Exam 1: Mobility Practice 30 Questions

A cast is applied to the involved extremity of an infant with talipes equinovarus (clubfoot). How often does the nurse tell the parents to bring their baby back to the clinic for a cast change? 1. each week 2. once a month 3. when the cast edges fray 4. if the cast becomes soiled

1 rationale: Casts are changed weekly to accommodate the rapid growth of early infancy. Once a month is not frequent enough in early infancy; the cast may become too tight because of the infant's rapid growth. The cast is not on the foot long enough for fraying to occur. Soiling is usually not a problem, because casts for clubfoot do not extend to the perineal area.

Identify abnormal assessment findings in the client's musculoskeletal system. Select all that apply. 1. joint crepitation 2. muscular atrophy 3. muscle strength of 5 4. tenderness of the spine 5. full range of motion in joints

1, 2, 4 rationale: Crepitation, a cracking and popping sound of the joint, is not a normal assessment finding. Muscular atrophy, wasting of the muscle, is also an abnormal finding. Spine tenderness on palpation of spine, joints, or muscles is not a normal finding on physical assessment of the musculoskeletal system. Muscle strength of 5 indicates active movement of the muscle against full resistance without evident fatigue, or normal muscle strength. Full range of motion in the joints is a normal finding.

The nurse is assessing a client's equilibrium to test his or her cerebellar function. The nurse finds that the client sways with his or her eyes closed. How should the nurse document this observation? 1. positive kernig sign 2. positive romberg sign 3. positive babinski sign 4. positive brudzinski sign

2 rationale: A positive Romberg sign indicates abnormal proprioception; clients with this condition are unable to maintain balance with their eyes closed. A positive Kernig sign and a positive Brudzinski sign indicate meningitis. A positive Babinski sign indicates the presence of central nervous system disease.

Which diagnostic study is used to determine a client's bone density? 1. diskogram 2. standard x-ray 3. computed tomography scan 4. magnetic resonance imaging

2 rationale: A standard X-ray is used to determine bone density. A diskogram is used to visualize abnormalities of the intervertebral disc. A computed tomography scan is used to identify soft tissues, bony abnormalities, and various types of musculoskeletal trauma. Magnetic resonance imaging is used to diagnose avascular necrosis, disc disease, tumors, osteomyelitis, ligament tears, and cartilage tears.

Which information should the nurse refrain from including when teaching a parent about changes that the child will exhibit after the first birthday? 1. "The child won't sleep as long." 2. "The child will have more food choices." 3. "The child will have an increased need for fats." 4. "The child will exhibit an increased activity level."

3 rationale: As an infant enters the toddler stage, the toddler needs less fat and more protein. Hence the nurse is not likely to inform the parent that the child needs more fat in the diet. During this transition, the need for sleep declines. At this time, toddlers establish lifetime eating habits, and there is increased emphasis on food choices. A toddler's activity level is also greater than an infant's.

Which nursing intervention is indicated for aging clients with decreased bone density? 1. Teaching the client isometric exercises 2. Advising the client to take a moist heat shower 3. Providing supportive armchairs to the client 4. Demonstrating weight-bearing exercises to the client

4 rationale: Decreased bone density leads to osteoporosis; weight-bearing exercises help to build and maintain bone density. Isometric exercises are indicated for clients with muscular atrophy. Clients with cartilaginous degeneration are advised to take moist heat showers to increase blood flow to the region. Correction of posture problems by sitting in a supportive armchair provides support to the bony structures for a client with kyphosis.

After an amputation, the client's residual limb is bandaged snugly throughout the postoperative period. Which goal should the nurse identify as the primary reason for this intervention? 1. promoting shrinkage 2. preventing injury to the area 3. preventing suture line infection 4. promoting drainage of secretions

1 rationale: Wrapping of the residual limb applies pressure that prevents swelling and shapes it for the fitting of a prosthesis in the future. A sock is used to protect the residual limb from irritation and injury. Infection is not prevented in this manner; surgical asepsis should be maintained. Secretion drainage is not promoted by wrapping the limb; portable drainage systems are used for this purpose.

What statement by the mother of a 6-week-old girl leads the nurse to assess the infant for the presence of a skeletal abnormality? 1. "She seems to want to sleep curled up." 2. "It's hard to put the diaper between her legs." 3. "Her feet look flat when I put booties on her." 4. "When I try to stand her up her legs won't straighten."

2 rationale: Difficulty with abduction may indicate developmental dysplasia of the hip. Flexion of extremities is a young infant's typical position when sleeping. Flat feet and failure to straighten the legs are both expected findings in a young infant.

A nurse is assessing an infant with talipes equinovarus (clubfoot) who has had a corrective boot cast applied. Which peripheral vascular assessment cannot be performed while the cast is in place? 1. color 2. pulse 3. warmth 4. blanching

2 rationale: The pedal pulse cannot be palpated under a boot cast. Assessments of the color, warmth, and blanching of the toes are all appropriate neurovascular checks.

A nurse is caring for an older adult who had an open reduction and internal fixation of a fractured hip. What clinical finding requires the nurse to notify the primary healthcare provider? 1. Lack of a productive cough 2 days postoperatively 2. Rectal temperature of 100.2° F (37.9° C) 3 days postoperatively 3. Complaints of right-sided chest pain 6 days postoperatively 4. Fatigue in the leg on the unaffected side 5 days postoperatively

3 rationale: Chest pain, along with dyspnea, cough, hemoptysis, and apprehension, is a classic sign of a pulmonary embolism. Six days postoperatively is a prime time for symptoms of a pulmonary embolus to occur, because decreased mobility promotes the development of deep vein thrombosis. The lack of a productive cough does not require nursing intervention; a productive, not nonproductive, cough indicates a respiratory infection requiring intervention. An increase in temperature can result from the inflammatory process; the temperature-regulating mechanisms in older adults may be compromised slightly, and they may show a slight elevation in body temperature for a longer period of time after surgery than a younger client. Weight bearing is being done by the unaffected leg at this time, and fatigue is expected.

A college basketball player complains of a "click" in the knee when walking. The client states that the knee occasionally gives way when running and sometimes locks. The client does not recall any specific injury. What does the nurse suspect that the diagnostic tests will reveal? 1. cracked patella 2. ruptured achilles tendon 3. injured cartilage in the knee 4. stress fracture of the tibial plateau

3 rationale: These adaptations are consistent with torn cartilage; this injury is common among basketball players. A fractured patella will cause pain and usually manifests itself at the time of the injury. A ruptured Achilles tendon is painful and prevents plantar flexion of the foot; adaptations usually are manifested at the time of the injury. A stress fracture is associated with pain, not with a clicking or locking of the knee.

Range-of-motion exercises are prescribed for a child with juvenile idiopathic arthritis. What criterion should the nurse use to evaluate the effectiveness of the exercises? 1. The pain is relieved. 2. The affected joints can flex and extend. 3. The pedal and radial pulses are diminished. 4. The subcutaneous nodules at the joints recede.

2 rationale: The exercises are done to preserve joint function. Exercises do not necessarily relieve pain. Circulation is not affected by the arthritic process. Exercise does not affect the subcutaneous nodules.

The nurse is teaching an elderly client isometric exercises. Which physiologic condition does the client have? 1. kyphosis 2. muscle atrophy 3. decreased bone density 4. decreased range of motion (ROM)

2 rationale: Muscle atrophy occurs due to muscular weakness; isometric exercises can help increase muscular strength. Kyphosis can be reduced by introducing the client to proper body mechanics and instructing the client to sit in supportive chairs with arms. Complications associated with decreased bone density can be reduced by teaching safety tips to prevent falls and by reinforcing the need to exercise. The nurse should assess the client's ability to perform activities of daily living and mobility in a client with a decreased ROM.

While performing a musculoskeletal assessment, the nurse notices that the client can complete range of motion with gravity eliminated. Which grade would the nurse assign to the client? 1. 1 2. 2 3. 3 4. 4

2 rationale: When rating muscle strength, grade 2 indicates complete range of motion with gravity eliminated. Grade 1 indicates no joint motion and slight evidence of muscle contractility. Grade 3 is indicated by complete range of motion against gravity only. If there is complete range of motion against gravity with some resistance, then the grade would be 4.

A client develops a nonhealing ulcer of a lower extremity and complains of leg cramps after walking short distances. The client asks the nurse what causes these leg pains. Which would be the best response by the nurse? 1. "Muscle weakness occurs in the legs because of a lack of exercise." 2. "Edema and cyanosis occur in the legs because they are dependent." 3. "Pain occurs in the legs while walking because there is a lack of oxygen to the muscles." 4. "Pressure occurs in the legs because of vasodilation and pooling of blood in the extremities."

3 rationale: Intermittent claudication is the pain that occurs during exercise because of a lack of oxygen to muscles in the involved extremities. It is exercise, not the lack of exercise, that precipitates muscle weakness. Edema and cyanosis in the legs and pressure in the legs are related to venous problems, not an arterial problem.

Which type of burn/injury may cause a client to have a cervical spine injury? 1. electrical burns 2. chemical burns 3. inhalation injury 4. cold thermal injury

1 rationale: Electrical burns may cause injuries to the cervical spine because intense electrical currents can fracture long bones and vertebrae. Chemical burns may cause eye and tissue damage. Inhalation injuries may damage the respiratory tract. Cold thermal injuries may cause tissue damage.

During a follow-up office visit, an older client who has been undergoing treatment for the last 5 months for osteomyelitis notes perianal itching and diarrhea. Which other finding does the nurse correlate with this information? 1. Whitish-yellow lesions in the oral cavity 2. Presence of glucose and ketones in urine 3. Flexion contracture of the lower extremities 4. Overgrowth of genital wart-like lesions

1 rationale: Whitish-yellow lesions in the oral cavity is correlated to the perianal itching and diarrhea. The antibiotics that are effective against osteomyelitis may be used for as long as 6 months. Long-term antibiotic therapy can result in overgrowth of Candida albicans and Clostridium difficile in the gastrointestinal tract. This can in turn result in genitourinary changes such as perianal itching, diarrhea, and gastrointestinal tract changes such as whitish-yellow lesions in the oral cavity, especially in older adults. The presence of glucose and ketones is not a reason for perianal itching and diarrhea. Flexion contracture of the lower extremities does not cause perianal itching and diarrhea. While genital warts can cause itching and diarrhea, they are not the cause for this scenario. The prolonged use of antibiotics has disrupted the normal flora (biome).

What clinical finding does the nurse expect when assessing a client with myasthenia gravis? 1. Partial improvement of muscle strength with mild exercise 2. Fluctuating weakness of muscles innervated by the cranial nerves 3. Dramatic worsening in muscle strength with anticholinesterase drugs 4. Minimal changes in muscle strength regardless of the therapy initiated

2 rationale: Myasthenia gravis is a chronic disorder of muscles enervated by weakened cranial nerves; eyelid movement, chewing, swallowing, speech, facial expression, and breathing often are affected. Muscle strength increases with rest and decreases with activity. Anticholinesterase drugs increase, not decrease, muscle strength. Anticholinesterase drugs improve muscle strength.

Four clients with osteomyelitis are prescribed antibiotics. Which client is at risk for Achilles tendon rupture? 1. client a 2. client b 3. client c 4. client d

2 rationale: Osteomyelitis is a severe infection of the bone, bone marrow, and surrounding soft tissue. Tendon rupture can occur with use of the fluoroquinolones. Therefore client B, prescribed ciprofloxacin, is at risk for Achilles tendon rupture. Client A, prescribed gentamicin, is at risk for visual and hearing problems. Client C, prescribed cefazolin, is at risk for severe watery diarrhea and mouth sores. Client D, prescribed tobramycin, is at risk for nephrotoxicity.

A client has an open reduction and internal fixation of the hip. The client is to be transferred to a chair for a half hour on the second postoperative day. Before transferring the client, what should the nurse do? 1. Assess the strength of the affected leg. 2. Explain the transfer procedure step by step. 3. Instruct the client to bear weight evenly on both legs. 4. Encourage the client to keep the affected leg elevated.

2 rationale: The client should understand the steps in the transfer to assist appropriately and avoid injury. Assessing strength in the affected leg is not advisable because it may disrupt the repair of the affected hip; also, weight bearing initially is not permitted on the operative leg. Bearing weight on the affected leg is contraindicated initially. The client may touch the floor with the foot of the affected leg, but may not bear weight on the affected leg. Elevating the leg will cause hip flexion, which is contraindicated initially because it may precipitate hip dislocation.

The nurse is reviewing the diagnostic reports of four clients with complications of fracture. Which client may be treated with a fasciotomy? 1. client a 2. client b 3. client c 4. client d

2 rationale: The client with compartment syndrome will most likely need a fasciotomy. Compartment syndrome is a condition in which swelling and increased pressure within a limited space (a compartment) press on and compromise the function of blood vessels, nerves, or tendons that run through that compartment. Fasciotomy, surgical decompression of the affected compartment, is used to treat compartment syndrome. Acute respiratory distress syndrome can be treated with administration of oxygen to the client as well as mechanical ventilation. Anticoagulants, sequential compression devices, and compression gradient stockings are used to treat venous thromboembolism. Fat embolism syndrome is treated by correcting acidosis, administering fluids, and replacing lost blood.

A nurse is assessing a client for the potential for osteoporosis. Which factor in the client's history increases the risk for this disorder? 1. estrogen therapy 2. hypoparathyroidism 3. prolonged immobility 4. excessive calcium intake

3 rationale: Prolonged immobility results in bone demineralization because there is decreased bone production by osteoblasts and increased resorption by osteoclasts. Estrogen helps prevent bone demineralization. Hypoparathyroidism decreases mobilization of calcium from the bones, thereby reducing the serum level of calcium. Decreased calcium intake or absorption may precipitate osteoporosis.

client with osteoporosis is prescribed raloxifene. What should the nurse monitor in the client? 1. check serum creatinine 2. monitor urinary calcium 3. monitor liver function tests 4. observe for anxiety and drowsiness

3 rationale: Raloxifene increases the risk for hepatic disease. Therefore the liver function test is monitored in a client who is prescribed this drug. Serum creatinine is checked in a client who is prescribed zoledronic acid. Urinary calcium is monitored in a client who is prescribed calcium supplements. Anxiety and drowsiness is observed in a client who is prescribed risedronate.

In which positions should the nurse place a client who has just had a right pneumonectomy? 1. right or left side lying 2. high Fowler or supine 3. supine or right side lying 4. left side lying or low Fowler

3 rationale: Supine or right side-lying permits ventilation of the remaining lung and prevents fluid from draining into the sutured bronchial stump. Lying on the unoperative side restricts left lung excursion and may allow fluid to drain into the right bronchial stump. Although the high-Fowler position promotes ventilation, it may be tiring for a postoperative client. Lying on the unoperative side restricts left lung excursion and may allow fluid to drain into the right bronchial stump.

While on a hike, a rusty nail pierces the sole of a client's foot and he is brought to the emergency department of a local hospital. Tetanus immune globulin is prescribed because the client does not know when the last tetanus immunization was received. What information will the nurse include when teaching the client about this drug? 1. It will take about a week to become effective. 2. Immune globulin provides lifelong passive immunity. 3. It provides immediate, passive, short-term immunity. 4. Immune globulins stimulate the production of antibodies.

3 rationale: Tetanus immune globulin contains ready-made antibodies and provides immediate, short-term, passive immunity. Passive immunity lasts a short time, not throughout life. Immune globulins confer passive artificial immunity, not long-lasting active immunity. Immune globulins are antibodies; they do not stimulate the production of antibodies.

A primary healthcare provider prescribes a diagnostic workup for a client who may have myasthenia gravis. What is the initial nursing goal for the client during the diagnostic phase? 1. adhere to a teaching plan 2. achieve psychologic adjustment 3. maintain present muscle strength 4. prepare for the development of myasthenic crisis

3 rationale: Until the diagnosis is confirmed, the primary goal should be to maintain adequate activity and prevent muscle atrophy. It is too early to develop a teaching plan; the diagnosis is not yet established. It is too early to achieve psychologic adjustment; the client cannot adjust if a diagnosis is not yet confirmed. Preparing for the development of myasthenic crisis is not a goal.

A nurse is teaching a client with a non-weight-bearing long leg cast. Which statement indicates the need for the nurse to reinforce discharge teaching? 1. "The cast can be wrapped in plastic when I take a shower." 2. "I called my office to let them know I will be back at work next week." 3. "The physical therapist is going to teach me how to walk with crutches." 4. "I am going to give myself a pedicure with red nail polish when I get home."

4 rationale: Red nail polish will interfere with the ability to assess the toes for capillary refill; effective capillary refill, after releasing compression of the toenail, confirms that the cast is not compromising circulation to the distal part of the extremity. Wrapping the cast in plastic is an effective way of protecting the long leg cast during a shower. Usual daily activities can be resumed after the application of a cast. Teaching the client how to use the crutches is the role of the physical therapist.

A newborn has been diagnosed with developmental dysplasia of the hips and is placed in a Pavlik harness. The parents have been instructed that the infant is to wear the appliance full time except for bathing. What additional instruction should the nurse give the parents about the harness? 1. Avoid undershirts or diapers under the harness. 2. The harness may be adjusted as needed as the baby grows. 3. Apply lotion or baby powder under the harness to prevent skin breakdown. 4. Avoid using the legs to lift the infant's buttocks when changing the diaper at bath time.

4 rationale: The Pavlik harness abducts and flexes the hips. If the legs are used to lift the buttocks when the child is out of the harness, it may negate the harness position. Undershirts and diapers should be placed under the straps to reduce irritation. Parents should never adjust the harness; this is the responsibility of the primary healthcare provider. Lotion and powders may cake under the harness and cause skin irritation.

A registered nurse teaches a client about magnetic resonance imaging to diagnose osteomyelitis. Which statement made by the client indicates the need for further education? 1. "I expect no pain from the procedure." 2. "I can take an anti-anxiety agent if needed." 3. "I should remain still throughout the procedure." 4. "I will hear loud noises and alarms."

4 rationale: The nurse should explain to the client that the machine will make loud tapping noises intermittently; alarms will not go off during this procedure so the nurse needs to correct this misinformation. All the other statements are correct, and the client will need no further education. The procedure is painless. The client can take anti-anxiety agents if indicated. The client must remain still throughout the procedure.

On the first postoperative day after a total hip replacement a client asks for assistance onto the bedpan. What should the nurse instruct the client to do? 1. "Use your elbows and hands to lift your pelvis off the bed." 2. "Extend both legs and pull on the trapeze to lift your pelvis." 3. "Turn gently toward the operative side while lifting your pelvis off the bed." 4. "Flex the knee on the unoperated leg and pull on the trapeze to lift your pelvis."

4 rationale: The pelvis is elevated by actions involving the unaffected upper extremities and unoperated leg. It is impossible to lift the pelvis with the elbows and hands. The involved leg should not be used, because it may dislodge the prosthesis. The client should not turn on the operative side immediately after surgery.