(Select all that apply)
In which areas would the patient experience pain if a urinary tract infection is present? (Select all that apply)
Which action by the nurse initiates the physical assessment of a patient’s mobility?
Which action by the nurse initiates the physical assessment of a patient’s mobility?
Which patient finding would alert the nurse to stop passive range-of-motion exercises?
Which patient finding would alert the nurse to stop passive range-of-motion exercises?
Which finding would be unexpected when the nurse is assessing for mobility issues?
Which finding would be unexpected when the nurse is assessing for mobility issues?
Patient reports of shortness of breath and fatigue while performing activities of daily living are indicative of which alteration?
Patient reports of shortness of breath and fatigue while performing activities of daily living are indicative of which alteration?
Which nutritional alteration is associated with immobility?
Which nutritional alteration is associated with immobility?
Which interpretation would the nurse make when observing a darkened or reddened area of skin in an immobile patient?
Which interpretation would the nurse make when observing a darkened or reddened area of skin in an immobile patient?
A patient with redness, warmth, and swelling in the right lower leg is at risk for which complication?
A patient with redness, warmth, and swelling in the right lower leg is at risk for which complication?
Which response would the nurse make to an immobile patient who says, “I am just not hungry. I don’t understand it. I am always hungry”?
Which response would the nurse make to an immobile patient who says, “I am just not hungry. I don’t understand it. I am always hungry”?
Question 9 of 18
Which movement is the nurse assessing in the image?
Question 9 of 18
Which movement is the nurse assessing in the image?
Which fall risk score would the nurse anticipate in a patient who is weak?
Which fall risk score would the nurse anticipate in a patient who is weak?
Which graphic record cue is associated with constipation?
Which graphic record cue is associated with constipation?
Which musculoskeletal alterations does immobility predispose a patient to developing?
(Select all that apply.)
Which musculoskeletal alterations does immobility predispose a patient to developing? (Select all that apply.)
Patients on bed rest are likely at risk for which physiologic effects and conditions?
(Select all that apply.)
Patients on bed rest are likely at risk for which physiologic effects and conditions? (Select all that apply.)
Which changes in vital signs are indicative of postural hypotension when a patient stands up?
(Select all that apply.)
Which changes in vital signs are indicative of postural hypotension when a patient stands up? (Select all that apply.)
Which parameters would the nurse assess to determine if a urinary tract infection (UTI) has developed?
(Select all that apply.)
Which parameters would the nurse assess to determine if a urinary tract infection (UTI) has developed? (Select all that apply.)
Which cues would likely occur with atelectasis?
(Select all that apply.)
Which cues would likely occur with atelectasis? (Select all that apply.)
Match the alteration to its patient cues.
Match the alteration to its patient cues.
Match the pressure injury stage to its cues.
Match the pressure injury stage to its cues.
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Study Notes
Musculoskeletal System Assessment
- To evaluate musculoskeletal issues, inquire about specific symptoms experienced by the patient.
- Expected findings may include appropriate range of motion and muscle strength during assessment.
Mobility and Movement
- Observe specific movements in images to assess the range of motion.
- Notable responses during patient mobility assessments could indicate the need to halt passive range-of-motion exercises.
Effects of Immobility
- Unexpected findings during mobility evaluations may include abnormalities such as joint stiffness or unusual pain.
- Common complications from immobility include tissue ischemia, which can lead to skin breakdown and pressure injuries.
Activity Intolerance
- Relevant cues for activity intolerance can include fatigue, shortness of breath, and decreased endurance during daily activities.
- Psychological effects of immobilization often manifest as feelings of loneliness or depression.
Complications from Immobility
- Deep vein thrombosis (DVT) risk factors include swelling, warmth, and redness in the affected limb.
- Complications from immobility can also cause alveoli collapse, leading to atelectasis.
Nutritional Considerations
- Anorexia-related cues may emerge in patients reporting a lack of appetite, affecting their nutritional intake.
- Nutritional changes associated with immobility include decreased protein and calorie consumption.
Vital Signs and Postural Changes
- Monitor for signs of postural hypotension, such as dizziness or changes in blood pressure when a patient stands.
Patient Safety and Care Interventions
- Identify patients at risk for reduced bone density due to age, inactivity, or specific medical conditions.
- Complications from immobility can predispose individuals to urinary tract infections and constipation, which need thorough assessment.
Identifying Urinary Tract Infections
- Assessing for UTI involves checking for symptoms like dysuria, urgency, and changes in urine appearance.
Physical Assessment Initiation
- Begin a physical assessment by observing patient posture and gait to gauge mobility.
Cues for Complex Conditions
- Recognize cues linked to atelectasis such as decreased breath sounds and increased respiratory effort.
- Pressure injury staging involves correlating skin and tissue changes with specific cues observed during assessment.
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