Exam 3 MSK Skin review

A nurse in a busy emergency department provides care for many clients who present with contusions, strains, or sprains. What are treatment modalities that are common to all of these musculoskeletal injuries? Select all that apply.

2.Applying ice 3.Compression dressings 4.Resting the affected extremity 6.Elevating the injured limb Rationale: Treatment of contusions, strains, and sprains consists of resting and elevating the affected part, applying cold, and using a compression bandage. Massage and corticosteroids are not used to treat these injuries.

The nurse is caring for a client with osteoporosis. Which information will the nurse include when teaching actions to manage the condition? Select all that apply.

1.Avoid excessive alcohol intake 2.Plan for smoking cessation 3.Engage in regular weight-bearing exercise Rationale: Care of the client with osteoporosis focuses on actions to improve bone density. These actions include avoiding the excessive intake of alcohol. Clients who use tobacco products should be advised to quit. Regular weight-bearing exercise promotes bone formation. Recommendations include 20 to 30 minutes of aerobic, bone-stressing exercise daily. Current guidelines recommend that hormone therapy with estrogen not be used for primary prevention of bone loss in female clients who are postmenopausal. Swimming is not a weight-bearing exercise.

A nurse is caring for a client who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. What nursing action will best achieve these goals?

1.Encouraging the client to turn from side to side and to assume a prone position Rationale: The nurse encourages the client to turn from side to side and to assume a prone position, if possible, to stretch the flexor muscles and to prevent flexion contracture of the hip. Postoperative ROM exercises are started early, because contracture deformities develop rapidly. ROM exercises include hip and knee exercises for clients with BKAs. The nurse also discourages sitting for prolonged periods of time.

An x-ray demonstrates a fracture in which the fragments of bone are driven inward. This type of fracture is referred to as

depressed Rationale: Depressed skull fractures occur as a result of blunt trauma. A compound fracture is one in which damage also involves the skin or mucous membranes. A comminuted fracture is one in which the bone has splintered into several pieces. An impacted fracture is one in which a bone fragment is driven into another bone fragment.

A client who was injured while playing basketball reports an extremely painful elbow, which is very edematous. What type of injury has the client experienced?

1. sprain Rationale: Sprains are injuries to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A contusion is a soft tissue injury resulting from a blow or blunt trauma. Sprains are injuries to the ligaments surrounding a joint.

To prepare a client who has a fractured femur for ambulation, the nurse teaches the client how to do quadriceps setting exercises. Which instruction is the most accurate?

1."Press the back of your knee against the bed." Rationale: Quadriceps setting exercises help the immobilized client keep the quadriceps muscles strong and ready for resuming ambulation. Pressing the back of the knee against the bed promotes tightening of the quadriceps muscle.

A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care?

1.Fluid status Rationale: During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection control and early nutritional support are important, but fluid resuscitation is an immediate priority. Coping is a higher priority later in the recovery period.

The nurse reviews information collected during a health history with a client. Which information will the nurse identify that increases the client's risk of developing gout? Select all that apply.

1.Older adulthood 2.Male gender 3.Body mass index 38 4.Ingests 4 cans of beer a day 5.Works as a computer programmer Rationale:Gout is the most common form of inflammatory arthritis. The incidence of gout increases with age and men are 3 to 4 times more likely to be diagnosed with gout than women. The incidence also increases with body mass index and alcohol consumption. Gout is not associated with any particular vocation.

A client seeks medical attention for a new skin condition. Which finding indicates to the nurse that the client is not experiencing contact dermatitis?

1.Silvery scales Rationale: Contact dermatitis is an inflammatory reaction of the skin to physical, chemical, or biological agents. The epidermis is damaged by repeated physical and chemical irritations. The eruptions begin when the causative agent contacts the skin. The first reactions include pruritis and burning. Later reactions include papules and vesicles. Silvery scales are associated with psoriasis.

A nurse is assessing a client for risk factors known to contribute to osteoarthritis. What assessment finding should the nurse interpret as a risk factor?

1.The client's body mass index is 34 (obese). Rationale: Risk factors for osteoarthritis include obesity and previous joint damage. Risk factors of OA do not include smoking or hypertension. Incidence increases with age, but a client who is 58 years old would not yet face a significantly heightened risk.

A nurse is caring for a client with a warm and painful toe from gout. What medication will the nurse administer?

1.colchicine Rationale: A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The health care provider orders colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin reduces joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no effect on urate crystal formation. Furosemide is a diuretic; it is not used to relieve gout. Calcium gluconate reverses a negative calcium balance and relieves muscle cramps; it is not used to treat gout.

The most important principle of psoriasis treatment is which of the following?

1.Gentle removal of scales Rationale: The most important principle of psoriasis treatment is gentle removal of scales. This can be accomplished with baths. After bathing, the application of emollient creams containing alpha-hydroxy acids or salicylic acid continues to soften thick scales. The patient and family should be encouraged to establish a regular skin care routine that can be maintained even when the psoriasis is not in an acute stage. Although dressing changes may be done in the treatment of psoriasis, it is not the most important principle of treatment.

Which statements describe open reduction of a fracture? Select all that apply.

1.It is performed in the operating room. 2.The bone is surgically exposed and realigned. 3.The client usually receives general or spinal anesthetic. Rationale: Statements describing open reduction are the following: It is performed in the operating room, the bone is surgically exposed and realigned, and the client usually receives general or spinal anesthetic. The bone is restored to its normal position by external manipulation with closed reduction.

A nurse should advise a client with gout to avoid which foods?

1.Organ meats Rationale: An excessive intake of foods that are high in purines (shellfish, organ meats) may result in symptoms of gout in susceptible persons. A diet low in purine is recommended.

A group of students is reviewing information about cast composition in preparation for a discussion on the advantages and disadvantages of each. The students demonstrate understanding of the topic when they cite which of the following as an advantage of a plaster cast?

1.Quicker drying Rationale: Plaster casts require a longer time for drying but mold better to the client and are initially used until the swelling subsides. Fiberglass casts dry more quickly, are lighter in weight, longer lasting, and breathable.

Which nursing intervention is essential in caring for a client with compartment syndrome?

1.Removing all external sources of pressure, such as clothing and jewelry Rationale: Nursing measures should include removing all clothing, jewelry, and external forms of pressure (such as dressings or casts) to prevent constriction and additional tissue compromise. The extremity should be maintained at heart level (further elevation may increase circulatory compromise, whereas a dependent position may increase edema). A compression wrap, which increases tissue pressure, could further damage the affected extremity. There is no indication that diagnostic studies would require I.V. access in the affected extremity.

A provider asks the nurse to teach a client with low back pain how to sit in order to minimize pressure on the spine. Which teaching points would the nurse include? Select all that apply.

1.Sit in a straight-backed chair with arm rests. 2.Use a firm pillow placed behind the thoracic vertebrae to straighten the small of the back. 3.Avoid hip extension. 4.Place feet flat on the floor. 5. Sit with the buttocks "tucked under." Rationale: All choices are correct, except that a soft pillow support is recommended to eradicate the hollow of the back.

A 1-year-old client has a localized rash and is miserably itchy. The client's mother indicates having just started to use a new skin cream and that the rash developed within 12 hours of the first dose. What treatments would pediatrician prescribe? Select all that apply.

1.remove allergen Rationale: Treatment for both types of dermatitis is to remove the substances causing the reaction. This is done by flushing the skin with cool water.

A client arrives in the emergency department after being burned in a house fire. The client's burns cover the face and the left forearm. What extent of burns does the client most likely have, measured as a percentage?

18 Rationale: When estimating the percentage of body area or burn surface area that has been burned, the Rule of Nines is used: the face is 9%, and the forearm is 9% for a total of 18% in this client.

A client who has fractured the radial head asks the nurse about factors that will promote bone healing. Which statement should the nurse include when responding to the client? Select all that apply.

1."Immobilization of the fracture will promote healing by maximizing contact of bone fragments." 2."Fractured bones require a good blood supply and adequate nutrition for healing." 3."Weight bearing stimulates healing of the long bones of the leg, if the fracture is stabilized." Rationale: Factors that enhance fracture healing include immobilization of the fracture fragments, sufficient blood supply, proper nutrition, and weight bearing for stabilized long bones of the lower extremities. Older adults heal more slowly. Corticosteroids inhibit the repair rate and can cause osteoporosis.

The nurse is providing instructions to the client following application of a fiberglass cast. Which statement by the client indicates further education is needed?

1."Under no circumstances should I get my cast wet." Rationale: Some fiberglass casts are waterproof, allowing the client to shower or swim. A wet fiberglass cast is susceptible to denting while it is wet. Fiberglass casting involves an exothermic reaction as the cast hardens. The cast should not come in contact with other plastics as the reaction occurs.

The nurse is caring for a patient with a pelvic fracture. What nursing assessment for a pelvic fracture should be included? (Select all that apply.)

1.Checking the urine for hematuria Palpating peripheral pulses in both lower extremities Rationale: In pelvic fracture, the nurse should palpate the peripheral pulses, especially the dorsalis pedis pulses of both lower extremities; absence of a pulse may indicate a tear in the iliac artery or one of its branches. To assess for urinary tract injury, the patient's urine is analyzed for blood.

The client with osteoarthritis is seen in the clinic. Which assessment finding indicates the client is having difficulty implementing self-care?

1.Has a weight gain of 5 pounds Rationale: Obesity is a risk factor for osteoarthritis. Excess weight is a stressor on the weight-bearing joints. Weight reduction is often a part of the therapeutic regimen.

The client has just been diagnosed with osteomyelitis. What of the following is not a possible causes of osteomyelitis?

1.Progressive osteoporosis Rationale: The following are all causes of osteomyelitis: trauma, such as penetrating wounds or compound fractures; vascular insufficiency in clients with diabetes or peripheral vascular disease; and surgical contamination, such as pin sites of skeletal traction. Osteoporosis is not a cause of osteomyelitis.

What laboratory value observed by the nurse is unexpected during the fluid remobilization phase of a major burn?

1.Serum sodium level of 140 mEq/L (normal) Rationale: In the acute/intermediate (fluid remobilization) phase of burn care, sodium is lost with water due to diuresis, and existing serum sodium is diluted with water influx, resulting in a decreased serum sodium level. Normal serum sodium level is 135 to 145 mEq/L, so 140 mEq/L is a normal finding, which is unexpected in the acute/intermediate phase of burn care. Normal hematocrit, metabolic acidosis, and hypokalemia are all expected findings during this phase.

A client with chronic osteomyelitis has undergone 6 weeks of antibiotic therapy. The wound appearance has not improved. What action would the nurse anticipate to promote healing?

1.Surgical debridement Rationale: In chronic osteomyelitis, surgical debridement is used when the wound fails to respond to antibiotic therapy. Wound packing, vitamin supplements, and wound irrigation are not the standard of care when treating chronic osteomyelitis.

A nurse is providing a class on osteoporosis at the local center for older adults. Which statement related to osteoporosis is most accurate?

1.The use of corticosteroids increases the risk of osteoporosis. Rationale: Corticosteroid therapy is a secondary cause of osteoporosis when taken for long-term use. Adequate levels of vitamin D are needed for absorption of calcium. A person's level of physical activity is a modifiable factor that influences peak bone mass. Lack of activity increases the risk for the development of osteoporosis. Primary osteoporosis occurs in women after menopause.

A client presents at an ambulatory clinic and reports pain and aching in the lower left leg. After examining the client, a health care provider determines the client has experienced a strain related to the client's exercise regimen. The treatment plan includes analgesics, rest, and cold and heat therapies. Which guideline should be included in the care plan?

1.After 48 hours, apply heat for periods of 15 to 30 minutes. Rationale: The injury should be managed with cold therapy for the first 48 hours, followed by heat therapy for periods of 15 to 30 minutes. Cold applications should be intermittent to avoid temperature-related injuries to the skin. Physical activities should be restricted for 2 to 5 days depending on the severity of the injury.

The nurse recognize what as an early sign of sepsis in a client with a burn injury?

1.Widened pulse pressure Rationale: In clients with burn injuries early sepsis can be hard to detect. Clients with burn injuries exhibit tachycardia, tachypnea, and elevated body temperature, all typical indications of sepsis. In the client with burn injury, indications of sepsis include elevated serum glucose values, increased heart rate, and narrowing mean arterial pressure. Both the typical elevated temperature and a temperature of less than 96.8 F (36 C) can indicate sepsis in a client with a burn injury.

A client presents with silvery scales on the elbows and knees. The physician has made a diagnosis of plaque psoriasis. What is the probable cause of psoriasis? Select two that apply.

1.genetic predisposition 2.a triggering mechanism, such as systemic infection, injury to the skin, vaccination, or injection Rationale: Probable causes include genetic predisposition; or a triggering mechanism such as systemic infection, injury to the skin, vaccination, or injection. Furuncles and carbuncles are caused by injury, such as squeezing a lesion. They are also associated with diabetes mellitus because an elevated blood glucose level promotes microbial growth.

Lifestyle risk factors for osteoporosis include

1.lack of exposure to sunshine. Rationale: Lifestyle risk factors for osteoporosis include lack of exposure to sunshine, a diet low in calcium and vitamin D, cigarette smoking, consumption of alcohol and/or caffeine, and lack of weight-bearing exercise. Lack of weight-bearing exercise, not lack of aerobic exercise, is a lifestyle risk factor for osteoporosis. A diet low in calcium and vitamin D, not a low-protein, high-fat diet, is a lifestyle risk factor for osteoporosis. An estrogen deficiency or menopause is an individual risk factor for osteoporosis.

A client with a right leg fracture is returning to the orthopedist to have the cast removed. During cast removal, it is important for the nurse to assure:

1.the client that he or she won't be cut. Rationale: Casts are removed with a mechanical cast cutter. Cast cutters are noisy and frightening but the blade does not penetrate deep enough to cut the client. The client needs reassurance that the machine will not cut into the skin. The other options are either irrelevant or not something the nurse knows for certain at this time.

The nurse provides teaching to a client with osteoarthritis (OA). Which statement(s) indicate that teaching about pain management and functional ability were effective? Select all that apply.

1."I will need to lose some weight." 2."I will increase the amount of walking I do every day." Rationale: Pain management and optimal functional ability are the major goals of nursing interventions. With those goals in mind, nursing management of the client with OA includes pharmacologic and nonpharmacologic approaches as well as education. Weight loss is an important approach to lessen pain and disability caused by OA. Exercises such as walking should be begin in moderation and gradually increase. A sedentary lifestyle contributes to the development of OA so resting would not be encouraged. Canes or other assistive devices for ambulation should be considered, and any stigma about the use of these devices should be explored. Clients should plan daily exercise for a time when the pain is least severe or plan to use an analgesic agent before exercising.

A client with a burn over the lower leg asks why surgery is planned to remove the dead burned tissue. Which response will the nurse make?

1."It reduces the risk of complications from an infection." Rationale: Early surgical excision to remove devitalized tissue along with early burn wound closure has long been recognized as one of the most important factors contributing to survival in a client with a major burn injury. When conducted in a timely and efficient manner, surgical excision results in shorter lengths of hospital stay and decreased risk of complications from invasive burn wound sepsis. Surgical debridement is not done to reduce the amount of scarring or the amount of wound care that will be needed. Natural debridement is a bodily process that liquefies any damaged tissue and may take weeks to months to occur.

The side effect of bone marrow depression may occur with which medication used to treat gout?

1.Allopurinol Rationale: A client taking allopurinol needs to be monitored for the side effects of bone marrow depression, vomiting, and abdominal pain.

A nurse is caring for a client who is being assessed following reports of severe and persistent low back pain. The client is scheduled for diagnostic testing in the morning. Which of the following is not appropriate diagnostic tests for assessing low back pain?

1.Angiography Rationale: A variety of diagnostic tests can be used to address lower back pain, including CT, MRI, ultrasound, and x-rays. Angiography is not related to the etiology of back pain.

A client with a right below-the-knee amputation is being transferred from the postanesthesia care unit to a medical-surgical unit. What is the highest priority nursing intervention by the receiving nurse?

1.Ensure that a large tourniquet is in the room. Rationale: The client with an amputation is at risk for hemorrhage. A tourniquet should be placed in plain sight for use if the client hemorrhages. Documenting the receiving report is important but is not the highest priority. The nurse may delegate to unlicensed assistive personnel (UAP) the job of gathering more pillows for positioning, but this is not the highest priority. The nurse will need to review the physician's orders for pain medication, but again, this is not the highest priority, because any hemorrhaging by the client needs to be addressed first.

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until the femur can be rodded in surgery. For what early complication(s) should the nurse monitor this client? Select all that apply.

1.Deep vein thrombosis 2.Compartment syndrome 3.Fat embolism Rationale: Early complications include shock, fat embolism, compartment syndrome, and venous thromboemboli (deep vein thrombosis [DVT], pulmonary embolism [PE]). Infection and complex regional pain syndrome are later complications of fractures.

A client presents with an edematous and red left great toe and reports the same symptoms occurred 2 months ago. Which questions will the nurse ask to determine if the client is experiencing gout? Select all that apply.

1."Have you had any recent surgeries?" 3."What time of day does the pain occur?" 4."Do you consume alcoholic beverages?" 5."How long did the previous episode last?" Rationale: Acute arthritis is the most common early clinical manifestation of gout. The attack may be precipitated by stress from a recent surgery. The abrupt onset of an attack often occurs at night that awakens the client with severe pain, redness, swelling, and warmth of the affected joint. The attack may be precipitated by alcohol intake. Previous attacks tend to subside spontaneously over 3 to 10 days without treatment which is followed by a symptom-free period until the next attack, which may not come for months or years.

The clinic nurse is caring for a client with an injured body part that does not require rigid immobilization. What method of immobilization would the nurse expect the health care provider to use on a short-term basis?

1.Splint Rationale: A splint immobilizes and supports an injured body part in a functional position and is used when the condition does not require rigid immobilization, causes a large degree of swelling, or requires special skin treatment. Casts and traction provide rigid immobilization. A brace provides support, controls movement, and prevents additional injury for more long-term use.

A client presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as

18 Rationale: The rule-of-nines system is based on dividing anatomic regions, each representing approximately 9% of the total body surface area (TBSA), quickly allowing clinicians to obtain an estimate. If a portion of an anatomic area is burned, the TBSA is calculated accordingly—for example, if approximately half of the anterior leg is burned, the TBSA burned would be 4.5%. More specifically, with an adult who has been burned, the percent of the body involved can be calculated as follows: head = 9%, chest (front) = 9%, abdomen (front) = 9%, upper/mid/low back and buttocks = 18%, each arm = 9% (front = 4.5%, back = 4.5%), groin = 1%, and each leg = 18% total (front = 9%, back = 9%). In this case the client's abdomen (9%) and front of the left leg (9%) add up to 18%.

A nurse's assessment of a client's knee reveals edema, tenderness, muscle spasms, and ecchymosis. The client states that 2 days ago the client ran in a long-distance race and now it "really hurts to stand up." The nurse should plan care based on the belief that the client has experienced what injury?

1. A second-degree burn Rationale: A second-degree strain involves tearing of muscle fibers and is manifested by notable loss of load-bearing strength with accompanying edema, tenderness, muscle spasm, and ecchymosis. A first-degree strain reflects tearing of a few muscle fibers and is accompanied by minor edema, tenderness, and mild muscle spasm, without noticeable loss of function. However, this client states a loss of function. A sprain normally involves twisting, which is inconsistent with the client's overuse injury.

A client comes to the clinic 1 day after sustaining a sprain to the left ankle. What intervention can the nurse encourage the client to perform that will help improve circulation?

1.Applying cold compresses Rationale: Applying cold compresses in the first 24 to 48 hours after an injury to reduce swelling and relieve pain. After 2 days, when swelling is no longer likely to increase, applying heat reduces pain and relieves local edema by improving circulation. Full use of the injured joint is discouraged temporarily. Non-steroidal anti-inflammatory drugs will ease discomfort but not improve circulation.

A nurse is caring for a client who has been diagnosed with psoriasis. The nurse is creating an education plan for the client. What information should be included in this plan?

1.Lifelong management is likely needed. Rationale: Psoriasis usually requires lifelong management. Psoriasis is not contagious. Many clients need reassurance that the condition is not infectious, not a reflection of poor personal hygiene, and not skin cancer. Excessive frequent washing of skin produces more soreness and scaling. Overuse of topical corticosteroids can result in skin atrophy, striae, and medication resistance.

A client is recovering from a below-the-knee traumatic amputation and is 72 hours post surgery. Which actions will the nurse take to promote healing of the wound? Select all that apply.

1.Measure the residual limb every 8 to 12 hours. 3.Assess neurovascular function of the residual limb. 4.Apply an elastic compression bandage over the wound site. Rationale: Amputation is the removal of a body part by a surgical procedure or trauma. Trauma is the second most common indication for an amputation. To promote wound healing, the residual limb should be measured every 8 to 12 hours. Neurovascular status of the residual limb should also be assessed every 8 to 12 hours. If the rigid or soft dressing inadvertently comes off, the residual limb should be wrapped with an elastic compression bandage. Application of consistent pressure to the residual limb reduces edema formation and helps to shape the residual limb so that it may fit a prosthetic. The limb should only be elevated for 24 hours after the amputation. After this period, elevation, abduction, external rotation, and flexion of the lower limb are to be avoided. The client is encouraged not to sit for long periods of time to prevent flexion contracture or with the affected extremity dangling or in a dependent position to prevent edema.

Which of the following are associated with compartment syndrome? Select all that apply.

1.Trauma from accidents 2.Surgery 3.Casts 4.Tight bandages 5. Crushing injuries Rationale: Risk factors for compartment syndrome include trauma from accidents, surgery, casts, tight bandages, and crushing injuries. In addition, it may be caused by any condition that increases the risk of bleeding or edema in a confined space including patients with soft tissue injury, without fractures, who are on anticoagulants or have bleeding disorders.

A client with diabetes punctured the foot with a sharp object. Within a week, the client developed osteomyelitis of the foot. The client was admitted for IV antibiotic therapy. How long does the nurse anticipate the client will receive IV antibiotics?

1.At least 4 weeks Rationale: Identification of the causative organism to initiate appropriate and ongoing antibiotic therapy for infection control. IV antibiotic therapy is administered for at least 4 weeks, followed by another 2 weeks (or more) of IV antibiotics or oral antibiotics.

The current phase of a client's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the client is in what phase of burn care?

1.Acute Rationale: The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (i.e., wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound débridement, and wound grafting), pain management, and nutritional support are priorities at this stage. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

A client is complaining of severe pain in the left great toe. What lab studies that the nurse reviews indicate that the client may have gout?

1.Elevated uric acid levels Rationale: Gout is characterized by hyperuricemia (accumulation of uric acid in the blood) caused by alterations in uric acid production, excretion, or both. An elevated white blood count may be indicative of any inflammatory response and is not specific to gout. A decreased hemoglobin and hematocrit may indicate bleeding from somewhere in the body. Increased AST and ALT would indicate liver dysfunction.

The nurse is monitoring for fluid and electrolyte changes in the emergent phase of burn injury for a patient. Which of the following will be an expected outcome? Select all that apply.

1.Base-bicarbonate deficit 2.Elevated hematocrit level 4.Sodium deficit Rationale: At the time of burn injury, some red blood cells may be destroyed and others damaged, resulting in anemia. Despite this, the hematocrit may be elevated due to plasma loss. Immediately after burn injury, hyperkalemia (excessive potassium) may result from massive cell destruction. Hyponatremia (serum sodium depletion) may be present as a result of plasma loss. There is a loss of bicarbonate ions accompanying sodium loss, which results in metabolic acidosis (base-bicarbonate deficit).

Which drug is a topical corticosteroid used to treat psoriasis?

Triamcinolone Rationale: Triamcinolone is a topical corticosteroid used to treat psoriasis. Coal tar is used for mild to moderate lesions of psoriasis. Neutrogena is a medicated shampoo. Methotrexate is a systemic therapy for psoriasis.

A patient is diagnosed with osteomyelitis of the right leg. What signs and symptoms does the nurse recognize that are associated with this diagnosis? (Select all that apply.)

1.Pain 2.Erythema 3.Fever 5.Purulent drainage Rationale: When the infection is bloodborne, the onset is usually sudden, occurring often with the clinical and laboratory manifestations of sepsis (e.g., chills, high fever, rapid pulse, general malaise). The systemic symptoms at first may overshadow the local signs. As the infection extends through the cortex of the bone, it involves the periosteum and the soft tissues. The infected area becomes painful, swollen, and extremely tender. The patient may describe a constant, pulsating pain that intensifies with movement as a result of the pressure of the collecting purulent material (i.e., pus). When osteomyelitis occurs from spread of adjacent infection or from direct contamination, there are no manifestations of sepsis. The area is swollen, warm, painful, and tender to touch.

A client reports pain in the right knee, stating, "My knee got twisted when I was going down the stairs." The client was diagnosed with an injury to the ligaments and tendons of the right knee. Which terminology, documented by the nurse, best reflects the injury?

1.Sprain Rationale: A sprain is an injury to the ligaments and tendons surrounding a joint, usually caused by a wrenching or twisting motion. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation or dislocation of joint surfaces. Strain refers to a muscle pull or tear.

The nurse is preparing to initiate fluid resuscitation for a patient weighing 130 pounds (59 kg) who suffered a 58% total body surface area (TBSA) thermal burn. The health care provider ordered: 2 mL lactated Ringer's (LR) × patient's weight in kilograms × %TBSA to be administered over 24 hours. The nurse will administer ________________________ mL of fluid over the first 8 hours post-burn injury?

3422 Rationale: Convert pounds. to kilograms = 130/2.2 = 59 kg 2 mL x 59 kg x 58% TBSA = 6844 mL/24 hr. The infusion is regulated so that one-half of the calculated volume is administered in the first 8 hours after burn injury, so the nurse would infuse 3422 in the first eight hours and the second half of the calculated volume over the next 16 hours. Fluid resuscitation formulas are only a guideline. It is imperative that the rate of infusion be titrated hourly as indicated by physiologic monitoring of the patient's response.

A 75-year-old client had surgery for a left hip fracture yesterday. When completing the plan of care, the nurse should include assessment for which complications? Select all that apply.

1.Pneumonia 3.Skin breakdown 4.Atelectasis 5. Delirium Rationale: Complications in clients with hip fractures are often related to the client's age. During the first 24 to 48 hours following surgery for hip fracture, atelectasis or pneumonia can develop as a result of the anesthesia. Thromboemboli are possible, as is sepsis. Elderly clients are also at risk for delirium in hospital settings because of the stress of the trauma, unfamiliar surroundings, sleep deprivation, and medications. An elderly client with decreased mobility is at risk for skin breakdown. Necrosis is a potential complication of the surgery, but the complication would be with the femur, not the humerus

A client is diagnosed with several fractured ribs after a motor vehicle crash. Which actions will the nurse take when caring for this client? Select all that apply.

1.Provide analgesics as prescribed. 3.Instruct on the use of an incentive spirometer. 4.Demonstrate the use of a pillow to splint the area. 5.Remind to take deep breaths and cough every hour. Rationale: Rib fractures are some of the most common thoracic injuries; they occur frequently in adults of all ages, typically from blunt trauma such as motor vehicle crashes or falls, and usually result in no impairment of function. The mainstay of treatment is pain control to decrease chest wall splinting and subsequent atelectasis. Therefore, analgesics should be provided as prescribed. An incentive spirometer should be used to prevent pooling of secretions. A pillow should be used to splint the area prior to deep breathing and coughing. Chest binders to immobilize the rib fracture are not used, because decreased chest expansion may result in atelectasis and pneumonia.

The nurse is caring for a client 48 hours after their burn injury. Which treatment will the nurse anticipate to reduce the client's risk of mortality?

1.Remove burned tissue Rationale: The acute/intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of body functions. One of the most important medical interventions for clients with burns that positively affect mortality is early excision (surgical removal of tissue). The presence of open wounds or invasive organisms triggers the response to a large burn injury, a systemic cascade of events. Excising the necrotic tissue can ameliorate this response and preserve underlying viable tissue. Intravenous antibiotics and intravenous fluid therapy are not identified as interventions to reduce the risk of mortality. Regular bathing of unburned areas and changing linens can help prevent infection, but burned areas are not bathed.

A client is diagnosed with a first-degree strain of the left ankle related to running 5 miles daily. How would the nurse differentiate the first-degree strain from other strains and sprains?

1.The client has some edema of the left ankle with muscle spasms but is able to walk without assistive devices. Rationale: A first-degree strain involves mild stretching of the muscle or tendon, causing some edema and muscle spasm, but no real loss of function. The second-degree strain is partial tearing of muscle or tendon, leading to inability to bear weight and causing edema, muscle tenderness, muscle spasm, and ecchymosis. The third-degree tear is severe muscle and/or tendon tearing, causing severe pain, muscle spasm ecchymosis, edema, and loss of function. A first-degree sprain involves stretching of the ligament fibers characterized by mild edema, tenderness, and pain if the joint is moved.

The nurse is collaborating with the health care provider on a plan of care for a 54-year-old male client with osteomyelitis of the left femur secondary to uncontrolled type 1 diabetes. Click to highlight the prescriptions for care that the nurse should anticipate for this client.

2.Perform neurovascular checks of lower extremities every 8 hours. 3.Administer IV antibiotic based on culture and sensitivity report. 5.Administer ibuprofen 400 mg orally three times daily, as needed for pain. 6.Make referral to dietitian to discuss nutrition for healing and blood glucose control. 7.Provide education on self-blood glucose monitoring and insulin administration. Rationale: Osteomyelitis is a bone infection that produces pain, inflammation, swelling, and impaired mobility and requires prompt treatment to treat the infection and prevent loss of limb. The nurse should perform neurovascular checks of the affected leg every 8 hours to detect the development of nerve or vascular impairment. Osteomyelitis is treated with IV antibiotics determined by the identified pathogen on culture and sensitivity testing. Because there is reduced penetration of antibiotics in the bone tissue, IV antibiotic therapy may be needed for 6 to 12 weeks, followed by oral antibiotics. The pain of osteomyelitis can be controlled with oral analgesics, such as ibuprofen. The client should consume a healthy diet to promote bone healing and control blood glucose levels. Because uncontrolled blood glucose levels increase the risk for osteomyelitis and impair bone healing, the nurse should educate the client about self-blood glucose monitoring and insulin administration. The client's affected left leg should be elevated to reduce swelling and pain. The affected leg should not be placed in the dependent position. Because the bone is weakened by the infectious process, the client should avoid placing stress on the bone through weight-bearing activity.