Lewis NCLEX Ch 62 - Musculoskeletal
System
A 63-year-old woman has been taking prednisone (Deltasone) daily for
several years after a kidney transplant to prevent organ rejection. What is
most important for the nurse to assess?
A. Staggering gait
B. Ruptured tendon
C. Back or neck pain
D. Tardive dyskinesia - correct answer ✔C. Back or neck pain
Osteoporosis with resultant fractures is a frequent and serious complication of
systemic corticosteroid therapy. The ribs and vertebrae are affected the most,
and patients should be observed for signs of compression fractures (back and
neck pain). Phenytoin (Dilantin) is an antiseizure medication. An adverse
effect of phenytoin is an ataxic (or staggering) gait. A rare adverse effect of
ciprofloxacin (Cipro) and other fluoroquinolones is tendon rupture, usually of
the Achilles tendon. The highest risk is in people age 60 and older and in
people taking corticosteroids. Antipsychotics and antidepressants may cause
tardive dyskinesia, which is characterized by involuntary movements of the
tongue and face.
The home care nurse visits an 84-year-old woman with pneumonia after her
discharge from the hospital. Which assessment finding would the nurse
expect because of age-related changes in the musculoskeletal system?
A. Positive straight-leg-raising test
B. Muscle strength is scale grade 3/5
C. Lateral S-shaped curvature of the spine
, D. Fingers drift to the ulnar side of the forearm - correct answer ✔B. Muscle
strength is scale grade 3/5
Decreased muscle strength is an age-related change of the musculoskeletal
system caused by decreased number and size of the muscle cells. The other
assessment findings indicate musculoskeletal abnormalities. A positive
straight-leg-raising test indicates nerve root irritation from intervertebral disk
prolapse and herniation. An ulnar deviation or drift indicates rheumatoid
arthritis due to tendon contracture. Scoliosis is a lateral curvature of the spine.
The nurse admits a 55-year-old female with multiple sclerosis to a long-term
care facility. Which finding is of most immediate concern to the nurse?
A. Ataxic gait
B. Radicular pain
C. Severe fatigue
D. Urinary retention - correct answer ✔A. Ataxis gait
An ataxic gait is a staggering, uncoordinated gait. Fall risk is the highest in
individuals with gait instability or visual or cognitive impairments. The other
signs and symptoms (e.g., fatigue, urinary retention, radicular pain) may also
occur in the patient with multiple sclerosis and need to be managed, but are
not the priority.
A 57-year-old postmenopausal woman is scheduled for dual-energy x-ray
absorptiometry (DXA). Which statement, if made by the patient to the nurse,
indicates understanding of the procedure?
A. "The bone density in my heel will be measured."
B. "This procedure will not cause any pain or discomfort."
System
A 63-year-old woman has been taking prednisone (Deltasone) daily for
several years after a kidney transplant to prevent organ rejection. What is
most important for the nurse to assess?
A. Staggering gait
B. Ruptured tendon
C. Back or neck pain
D. Tardive dyskinesia - correct answer ✔C. Back or neck pain
Osteoporosis with resultant fractures is a frequent and serious complication of
systemic corticosteroid therapy. The ribs and vertebrae are affected the most,
and patients should be observed for signs of compression fractures (back and
neck pain). Phenytoin (Dilantin) is an antiseizure medication. An adverse
effect of phenytoin is an ataxic (or staggering) gait. A rare adverse effect of
ciprofloxacin (Cipro) and other fluoroquinolones is tendon rupture, usually of
the Achilles tendon. The highest risk is in people age 60 and older and in
people taking corticosteroids. Antipsychotics and antidepressants may cause
tardive dyskinesia, which is characterized by involuntary movements of the
tongue and face.
The home care nurse visits an 84-year-old woman with pneumonia after her
discharge from the hospital. Which assessment finding would the nurse
expect because of age-related changes in the musculoskeletal system?
A. Positive straight-leg-raising test
B. Muscle strength is scale grade 3/5
C. Lateral S-shaped curvature of the spine
, D. Fingers drift to the ulnar side of the forearm - correct answer ✔B. Muscle
strength is scale grade 3/5
Decreased muscle strength is an age-related change of the musculoskeletal
system caused by decreased number and size of the muscle cells. The other
assessment findings indicate musculoskeletal abnormalities. A positive
straight-leg-raising test indicates nerve root irritation from intervertebral disk
prolapse and herniation. An ulnar deviation or drift indicates rheumatoid
arthritis due to tendon contracture. Scoliosis is a lateral curvature of the spine.
The nurse admits a 55-year-old female with multiple sclerosis to a long-term
care facility. Which finding is of most immediate concern to the nurse?
A. Ataxic gait
B. Radicular pain
C. Severe fatigue
D. Urinary retention - correct answer ✔A. Ataxis gait
An ataxic gait is a staggering, uncoordinated gait. Fall risk is the highest in
individuals with gait instability or visual or cognitive impairments. The other
signs and symptoms (e.g., fatigue, urinary retention, radicular pain) may also
occur in the patient with multiple sclerosis and need to be managed, but are
not the priority.
A 57-year-old postmenopausal woman is scheduled for dual-energy x-ray
absorptiometry (DXA). Which statement, if made by the patient to the nurse,
indicates understanding of the procedure?
A. "The bone density in my heel will be measured."
B. "This procedure will not cause any pain or discomfort."
