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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. This is an appropriate first step in documenting any unusual findings during the assessment. However, based on the presence of dense white patches, the nurse should consider a referral for further evaluation, rather than just recording the findings.
B. The dense white patches seen on the tympanic membrane are more likely related to past ear infections (such as tympanosclerosis) or other conditions, not excess wax. Cleaning the ears would not address the underlying cause and could potentially cause harm.
C. This could be a reasonable action if there were concerns about hearing loss. However, the tympanic membranes appear mostly normal apart from the white patches, so hearing loss is not strongly indicated by the findings alone. A referral might be premature unless hearing issues are suspected.
D. The dense white patches on the tympanic membranes could be indicative of tympanosclerosis, a benign condition related to previous infections or tube insertions, but fungal growth is not the most likely cause in this case.

A. Document this finding in the medical record. B. Ask if the client recently received any antibiotics. C. Ask the client about use of irritating chemical agents. D. Schedule an appointment with a dermatologist.

Correct Answer is A

Explanation

A. Documenting the finding is important to ensure proper record-keeping, especially in clients with dark pigmented skin, where some variations in skin tone may be normal.
B. Asking about antibiotics is unnecessary unless there's suspicion of a drug-induced reaction or side effect.
C. While use of irritating chemicals could cause changes, this scenario does not directly suggest that as the cause.
D. Referral to a dermatologist is not required without further investigation to determine if the discoloration is concerning.

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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.

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?

Correct Answer is A

Explanation

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