MSK
When assessing the elbow, a nurse asks a client to hold the arm out and turn the palm down. The nurse is testing which of the following?
a) Pronation
b) Flexion
c) Rotation
d)Supination
Pronation
Turning the palm down tests pronation. Having the client turn the palm up would test supination. Flexion is tested by having the client bend the elbow and bring the hand to the forehead. Rotation is not assessed for the elbow.
An older adult client visits the clinic and tells the nurse that she has had shooting pain in both of her legs. The nurse should assess the client for signs and symptoms of
herniated intervertebral disc.
rheumatoid arthritis.
osteoporosis.
metastases.
herniated intervertebral disc.
Thirty-three bones: 7 concave-shaped cervical (C); 12 convex shaped thoracic (T); 5 concave-shaped lumbar (L); 5 sacral (S); and 3-4 coccygeal, connected in a vertical column. Bones are cushioned by elastic fibrocartilaginous plates (intervertebral discs) that provide flexibility and posture to the spine. Paravertebral muscles are positioned on both sides of vertebrae.
A client presents to the health care clinic with reports of pain in the hands and right wrist. Additional history reveals that the client is a factory worker who spends all day performing the same repetitive task. The nurse performs the Phalen's test and Tinel's tests with positive results. The hand grips are unequal with the right weaker than the left. What nursing diagnosis can the nurse confirm from this data?
a)Risk for Trauma
b)Impaired Physical Mobility
c)Disturbed Body Image
d)Activity Intolerance
Impaired Physical Mobility
This client is likely experiencing carpal tunnel syndrome because of the repetitive hand movements that inflame the median nerve as it passes through the wrist. Impaired Physical Mobility related to decreased muscle strength as evidenced by a weak right hand grip meets the major criteria to confirm this nursing diagnosis. Risk for Trauma cannot be confirmed because the client already has carpal tunnel syndrome so he is not at risk. Disturbed Body Image and Activity Intolerance do not meet any major defining characteristics to confirm these nursing diagnoses.
A nurse notices that a client's flexibility of the right elbow is less than the left elbow. What is an appropriate action by the nurse in regard to this finding?
a) notify healthcare provider
b) assess the client's hand grip
c)Measure movement with a goniometer
If the nurse identifies a limitation in the range of motion for a joint, a goniometer should be used to measure the exact angle of movement present. The goniometer is placed at the joint and then moved to match the angle of the joint being assessed. It is not necessary to notify the health care provider until all information is collected. The hand grips test strength, not range of motion. The dominant side of the body is stronger but does not necessarily have greater range of motion.
A client presents to the emergency department after falling off a ladder while doing some outside painting at home. The client's ankle appears swollen, out of alignment, and is painful to touch. What is the nurse's first action?
Check for a pulse, color, temperature, and capillary refill.
Splint and immobilize the affected extremity
Apply an ice pack to the affected extremity.
Encourage early weight bearing and ambulation
Check for a pulse, color, temperature, and capillary refill.
The first nursing actions include taking vital signs, monitoring pulses, and assessing color, temperature, and capillary refill distal to the injury to evaluate tissue perfusion. The ankle should then be immobilized after assessment. An ice pack may be applied after assessing for temperature and pulses, etc. The first action is no weight bearing until the ankle is fully assessed.