Exam 1 review 4310

the nurse is caring for a client with a fractured hip. which is the nurse trying to prevent by placing pillows around the injured area? -abduction -adduction -traction -elevation

abduction Rationale: abduction means to move the limb away from the median plane, or axis, of the body. in care of the client, the legs and hips must be aligned in an abducted position to prevent internal rotation, reduce the risk of dislocation, and decrease pain. in a client with a fractured hip, adduction of the limb, traction,, and elevation are not appropriate. adduction means to move limbs toward the medial plane, or axis, and traction involves the process of applying a pulling force in opposite directions using weights

which nursing intervention is correct for a client in skeletal traction? -add and remove weights as the client desires -assess pin sites at least every shift and PRN -ensure that the knots in the rope are tied to the pulley -perform ROM to joints proximal and distal to the fracture at least once a day

assess pin sites at least every shift and PRN Rationale: nursing care for a client in skeletal traction may include assessing pin sites every shift and as needed. the needed weight for a client in skeletal traction is prescribed by the PHCP, not desired by the client. the nurse also would ensure that the knots are not tied to the pulley and move freely. the performance of ROM is indicated for all joints except the ones proximal and distal to the fracture because this area is immobilized by the skeletal traction to promote healing and prevent further injury.

which assessment would the nurse complete after a client has an open reduction internal fixation of a fractured hip? -assess femoral pulse -assess toes for mobility -check condition of the pin -monitor ROM in knee

assess toes for mobility Rationale: monitoring the mobility of the toes assesses neural integrity distal to the surgical site; this Is part of a neurovascular assessment. the femoral artery is not assessed because it is not distal to the surgical site. no pin is present with open reduction and internal fixation of a fractured hip. an assessment of ROM of the knee may cause flexion of the hip , which is contraindicated

which type of treatment is buck extension? -skeletal traction -cutaneous traction -halter transfixation -balanced suspension

cutaneous traction Rationale: buck extension is an example of traction applied directly to the skin (cutaneous) by tape or by foam boot. skeletal traction is applied directly to the bony skeleton. there is no such intervention as halter transfixation. a halter (strap) may be used with cervical or pelvic traction. balanced suspension traction keeps the affected extremity elevated off the bed

A nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. which statement explains the nurse's rationale. -deep tendon reflexes have been lost -there is partial transection of the cord -there is damage above the 6th thoracic vertebra -flaccid paralysis of the lower extremities has occurred

there is damage above the 6th thoracic vertebra Rationale: the T6 level is the sympathetic visceral outflow level, and any injury above this level may result in autonomic dysreflexia. the reflex arc remains after spinal cord injury. it is important to know the level at which the injury occurs, not whether the cord is transected. flaccid paralysis of the lower extremities is not related to autonomic dysreflexia. all cord injuries result in flaccid paralysis during the period of spinal shock; as the inflammation subsides, spasticity gradually increases.

which response would the nurse provide a client when asked the purpose for using buck traction before surgery? -to reduce the fracture -to immobilize the fracture -to maintain abduction of the leg -to eliminate rotation of the femur

to immobilize the fracture Rationale: a continuous pull on the lower extremities keeps bone fragments from moving and causing further trauma, pain, and edema. the fracture will be reduced by surgery; buck traction is a temporary measure before surgery. moving the leg away from the midline will not keep the leg in alignment; it is not the purpose of buck traction. external rotation of the femur may still occur with buck traction.

a client has a stage II pressure injury. which nursing intervention can prevent further injury by eliminating shearing force? -maintain head of bed at 30º of less -use life sheets to pull up, transfer, and position client -reposition client Q2 hours, propping with pillows -perform passive ROM exercises Q8 hours

use life sheets to pull up, transfer, and position client Rationale: shearing force is the pressure exerted on the skin when a debilitated client is pulled up in bed without a draw sheet or when the client slides down in bed. when shearing, the skin adheres to the bed linens while the layers of subcu tissue and bone slide in the direction of the body movements, causing tearing of the skin. using a lift sheet can reduce an minimize friction and shearing force. limiting head of bed elevation, repositioning and ROM exercises are interventions that may prevents pressure related injury versus shear injury.

When a client is admitted to the emergency department with a possible spinal cord injury, the nurse would monitor for which clinical manifestation? Select all that apply -bradycardia -hypotension -spastic paralysis -urinary retention -increased pulse pressure

-bradycardia -hypotension -urinary retention Rationale: bradycardia occurs with spinal shock because the vascular system below the level of injury dilates and the cardiac accelerator reflex is suppressed. initially there is a loss of vascular tone below the injury, resulting in vasodilation and hypotension. urinary retention may occur in spinal shock because of autonomic nervous system dysfunction. initially, flaccid paralysis is associated with spinal shock; as spinal shock subsides, spastic paralysis develops. there is a decreased, not increased, pulse pressure associated with hypotension and shock

which clinical manifestations would the nurse expect to identify in a client experiencing spinal shock immediately after sustaining a functional transection of the spinal cord at C7-C8? select all that apply -spasticity -incontinence -flaccid paralysis -respiratory failure -lack of reflexes below the injury

-flaccid paralysis -lack of reflexes below the injury Rationale: spinal shock is immediate after a transection of the spinal cord; it results in flaccid paralysis of all skeletal muscles and usually lasts for 48 hours =, but may persist for several weeks. transection of the spinal cord caused the spinal shock and resulted in a loss of reflex activity below the level of injury. spasticity occurs after spinal shock has subsided. during the acute phase, retention of urine and feces occurs because of decreased tone of the bladder and bowel; thus incontinence is unusual. respirations are labored, but spontaneous breathing continues, indicating the level of injury is below C4 and respirations re not effected

which dressing would the nurse view as beneficial for the recovery of a clients red- colored wound that was caused by pressure? select all that apply -absorptive dressings -hydrocolloid dreessing -transparent film -moist gauze dressing with antibiotics -non-adhering dressing with antibiotic ointment

-hydrocolloid dreessing -transparent film -non-adhering dressing with antibiotic ointment Rationale: hydrocolloid dressing, transparent film, and non-adhering dressing with antibiotic ointment are beneficial for the healing of a red wound caused by pressure injuries. use absorptive dressing and moist gauze with antibiotics to treat yellow wounds, such as wounds with nonviable necrotic tissue.

which finding would the nurse expect when completing an admission physical for a client with Parkinson disease? select all that apply -muscle rigidity -blank facial expression -leaning toward the affected side -intention tremors with movement -hyperextension of the affected extremity

-muscle rigidity -blank facial expression Rationale: muscle rigidity occurs as a result of an imbalance between excitatory and inhibitory messages in the basal ganglia. with parkinson disease, there is a lack of neural control of fine motor movements, resulting in a characteristic masklike face. leaning toward an affected side is unrelated to Parkinson; this is often associated with a brain attack. movement usually abolishes tremors; these are known as non-intentional tremors. hyperextension of the affected extremities does not occur with Parkinson disease; both arms fall rigidly to the sides and do not swing with a regular rhythm when walking, producing a shuffling gait

which findings would support a clients diagnosis of Parkinson disease? Select all that apply -non-intentional tremors -frequent bouts of diarrhea -masklike facial expression -hyperextension of the neck -rigidity to passive movements

-non-intentional tremors -masklike facial expression -rigidity to passive movements Rationale: non-intentional tremors associated with parkinson disease result from degeneration of the dopaminergic pathways and excess cholinergic activity in the feedback circuit. a masklike facial expression results from nigral and basal ganglia depletion of dopamine, an inhibitory neurotransmitter. cogwheel rigidity is increased resistance to passive motion and is a classic sign of parkinson disease. constipation, not diarrhea, is a common problem because of a weakness of muscles used in defecation. the tendency is for the head and neck to be drawn forward, not hyperextended, because of loss of basal ganglia control.

which nursing intervention would the nurse include in the plan of care for a client after a hip replacement? Select all that apply -place a pillow between the clients legs -require the client to sit in an armless chair -cross the clients legs at the ankles and knees -require the client to use an elevated toilet seat -keep the clients hip in a neutral, straight position

-place a pillow between the clients legs -require the client to use an elevated toilet seat -keep the clients hip in a neutral, straight position Rationale: A client who has undergone hip replacement needs help while standing; therefore, the ensures should not have the client sit in an armless chair because the client may experience discomfort and difficulty when standing. crossing the clients legs at the ankles and knees after a hip replacement may cause pain and venous stasis, promoting thrombus formation. using a pillow between he legs provides comfort and help keeps the joint abducted. use of an elevated toilet seat allows for easy movement and prevents hip dislodgment. keeping clients hips in a neutral, straight position prevents pain and discomfort and hip dislocation.

which intervention would the nurse include in plan of care after total hip replacement? Select all that apply -maintain affected hip in adduction position when moving client -regularly scheduled analgesics and as needed meds for pain control -client should sit in chair at the height to encourage flexion of hip joint -frequent neurovascular assessment should be done and compared with the unaffected side -when turning, the client should be log rolled to prevent the leg form falling forward or backward

-regularly scheduled analgesics and as needed meds for pain control -frequent neurovascular assessment should be done and compared with the unaffected side -when turning, the client should be log rolled to prevent the leg form falling forward or backward Rationale: pain control should include regularly scheduled analgesics because decreased pain will air in earlier mobilization. assessing pain level is standard postop care, and pain must be managed accordingly. frequent neurovascular assessment should be done when assessing VS to observe for circulatory compromise. when turning a client after a total hip replacement, client should have an abductor pillow in place to ensure the hip does not become adducted. turning as a whole prevents the leg from moving out of alignment. the affected hip should not be in the adducted position, but rather the abducted position. client should sit in a chair high enough to minimize flexion of the joint, particularly hyper-flexion, which is bending forward more than 90º

Which statement indicates understanding of the instructions when a client who had a total hip replacement is taught wound care by the nurse in preparation for discharge? -I will inspect the incision for healing when I change the dressing -I will sit in a chair for several hours every day -I will check to see whether the staples have dissolved within a few days -I will call the health care clinic if I see any clear drainage coming from the incision

I will inspect the incision for healing when I change the dressing Rationale: at each dressing change, the incision should be assessed for approximation of the edges, extent of healing, and signs of infection. sitting should last for 45v min or less to prevent hip stiffness, hip flexion contracture, and prosthetic dislocation. staples do not dissolve; they are removed by a primary health care provider. serous drainage may persist until healing of the incision is complete.

which factor would the nurse consider as a possible cause when caring for a client with signs of autonomic hyperreflexia? -positional vertigo -deteriorating myelin sheath -distended large intestine -fluid volume overload

distended large intestine Rationale: bowel or bladder distention causes autonomic nerve impulses to ascend via the cord to the point of injury; here the reflex is completed, and autonomic outflow causes piloerection (goose bumps), sweating, and splanchnic vasoconstriction. splanchnic vasoconstriction causes hypertension and a pounding headache. positional changes or vertigo is not involved in the autonomic hyperreflexia phenomenon. the myelin sheath deteriorating is not involved. hypervolemia does not cause autonomic hyperreflexia.

the nurse finds a client on the floor, crying for help, with signs of a hip fracture. which action would the nurse take first? -administer pain med -place affected extremity in traction -immobilize the affected extremity -notify PHCP on call

immobilize the affected extremity Rationale: the nurse would immobilize the affected extremity first. further damage and internal bleeding could occur if the extremity is not immobilized clients do experience pain with hip fracture and will require pain med; however, the emergency management for a fractured hip is to immobilize the extremity. nurse will need to notify PHCP, but priority is immobilization of the extremity.

what is the purpose of placing a child in cervical traction after sustaining a fractures cervical vertebra? -hyperextending the neck maintains an open airway -flexing the head prevents stretching of the neck muscles -immobilizing the area minimizes injury to the spinal cord -aligning the body allows for cerebrospinal fluid to encircle the spinal cord

immobilizing the area minimizes injury to the spinal cord Rationale: the goal is to prevent spinal cord injury; cervical traction immobilizes the area and extends the neck muscles, allowing the vertebra to separate and thus minimizing spinal cord compression. hyperextension may cause further injury to the spinal cord. flexion may cause further injury. traction is not related to the movement of spinal fluid.

which combination of client responses would the nurse determine represents the highest risk for the development of pressure injuries? -incontinence; inability to move independently -periodic diaphoresis; occasional sliding down in bed -minimal reaction to painful stimuli; receiving tube feeding -spending excessive time in a chair; body mass index of 23

incontinence; inability to move independently Rationale: constant exposure to moisture and prolongs pressure that compresses capillary beds places a client at high risk for pressure injuries. although periodic exposure to moisture and occasional friction are risk factors for pressure injuries, they do not place a client at highest risk. although minimal reaction to painful stimuli places a client at risk for pressure injuries, tube feedings should meet the clients nutritional needs and promote tissue integrity. although being chair bound increases a client risk for pressure injuries, a BMI of 23 indicates normal body weight. if the client has upper body strength, weight can be shifted periodically to relieve pressure.

which action would the nurse instruct the UAP to preform to prevent hip dislocation in a client recovering form a total hip arthroplasty via posterior approach? -raise heels off the bed -change positions slowly -use a gait belt during ambulation -insert abduction pillow between legs

insert abduction pillow between legs Rationale: the nurse will instruct an abduction pillow between the legs of a client recovering to prevent dislocation of the hip. raising heels prevents skin breakdown. changing positions slowly prevents injury from orthostatic hypotension. using a gait belt during ambulation decreases the risk for falls

the nurse is completing an assessment on an older adult who fell and fractures the left hip. which clinical indicator would the nurse identify as typical with a fractured left hip? -left hip is ecchymotic -left leg is noticeably shorter than the right -left leg is internally rotated -left hip is tender when touched

left leg is noticeably shorter than the right Rationale: there is overriding of bones in the fractured hip, and the leg on the affected side appears noticeably shorter than the unaffected leg. ecchymosis is evidence of soft tissue and blood vessel damage; this may or may not be associated with a fractured hip. the affected leg is externally, not internally, rotated with a fractured hip. pain associated with a fractured hip is not mild; it causes extreme pain.

which MOA would the nurse identify for levodopa therapy prescribed to a client with Parkinson disease? -blocks the effects of acetylcholine -increases production of dopamine -restores dopamine levels in brain -promotes production of acetylcholine

restores dopamine levels in brain Rationale: levodopa is a precursor of dopamine, a catecholamine neurotransmitter; it increases dopamine levels in the brain that are depleted in parkinson disease. blocking effects of acetylcholine is accomplished by anticholinergic medications. increasing production of dopamine is ineffective because it is believed that the cells that produce dopamine have degenerated in parkinson disease. levodopa does not affect acetylcholine production

which stages would the nurse document for a client with a pressure injury that has exposed bone and tendons? -stage I -stage II -stage III -stage IV

stage IV Rationale: a stage IV pressure injury involves full thickness loss and tendons, bones, or muscles are exposed. in stage I, the skin is intact and there is a nonblanchable redness at a localized area, usually over a bony prominence. in stage II, there is a partial thickness loss of the dermis manifesting as a shallow open ulcer with a red-pink wound bed, without slough. in stage III, full thickness tissue is lost.

an emaciated older adult with dementia develops a large pressure injury after refusing to change position for extended periods. the family blames the nurses and threatens to sue. which factors is considered when determining the source of blame for the pressure injury? -the client should have been turned regularly -older client frequently develop pressure injury -nurse is no responsible to the the clients family -nurses should respect a clients right not to be moved

the client should have been turned regularly Rationale: clients should change position Q2 hours to prevent pressure ulcers. nurse would not deviate from this standard of practice because of the cognitively impaired clients refusal to move. the nurse was negligent for not changing the clients position

which priority nursing intervention would the nurse include in the plan of care for an older adult who sustained a right hip fracture? -O2 therapy -cardiac monitoring -nutrition supplements -venous thromboembolism (VTE) prevention

venous thromboembolism (VTE) prevention Rationale: after hip surgery, development of VTE commonly occurs. nursing must implement preventative intervention; this is a component of core measures. O2 therapy, cardiac monitoring, and nutritional supplements may be necessary in some clients with hip fractures, but not in all.