The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? Select all that apply.
Osteopenia.
Contracture.
Atrophy.
Kyphosis.
Crepitus.
Correct Answer : B,C,D
A. Osteopenia refers to decreased bone density, which is often noted on X-ray or bone mineral density tests rather than through direct visual inspection. However, the nurse may observe signs of frailty or changes in posture that could suggest underlying osteopenia.
B. Contractures, which are abnormal shortening of muscles or tendons leading to limited joint mobility, are often detectable through inspection. The nurse may observe deformities or restricted movement in the joints, especially in patients with neurological or musculoskeletal disorders.
C. Muscle atrophy, or the wasting away of muscle tissue, can be observed during inspection. The nurse may note reduced muscle bulk or asymmetry in muscle size, which is a sign of muscle wasting.
D. Kyphosis, an abnormal curvature of the spine resulting in a hunchback appearance, can be easily observed during inspection of the client’s posture. This condition is common in older adults and may indicate musculoskeletal or age-related changes.
E. Crepitus refers to the grinding or popping sounds felt or heard when moving joints. While crepitus is assessed by palpation or auscultation rather than visual inspection, the nurse may note joint deformities that suggest the presence of crepitus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Understanding the onset and activities related to the back pain can help the nurse determine if it is musculoskeletal, posture-related, or indicative of a more serious underlying issue.
B. Asking about medication is secondary until more information is gathered about the pain's onset and nature.
C. Changing positions may be relevant later, but initially, it is important to identify any possible triggers for the pain.
D. Asking about previous pain episodes may be helpful, but understanding the current episode’s cause is more pressing.
Correct Answer is ["B","C","D"]
Explanation
A. Osteopenia refers to decreased bone density, which is often noted on X-ray or bone mineral density tests rather than through direct visual inspection. However, the nurse may observe signs of frailty or changes in posture that could suggest underlying osteopenia.
B. Contractures, which are abnormal shortening of muscles or tendons leading to limited joint mobility, are often detectable through inspection. The nurse may observe deformities or restricted movement in the joints, especially in patients with neurological or musculoskeletal disorders.
C. Muscle atrophy, or the wasting away of muscle tissue, can be observed during inspection. The nurse may note reduced muscle bulk or asymmetry in muscle size, which is a sign of muscle wasting.
D. Kyphosis, an abnormal curvature of the spine resulting in a hunchback appearance, can be easily observed during inspection of the client’s posture. This condition is common in older adults and may indicate musculoskeletal or age-related changes.
E. Crepitus refers to the grinding or popping sounds felt or heard when moving joints. While crepitus is assessed by palpation or auscultation rather than visual inspection, the nurse may note joint deformities that suggest the presence of crepitus.
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