CHP 38&39 Activity and movement: Assess and recognize cues
35 Questions
26 Views

CHP 38&39 Activity and movement: Assess and recognize cues

Created by
@ExultantHummingbird

Podcast Beta

Play an AI-generated podcast conversation about this lesson

Questions and Answers

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?

  • 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?

  • Rotation
  • Extension
  • Hyperextension
  • Lateral flexion (correct)

    • Question 4 of 4

    Which finding is unexpected when assessing effects of immobility?

    <p>Skin nonblanches</p> Signup and view all the answers

    Which cue is relevant to alterations in the musculoskeletal system?

    <p>Has a shoulder joint that is edematous</p> Signup and view all the answers

    Match the musculoskeletal system alteration to its cause.

    <p>Porous, brittle bones = Pathologic fracture Deterioration of the muscle itself = Muscle atrophy Tissue that is usually easy to move tightens and pulls inward = Contracture . = .</p> Signup and view all the answers

    Which patient would likely be prone to reduced bone density?

    <p>One who cannot perform weight-bearing exercises</p> Signup and view all the answers

    Which cues are relevant for weakness? (Select all that apply)

    <p>Flaccidity</p> Signup and view all the answers

    Which patient is prone to paralysis?

    <p>A patient with prolonged brain ischemia</p> Signup and view all the answers

    Which cues are relevant for activity intolerance?

    (Select all that apply.)

    <p>Struggles to complete activities of daily living</p> Signup and view all the answers

    Which graphic record cue indicates the patient has anorexia?

    <p>Eats less than 50% of meals</p> Signup and view all the answers

    Which finding is a psychological consequence of bed rest and manifests in the patient becoming lonely or depressed?

    <p>Feelings of isolation</p> Signup and view all the answers

    Tissue ischemia related to immobility can directly lead to the development of which complication?

    <p>Pressure injuries</p> Signup and view all the answers

    Which patient situation is a medical emergency?

    <p>Pulmonary embolus</p> Signup and view all the answers

    Which cues are relevant for a deep vein thrombosis (DVT)? (Select all that apply.)

    <p>Redness / Edema</p> Signup and view all the answers

    Which complication from immobility causes the alveoli to collapse?

    <p>Atelectasis</p> Signup and view all the answers

    In which areas would the patient experience pain if a urinary tract infection is present? (Select all that apply)

    <p>Back / Bladder</p> Signup and view all the answers

    Which action by the nurse initiates the physical assessment of a patient’s mobility?

    <p>Observing the patient</p> Signup and view all the answers

    Which patient finding would alert the nurse to stop passive range-of-motion exercises?

    <p>Resistance to movement is felt.</p> Signup and view all the answers

    Which finding would be unexpected when the nurse is assessing for mobility issues?

    <p>Joint crepitus</p> Signup and view all the answers

    Patient reports of shortness of breath and fatigue while performing activities of daily living are indicative of which alteration?

    <p>Activity intolerance</p> Signup and view all the answers

    Which nutritional alteration is associated with immobility?

    <p>Decreased basal metabolic rate</p> Signup and view all the answers

    Which interpretation would the nurse make when observing a darkened or reddened area of skin in an immobile patient?

    <p>Tissue ischemia has occurred.</p> Signup and view all the answers

    A patient with redness, warmth, and swelling in the right lower leg is at risk for which complication?

    <p>Pulmonary embolism</p> Signup and view all the answers

    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”?

    <p>“You have been immobile for several days, which can decrease your metabolism and appetite.”</p> Signup and view all the answers

    Question 9 of 18

    Which movement is the nurse assessing in the image?

    <p>Adduction and abduction</p> Signup and view all the answers

    Which fall risk score would the nurse anticipate in a patient who is weak?

    <p>Hendrich II Fall Risk Model score of 8</p> Signup and view all the answers

    Which graphic record cue is associated with constipation?

    <p>Infrequent stools</p> Signup and view all the answers

    Which musculoskeletal alterations does immobility predispose a patient to developing? (Select all that apply.)

    <p>Weakness / Decreased muscle tone</p> Signup and view all the answers

    Patients on bed rest are likely at risk for which physiologic effects and conditions? (Select all that apply.)

    <p>Increased venous return / Decreased lung expansion</p> Signup and view all the answers

    Which changes in vital signs are indicative of postural hypotension when a patient stands up? (Select all that apply.)

    <p>Systolic blood pressure drops from 120 to 100 mm Hg / Heart rate increases from 65 to 85 beats/min</p> Signup and view all the answers

    Which parameters would the nurse assess to determine if a urinary tract infection (UTI) has developed? (Select all that apply.)

    <p>Chills / Urinary frequency</p> Signup and view all the answers

    Which cues would likely occur with atelectasis? (Select all that apply.)

    <p>Cyanosis</p> Signup and view all the answers

    Match the alteration to its patient cues.

    <p>Unable to move joints because of foot drop = Contracture Decreased muscle size with weak handgrip = Muscle atrophy Inability to move, with a loss of sensation = Paralysis Irregular patterns of behavior from inadequate coping = Altered Self-Concept</p> Signup and view all the answers

    Match the pressure injury stage to its cues.

    <p>Blistering of epidermis or dermis = Stage 2 Intact skin with reddened area = Stage 1 Exposure of muscle and bone = Stage 4 Subcutaneous injury with possible tunneling = Stage 3</p> Signup and view all the answers

    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.

    Studying That Suits You

    Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

    Quiz Team

    Description

    This quiz focuses on the key questions a nurse should ask to identify symptom-related issues pertaining to the musculoskeletal system. Test your knowledge on effective nursing assessments and patient care strategies related to this important body system.

    More Like This

    Use Quizgecko on...
    Browser
    Open
    Browser
    Browser