LOOK & FEEL
Before touching the patient, the nurse can gather information about posture, alignment, symmetry, and this important aspect of walking.
Gait (Particular style, manner or pattern of walking)
Moving an extremity away from the body's midline is called what?
Abduction
Muscle strength is commonly documented using a scale from ___ to ___.
0 to 5
A patient has smooth, coordinated movement and equal strength bilaterally. Expected or abnormal?
Expected
A patient reports pain when moving the right shoulder. Should the nurse force the shoulder through its full ROM?
No. Do not force a painful joint through ROM. Stop or modify the movement and assess further.
When assessing a joint, the nurse should compare the affected joint with what?
The corresponding joint on the opposite side.
The patient brings the toes upward toward the lower leg. Name this movement.
Dorsiflexion
A patient demonstrates full muscle strength against resistance. What muscle-strength grade should the nurse document?
5/5
A joint is red, warm, swollen, and tender. Expected or abnormal?
Abnormal; requires further assessment.
A patient says, “My knee hurts whenever I walk.” Is this subjective or objective data? Name one objective finding the nurse could collect.
Subjective.
Objective examples: gait, swelling, redness, ROM, tenderness, strength, alignment, or function.
During palpation of a patient's knee while it moves, the nurse feels a grating sensation. What is the correct term for this finding?
Crepitus
The patient rotates the forearm until the palm faces upward. Name the movement AND its opposite.
Supination; opposite = pronation.
A patient can move the leg through full ROM against gravity but cannot tolerate resistance. What muscle-strength grade should the nurse document?
3/5
A patient has full active ROM of a shoulder without pain. Expected or abnormal? Name one additional finding that would support a normal assessment.
Expected. Examples: symmetry, no swelling/tenderness, equal strength, or smooth movement.
The nurse observes a patient limping while walking.
Name FOUR additional musculoskeletal assessments the nurse could perform.
Any 4: gait, posture/alignment, bilateral comparison, ROM, strength, pain, joint inspection, tenderness, swelling, or warmth.
$400
A patient's right knee appears larger than the left.
Name THREE additional characteristics the nurse should assess when examining the knee.
Any 3: swelling, redness, warmth, tenderness, joint contour/alignment, ROM, pain, or strength/function.
The nurse asks a patient to raise both arms overhead without assistance. Is the nurse assessing active or passive ROM? Explain.
Active ROM. The patient is moving the joints independently.
The patient's right hand grip is noticeably weaker than the left. Should the nurse simply document “muscle weakness” and move on? What should happen next?
No. Further assess the weakness and compare bilaterally, including strength grade, ROM, pain, symmetry, and function.
The nurse notes decreased ROM of one knee compared with the other.
Name THREE things the nurse should assess before interpreting the finding.
Any 3: pain, swelling, tenderness, warmth, strength, function, injury history, onset, or bilateral differences.
A patient reports right-knee pain. Assessment reveals mild swelling, tenderness, and decreased active ROM. What should the nurse do with these findings?
Document the subjective and objective findings, recognize the abnormal cluster, and perform/facilitate further assessment rather than assigning a medical diagnosis.
$500
A patient walks into the examination room favoring the left leg.
The student documents:
“Patient has arthritis of the left knee.”
What is wrong with this documentation, and what would be a more appropriate way to document the finding?
The student has interpreted/diagnosed the cause rather than objectively documenting the assessment finding.
Appropriate documentation might include:
“Patient ambulates with a limp and favors the left lower extremity.”
Further assessment is required to determine the cause.
A patient cannot completely raise the right arm overhead during active ROM. Name THREE appropriate assessment actions the nurse should take next.
Any 3: compare shoulders bilaterally, assess pain, inspect for swelling/deformity, palpate as appropriate, assess strength, further assess ROM, or ask about onset/injury/function.
Right arm strength is 5/5 and left arm strength is 3/5.
What does 3/5 mean, and why is bilateral comparison important?
3/5 = movement against gravity but not resistance. Bilateral comparison identifies asymmetry/weakness.
During a musculoskeletal assessment, the nurse observes an accentuated posterior curvature of the thoracic spine.
Identify the finding and describe the nurse’s next assessment action.
Kyphosis.
(answer should include at least 2 of these) Further assess spinal alignment, ROM, pain/tenderness, gait/function, and relevant history, and document the finding objectively.
A patient has decreased right shoulder ROM, pain with movement, right arm strength 3/5, left arm strength 5/5, but no redness or swelling.
Identify the abnormal findings and one important next assessment.
Abnormal:
decreased ROM, pain, 3/5 strength, unequal strength.
Next: further assess pain, tenderness, ROM, function, onset/injury, or related findings.
A patient enters slowly, favoring the right leg, and reports knee discomfort.
Put these into a logical assessment approach: Strength — Inspection — ROM — Palpation — Bilateral Comparison.
Then identify one important safety principle.
Inspection → Palpation → ROM → Strength, with bilateral comparison throughout the assessment.
Safety: Do not force a painful joint through ROM; stop or modify movement that causes significant pain.