RESPONSE SET GRADED A+
◉ •How do we grade muscle strength? Answer: 0-5
◉ The musculoskeletal assessment requires a patient to perform
multiple exercises for identifying health status of this system. To test
trapezius muscle strength, the nurse should ask the patient to:
A.Shrug his shoulders against resistance
B.Lift his knee against resistance
C.Hyperextend his leg without resistance
D.Touch his toes from the standing position Answer: a
◉ While testing the patient's muscle strength, the nurse finds that
the patient can flex the arms when no resistance is applied but is
unable to flex when the nurse applies light resistance. The nurse
should document the patient's muscle strength as level
A.1
B.2
C.3
,D.4 Answer: c
◉ As the nurse assesses the patient, the following is noted. What
would be the most accurate assessment of this?
A.Boutonniere's deformity
B.Ulnar deviation
C.Bouchard's node
D.Swan-Neck deformity
Which musculoskeletal disorder is this most commonly associated
with? Answer: b
rheumatoid arthritis
◉ The nurse is performing a musculoskeletal assessment of an older
adult patient whose mobility has been decreasing progressively in
recent months. How should the nurse best assess the patient's range
of motion in the affected leg?
A.Observe the patient's unassisted ROM in the affected leg
B.Perform passive ROM, asking the patient to report any pain
C.Ask the patient to lift progressed weights with the affected leg
,D.Move both the patient's legs from a supine position to full flexion
Answer: a
◉ A 42-year-old male patient complains of shoulder pain when the
nurse moves his arm behind the back. Which question should the
nurse ask?
A."Are you able to feed yourself without difficulty?"
B."Do you have difficulty when you are putting on a shirt?"
C."Are you able to sleep through the night without waking?"
D."Do you ever have trouble lowering yourself to the toilet?" Answer:
b
◉ A nurse is instructing a student nurse how to perform passive
ROM on their patient. Which of the following are correct techniques
of passive ROM? Select all that apply.
A.The student nurse will instruct and mirror the ROM movement
before asking the patient to perform ROM
B.Instruct patient to flex arm while the student nurse moves the
patient's shoulder in a circular motion
C.Support the patient's elbow with one hand and shoulder in
another while gently rotating the patient's shoulder
D.While patient's muscles are relaxed, the student nurse will move
the patient's joint to assess ROM Answer: c, d
, ◉ •What are ADLs? Functional vs instrumental Answer: activities of
daily living
functional: dressing, walking, toileting, eating, bathing
instrumental:
driving, cooking, paying bills, grocery shopping, using phones,
cleaning the house
◉ •What are proper body mechanics? Answer: ØEnsure client or
object that you are handling is CLOSE to your body as possible
ØKeep abd muscles contracted & lower back in normal position
ØMaintain head upright with shoulders raised up
ØBow the hips slightly and squat
ØPivot or side-step rather than twisting
ØBend at the knees and use leg muscles when lifting; do not bend
over with back
◉ •What is 'protective positioning'? Answer: Involves aligning the
body in a neutral position, supporting the body's natural curves, and
eliminating pressure points, hyperextension, or lateral rotation.
◉ •How frequently do we change a patient's position in bed?
Answer: every 2 hours