Chp 23

A patient is being assessed for range-of-joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called:

• Flexion.

• Abduction.

• Adduction.

• Extension.

Answer explanation

Moving a limb toward the midline of the body is called adduction; moving a limb away from the midline of the body is called abduction. Flexion is bending a limb at a joint; and extension is straightening a limb at a joint.

A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which

movement?

• Flexion

• Abduction

• Adduction

• Extension

Answer explanation

Flexion, or bending a limb at a joint, is required to move the hand to the mouth. Extension is straightening a limb at a joint. Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body.

The nurse is checking the range of motion in a patients knee and knows that the knee is capable of which movement(s)?

• Flexion and extension

• Supination and pronation

• Circumduction

• Inversion and eversion

Answer explanation

The knee is a hinge joint, permitting flexion and extension of the lower leg on a single plane. The knee is not capable of the other movements listed.

A patient has been diagnosed with osteoporosis and asks the nurse, What is osteoporosis? The nurse

explains that osteoporosis is defined as:

• Increased bone matrix.

• Loss of bone density.

• New, weaker bone growth.

• Increased phagocytic activity.

Answer explanation

After age 40 years, a loss of bone matrix (resorption) occurs more rapidly than new bone formation. The net effect is a gradual loss of bone density, or osteoporosis. The other options are not correct.

The nurse is teaching a class on preventing osteoporosis to a group of perimenopausal women. Which of these actions is the best way to prevent or delay bone loss in this group?

• Taking calcium and vitamin D supplements

• Taking medications to prevent osteoporosis

• Performing physical activity, such as fast walking

• Assessing bone density annually

Answer explanation

Physical activity, such as fast walking, delays or prevents bone loss in perimenopausal women. The faster the pace of walking, the higher the preventive effect is on the risk of hip fracture. The other options are not correct

When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What grade of muscle strength should the nurse record using a 0- to 5-point scale?

• 2

• 3

• 4

• 5

Answer explanation

Complete range of motion against gravity is normal muscle strength and is recorded as grade 5 muscle strength. The other options are not correct.

When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be:

• Proximal to distal.

• Distal to proximal.

• Posterior to anterior.

• Anterior to posterior.

Answer explanation

The musculoskeletal assessment should be performed in an orderly approach, head to toe, proximal to distal, from the midline outward. The other options are not correct.