Giddens Chapter 26 Mobility
While caring for a client with a second-degree left ankle sprain, a nurse raises the injured part above heart level. What is the reason behind this nursing intervention?1To promote bone density2To prevent further edema3To reduce pain perception4To increase muscle strength
2
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?1234
2
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?1Avoid undershirts or diapers under the harness.2The harness may be adjusted as needed as the baby grows.3Apply lotion or baby powder under the harness to prevent skin breakdown.4Avoid using the legs to lift the infant's buttocks when changing the diaper at bath time.
4
A nurse is caring for a client who developed aseptic necrosis after a fracture of the head of the femur. The nurse prepares to administer care based on which factor?1Infection at the site of the wound2Weight-bearing before the fracture is healed3Immobilization after reduction of the fracture4Loss of blood supply to the head of the femur
4
The nurse is reviewing skin care of an immobilized patient with an unlicensed assistive employee. The nurse knows the employee understands the importance of skin care when making which statement?"Proper care of the skin is important because the immobilized patient does not want to smell bad.""Proper care of the skin is important because the immobilized patient is at high risk for breakdown.""Proper care of the skin is important because the immobilized patient will have many visitors.""Proper care of the skin is important because the immobilized patient will be incontinent."
"Proper care of the skin is important because the immobilized patient is at high risk for breakdown."
Which type of burn/injury may cause a client to have a cervical spine injury?1Electrical burns2Chemical burns3Inhalation injury4Cold thermal injury
1
Which drug may cause tooth and bone anomalies as a teratogenic effect?1Alcohol2Estrogen3Tetracycline4Valproic acid
3
What percentage of hip fractures is the result of falls?a. 50%b. 80%c. 90%d. 100%
A
6. What percentage of hip fractures is the result of falls?a.50%b.80%c.90%d.100%
C
Which information indicates a nurse has a correct understanding about skeletal muscles?1Skeletal muscle accounts for about half of a human being's body weight.2Skeletal muscle contraction propels blood through the circulatory system.3Skeletal muscle contraction is modulated by neuronal and hormonal influences.4Skeletal muscle occurs in the walls of hollow structures such as airways and arteries.
1
X-ray films reveal that a client has closed fractures of the right femur and tibia. In addition, multiple soft-tissue contusions are present. Which action is most important for the nurse to take?1Perform a neurovascular assessment of the extremity.2Reassure the client that these injuries are not that serious.3Gather equipment needed for the application of skeletal traction.4Prepare the client for a surgical reduction of the injured extremity.
1
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?1Color2Pulse3Warmth4Blanching
2
A nurse provides discharge instructions to a client who had surgery for a left total hip replacement. Which should the nurse include when teaching the client about how to protect the affected hip when in the sitting position?1"When sitting in a soft chair, the left leg should be elevated in a straight-out position."2"When sitting in a firm armchair, the left foot should be flat on the floor's surface."3"Sit in a firm armchair with the left leg elevated on a high stool."4"Sit in a soft chair with pillows tucked under the left hip."
2
A nurse provides education to a client with myasthenia gravis about how to prevent myasthenic crisis. The nurse evaluates that the teaching is effective when the client makes which statement?1"I'll take an antihistamine at the first sign of a cold."2"I should skip a dose of pyridostigmine bromide (Mestinon) if it upsets my stomach."3"We've told our daughter not to let her cold keep her from visiting us."4"The healthcare provider may need to adjust the dosage of my medication if I'm more active."
4
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
According to the common scale for grading muscle strength, what rating will be given to a client who can complete range of motion with some resistance?1234
4
5. The nurse and a student nurse are discussing the effects of bed immobility on patients. The nurse knows that the student nurse understands the concept of mobility when making which statement?a."Patients with impaired bed mobility have an increased risk for pressure ulcers."b."Patients with impaired bed mobility like to have extra visitors."c."Patients with impaired bed mobility need to have a mechanical soft diet."d."Patients with impaired bed mobility are prone to constipation."
A
7. The lack of weight bearing leads to what effects on the skeletal system?a.Demineralization, calcium lossb.Thickened bonesc.Increased range of motiond.Increased calcium deposition in the bones
A
A nurse observes a patient walking in the hall. Which assessment is the nurse able to complete?A. Gait and balanceB. Speech and hearingC. Mental alertnessD. Ability to follow directions
A
1. A patient who has been in the hospital for several weeks is about to be discharged. The patient is weak from the hospitalization and asks the nurse to explain why this is happening. What is the nurse's best response?a."Your iron level is low. This is known as anemia."b."Your immobility in the hospital is known as deconditioning."c."Your poor appetite is known as malnutrition."d."Your medications have caused drug induced weakness."
B
A patient who has been in the hospital for several weeks is about to be discharged. The patient is weak from the hospitalization and asks the nurse to explain why this is happening. What is the nurse's best response?a. "Your iron level is low. This is known as anemia."b. "Your immobility in the hospital is known as deconditioning."c. "Your poor appetite is known as malnutrition."d. "Your medications have caused drug induced weakness."
B
The nurse is reviewing skin care of an immobilized patient with an unlicensed assistive employee. The nurse knows the employee understands the importance of skin care when making which statement?A. "Proper care of the skin is important because the immobilized patient does not want to smell bad."B. "Proper care of the skin is important because the immobilized patient is at high risk for breakdown."C. "Proper care of the skin is important because the immobilized patient will have many visitors."D. "Proper care of the skin is important because the immobilized patient will be incontinent."
B
2. An older patient is talking with the nurse about hip fractures. The patient would like to know the best approach to strengthen the bones. What is the nurse's best response?a."Walk at least 5 miles every day for exercise."b."Wear proper fitting shoes to prevent tripping."c."Talk with your physician about a calcium supplement."d."Stand up slowly so you don't feel faint."
C
A child must experience mobility so he or she can explore and learn about the world. Lack of mobility in a child may interfere with which developmental milestone?A. Physiological bonding and growthB. Speech and hearing developmentC. Intellectual and psychomotor functionD. Childhood play interaction
C
3. Mobility for the patient changes throughout the life span. What is the term that best describes this process?a.Aging and illnessb.Illness and diseasec.Health and wellnessd.Growth and development
D
A child must experience mobility so he or she can explore and learn about the world. Lack of mobility in a child may interfere with which developmental milestone?Physiological bonding and growthSpeech and hearing developmentIntellectual and psychomotor functionChildhood play interaction
Intellectual and psychomotor function
During infancy, childhood, and adolescence, which nutrients are critical for the musculoskeletal development?Vitamins and mineralsProtein and calciumFats and carbohydratesZinc and potassium
protein and calcium
A nurse observes a patient walking in the hall. Which assessment is the nurse able to complete?Gait and balanceSpeech and hearingMental alertnessAbility to follow directions
gait and balance
The nurse is caring for a client with a spinal cord injury who has paraplegia. The nurse can expect which major problem early in the recovery period?1Bladder control2Nutritional intake3Quadriceps setting4Use of aids for ambulation
1
A client who had a total hip replacement is receiving continuous regional analgesia. The nurse recognizes what as the benefit of this treatment over conventional methods?1It is easy to adjust the dose.2Neuropathic pain can be relieved.3Systemic side effects are minimal.4The need for parenteral medication is prevented.
3
A client had a cerebrovascular accident (also known as a "brain attack"), and bed rest is prescribed. What can the nurse use to best prevent footdrop in this client?1Splints2Blocks3Cradles4Sandbags
1
A client has a total hip arthroplasty. What should the nurse do when caring for this client after surgery?1Use a pillow to keep the legs abducted.2Elevate the client's affected limb on a pillow.3Turn the client using the log-rolling technique.4Place a trochanter roll along the entire extremity.
1
A client has corrective surgery for a bladder laceration. What nursing intervention takes priority during this client's postoperative period?1Turning frequently2Raising side rails on the bed3Providing range-of-motion exercises4Massaging the back three times a day
1
A client is admitted to the hospital with a diagnosis of lower extremity arterial disease (LEAD) or peripheral arterial disease. Which is the most beneficial lifestyle modification the nurse should teach this client?1Stop smoking2Control blood glucose3Start a walking program4Eat a low-fat, low-cholesterol diet
1
A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestations of a pulmonary embolus should the nurse assess this client? Select all that apply.1 Sharp chest pain2 Acute onset of dyspnea3 Pain in the residual limb4 Absence of the popliteal pulse5 Blanching of the affected extremity
12
A nurse is caring for a client with compartment syndrome. Which nursing actions are appropriate? Select all that apply.1 Assisting with splitting the cast2 Assessing urine output3 Evaluating the pain on a scale4 Applying splints to the injured part5 Placing cold compresses to the affected area
123
Which physiologic changes of the musculoskeletal system are related to aging? Select all that apply.1 Slowed movement2 Cartilage degeneration3 Increased bone density4 Increased range of motion5 Increased bone prominence
125
After an open reduction and internal fixation of a fractured hip, what assessments of the client's affected leg should the nurse make? Select all that apply.1 Skin temperature2 Mobility of the hip3 Sensation in the toes4 Condition of the pins5 Presence of pedal pulse
135
What does the nurse instruct a client to do while performing McMurray's test?1To raise the leg to 60 degrees2To abduct the arm to 90 degrees3To flex, rotate, and extend the knees4To flex the knee to 30 degrees and pull the tibia forward
3
The nurse is caring for a client who is admitted with a crushing injury to the spinal cord above the level of phrenic nerve origin. What should the nurse consider about this type of injury when planning care?1Ventricular fibrillation2Vagus nerve dysfunction3Retention of sensation and paralysis of lower extremities4Lack of diaphragmatic contractions and respiratory paralysis
4
Upon palpation, the nurse identifies spongy swelling caused by synovial fluid. Which joint was most likely palpated?1Biaxial joint2Pivotal joint3Synovial joint4Temporomandibular joint
4
The lack of weight bearing leads to what effects on the skeletal system?a. Demineralization, calcium lossb. Thickened bonesc. Increased range of motiond. Increased calcium deposition in the bones
A
The nurse and a student nurse are discussing the effects of bed immobility on patients. The nurse knows that the student nurse understands the concept of mobility when making which statement?a. "Patients with impaired bed mobility have an increased risk for pressure ulcers."b. "Patients with impaired bed mobility like to have extra visitors."c. "Patients with impaired bed mobility need to have a mechanical soft diet."d. "Patients with impaired bed mobility are prone to constipation."
A
Patients who are experiencing immobility often have which of the following emotions?Select all that apply.A. HelplessnessB. HungerC. AngerD. AnxietyE. Increased communicationF. Improved self-worth
ACD
During infancy, childhood, and adolescence, which nutrients are critical for the musculoskeletal development?A. Vitamins and mineralsB. Protein and calciumC. Fats and carbohydratesD. Zinc and potassium
B
4. The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when making which statement?a."Patients must have a trapeze over the bed to move properly."b."Patients should move themselves in bed to prevent immobility."c."Patients should always have a two-person assist to move in bed."d."Patients must be moved correctly in bed to prevent shearing."
D
Mobility for the patient changes throughout the life span. What is the term that best describes this process?a. Aging and illnessb. Illness and diseasec. Health and wellnessd. Growth and development
D
A nurse is caring for a client who will have a below-the-knee amputation with an immediate postoperative prosthesis. The client asks the nurse the advantage of having an immediate prosthesis. What should the nurse explain is the advantage?1Decreases phantom limb sensations2Encourages a normal walking pattern3Reduces the incidence of wound infection4Allows for fitting of the prosthesis before discharge
Encourages a normal walking pattern
Patients who are experiencing immobility often have which of the following emotions?Select all that apply. HelplessnessHungerAngerAnxietyIncreased communicationImproved self-worth
HelplessnessAngerAnxiety
A young man who sustained a spinal cord injury at the cervical level expresses concern about sexual functioning. What should the nurse do when counseling this client?1Consider that the client most likely will be able to have reflex penile erections.2Arrange for the client to see the healthcare provider because sexual performance is unlikely.3Discourage the client from forming sexual relationships because little pleasure will be possible.4Reassure the client that he will be able to have sexual relationships with the ability to reproduce.
1
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?1Promoting shrinkage2Preventing injury to the area3Preventing suture line infection4Promoting drainage of secretions
1
An infant with talipes equinovarus has a plaster cast applied to the involved foot. How should the nurse move the infant while the cast is wet?1By handling the cast with just the palms2By touching the cast with just the fingertips3By turning the infant without touching the cast4By moving the infant's body while sliding the cast
1
An older client experiences urinary frequency and nocturia. While ambulating, the client develops severe back pain and is found to have a vertebral compression fracture. When planning care, the nurse will focus interventions on which type of fracture?1Collapse of vertebral bodies2Demineralization of the spinal cord3Wear and tear of the spinous processes4Bulging of the spinal cord from the vertebra
1
The nurse is assisting a client with myasthenia gravis to bathe. The nurse identifies that the client's arms become weaker with sustained movement. What action should the nurse take?1Encourage the client to rest for short periods.2Continue the bath while supporting the client's arms.3Gradually increase the client's activity level each day.4Administer a dose of pyridostigmine bromide.
1
An older patient is talking with the nurse about hip fractures. The patient would like to know the best approach to strengthen the bones. What is the nurse's best response?a. "Walk at least 5 miles every day for exercise."b. "Wear proper fitting shoes to prevent tripping."c. "Talk with your physician about a calcium supplement."d. "Stand up slowly so you don't feel faint."
C
A client with multiple sclerosis is informed that it is a chronic progressive neurologic condition. The client asks the nurse, "Will I experience pain?" What is the nurse's best response?1"Tell me about your fears regarding pain."2"Analgesics will be prescribed to control the pain."3"Pain is not a characteristic symptom of this condition."4"Let's make a list of the things you need to ask your primary healthcare provider."
3
A client with severe varicose veins has surgery that involves ligation, dissection, and removal of incompetent vessels. In which position should the nurse place the client after surgery?1Supine with the knee support of the bed raised2In a semi-Fowler position with the knees flexed3Supine with the legs elevated at a 15-degree angle4In a semi-Fowler position with the feet against a footboard
3
A nurse is caring for two clients. One has Parkinson disease, and the other has myasthenia gravis. For which common complication associated with both disorders should the nurse assess these clients?1Cogwheel gait2Impaired cognition3Difficulty swallowing4Nonintention tremors
3
Some clients self-prescribe over-the-counter glucosamine to help relieve joint pain and stiffness. Which condition should the nurse identify as a reason for a client to reconsider taking this medication?1Osteoarthritis2Heart disease3Hyperthyroidism4Diabetes mellitus
4
The healthcare provider prescribes enoxaparin to be administered subcutaneously daily to a client who had a total knee replacement. To ensure client safety, which measure would the nurse take when administering this medication?1Remove air pocket from prepackaged syringe before administration.2Rub the injection site after administration for 30 seconds.3Administer medication over 2 minutes.4Administer in the abdomen area only.
4
Which assessment finding supports the nurse's conclusion that a prosthesis for a client with an above-the-knee amputation fits correctly?1Skin that is cool to the touch2Shrinking of the residual limb3Absence of phantom limb pain4Evenly darkened skin of the residual limb
4
Which musculoskeletal abnormality does the nurse suspect in a client who exhibits short steps and drags a foot?1Torticollis2Pes planus3Spastic gait4Steppage gait
4
Which type of joint is present in between the client's tarsal bones?1Pivot joint2Hinge joint3Saddle joint4Gliding joint
4
The healthcare provider prescribes a progressive exercise program that includes walking for a client with a history of diminished arterial perfusion to the lower extremities. The nurse explains to the client what to do if leg cramps occur while walking. Which instruction did the nurse give the client?1Chew one aspirin twice a day.2Stop to rest until the pain resolves.3Walk more slowly while pain is present.4Take one nitroglycerin tablet sublingually.
2
The nurse is caring for a client who has sustained blunt trauma to the forearm. The nurse assesses the client for which early sign of compartment syndrome?1Warm skin at the site of injury2Escalating pain in the fingers3Rapid capillary refill in affected hand4Bounding radial pulse in the injured arm
2
What clinical finding does the nurse expect when assessing a client with myasthenia gravis?1Partial improvement of muscle strength with mild exercise2Fluctuating weakness of muscles innervated by the cranial nerves3Dramatic worsening in muscle strength with anticholinesterase drugs4Minimal changes in muscle strength regardless of the therapy initiated
2
A client who had a right total hip replacement is progressing from the use of a walker to the use of a cane. In which hand should the nurse teach the client to hold the cane?1Left hand2Right hand3Stronger hand4Dominant hand
1
A client who is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. What should the nurse teach the client to do in preparation for this activity?1Push-ups to strengthen arm muscles2Leg lifts to prevent hip contractures3Balancing exercises to promote equilibrium4Quadriceps-setting exercises to maintain muscle tone
1
A nurse assesses a client who is suspected of being in myasthenic crisis. Which assessment finding is most definitive in support of this conclusion?1Difficulty breathing2Decline in physical mobility3Disturbed sensory perception4Decreased tolerance to activity
1
A nurse is assessing an 18-month-old toddler with suspected developmental dysplasia of the left hip. In what position should the nurse place the toddler to elicit the Trendelenburg sign?1Standing on the affected leg2Supine with the back arched3Side-lying on the unaffected side4Sitting upright with the legs separated
1
A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and doing what next?1Bending and then straightening their knees2Bending at the waist and then straightening the back3Placing one foot in front of the other and then leaning back4Placing pressure against the client's axillae and then raising their arms
1
A nurse plans care to prevent deformities in a client with rheumatoid arthritis. Which intervention should be alternated with periods of rest?1Active exercises2Passive massage3Bracing of joints4Isometric exercises
1
A nurse reviews the prescribed treatment with the parents of an infant born with bilateral clubfeet. Which parental statement indicates to the nurse that further education is required?1"We'll have to start serial casting right away."2"The casts will have to be changed every week."3"The baby may have to have surgery if the problem is not fixed in a few months."4"We'll have to have the baby fitted with prosthetic devices before he'll be able to walk."
1
What should a nurse explains to a client is the best way to achieve stimulation of calcium deposition in the bone after a distal femoral fracture?1Resting the extremity2Weight-bearing activity3Normal aging processes4Ingesting foods high in calcium
2
A nurse assists a client who had bariatric surgery to be more mobile. What complication is the nurse attempting to prevent?1Incisional pain2Wound dehiscence3Anastomosis leakage4Pulmonary embolism
4
A nurse is caring for depressed older adults. What precipitating factors for depression are most common in the older adult without cognitive problems? Select all that apply.1 Dementia2 Multiple losses3 Declines in health4 A milestone birthday5 An injury requiring hospitalization
23
Which statements are true regarding chondrosarcoma? Select all that apply.1 Chondrosarcoma can arise from benign bone tumors.2 Chondrosarcoma develops in the medullary cavity of long bones.3 Chondrosarcoma is mostly treated by radiation and chemotherapy.4 Chondrosarcoma occurs mostly in young males between ages 10 and 25 years.5 Chondrosarcoma most commonly occurs in cartilage in the arm, leg, and pelvic bones.
15
A back brace is prescribed for a client who had a laminectomy. What should the nurse include in the client's teaching plan?1Use the brace when the back feels tired.2Apply the brace before getting out of bed.3Put the brace on while in the sitting position.4Wear the brace when performing twisting exercises.
2
A client admitted to the hospital has edematous ankles. What should the nurse do to best reduce edema of the lower extremities?1Restrict fluids.2Elevate the legs.3Apply elastic bandages.4Do range-of-motion exercises.
2
A client had an above-the-knee amputation of the left leg because of trauma from a motor vehicle collision. The primary healthcare provider prescribes ambulation with crutches until the residual limb is healed and the client can be fitted with a prosthesis. What should be the nurse's initial action?1Demonstrate the swing-through crutch walking gait.2Determine whether the client has ever used crutches before.3Introduce the client to another client who is using crutches.4Provide a pamphlet that has information about using crutches.
2
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?1Assess the strength of the affected leg.2Explain the transfer procedure step by step.3Instruct the client to bear weight evenly on both legs.4Encourage the client to keep the affected leg elevated.
2
A client is experiencing both tingling of the extremities and tetany. What should the nurse anticipate will be prescribed by the healthcare provider?1Dialysis2Calcium supplements3Mechanical ventilation4Intravenous fluids with potassium
2
A client sustains a complex comminuted fracture of the tibia with soft tissue injuries after being hit by a car while riding a bicycle. Surgical placement of an external fixator is performed to maintain the bone in alignment. Postoperatively it is most essential for the nurse to do what?1Cleanse the pin sites with alcohol several times a day.2Perform a neurovascular assessment of both lower extremities.3Ambulate the client with partial weight bearing on the affected leg.4Maintain placement of an abduction pillow between the client's legs.
2
Which nursing intervention is indicated for aging clients with decreased bone density?1Teaching the client isometric exercises2Advising the client to take a moist heat shower3Providing supportive armchairs to the client4Demonstrating weight-bearing exercises to the client
4
A client with extensive bone and soft tissue injuries to the right leg is on bed rest. How should the nurse position the client?1Keep the right leg resting straight on the bed, parallel to the left leg.2Elevate the entire right leg with pillows, keeping the foot higher than the knee.3Maintain both legs on the bed and use an abduction pillow to keep them separated.4Attach a padded ankle sling to a Balkan frame to support the right foot and elevate the leg.
2
A client with multiple sclerosis is in remission. Which diversional activity should the nurse encourage that best meets the client's needs while in remission?1Hiking2Swimming3Sewing classes4Watching television
2
A registered nurse is teaching isometric exercises to an 80-year-old client. Which age change in the client necessitates the teaching of this exercise?1Kyphotic posture2Muscular atrophy3Decreased bone density4Cartilaginous degeneration
2
After a cervical neck injury, a client is placed in a halo fixation device with a body cast. Which statement indicates the client's concern about body image has been resolved successfully?1"I hate having everyone else do things for me."2"I've gotten used to the brace. I may even miss it when it's gone."3"I've been keeping my daily calories low in an attempt to lose weight."4"I can't get to sleep. However, I make up for it in the morning by sleeping later."
2
After an above-the-knee amputation of a right leg, a client reports pain in the right foot. The nurse should inform the client that phantom limb pain is the result of what?1Tactile illusions associated with severed blood vessels2Nerve endings in the limb that are still intact and react to stimuli3An unconscious phenomenon to aid with grieving over the lost body part4Hallucinations secondary to emotional symptoms associated with the distress of amputation
2
During the neurologic assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, what does the nurse expect the client to manifest?1Diminished visual acuity2Increased muscular weakness3Pronounced muscular atrophy4Impairment in cognitive reasoning
2
How would the nurse explain that the skeletal system of toddlers differs from older adults?1Bones of toddlers are less pliable than those of older persons.2Bones of toddlers can withstand falls better than those of older adults.3Bones of toddlers are more susceptible to osteoporosis than those of older adults.4Bones of toddlers are more susceptible to bone loss than the bones of older persons.
2
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?1The pain is relieved.2The affected joints can flex and extend.3The pedal and radial pulses are diminished.4The subcutaneous nodules at the joints recede.
2
Which synovial joint movement is described as turning the sole outward away from the midline of the body?1Pronation2Eversion3Adduction4Supination
2
While assessing a client, the nurse suspects that the client has acute osteomyelitis. Which symptoms in the client support the nurse's suspicion? Select all that apply.1 Foot ulcer2 Temperature of 102° F3 Erythema of the affected area4 Tenderness of the affected area5 Drainage from the affected area
234
What should a nurse assess after applying a body jacket brace to a client with severe spine injuries following a car accident? Select all that apply.1 Pin sites2 Development of cast syndrome3 Signs of compartment syndrome4 Abdomen for decreased bowel sounds5 Areas of pressure over the bony prominences
245
The nurse is caring for a client with a long leg cast. Which clinical findings indicate compromised circulation? Select all that apply.1 Foul odor2 Swelling of the toes3 Drainage on the cast4 Increased temperature5 Prolonged capillary refill
25
A client has a fracture of the tibia, and a cast is applied. Which action will the nurse take?1Cover the cast with plastic wrap until dry.2Assist with weight bearing when the client ambulates.3Elevate the affected leg above the level of the heart.4Insert a finger inside the edges of the cast to check for skin abrasions.
3
A client is admitted after a motor vehicle crash. The primary healthcare provider has diagnosed the presence of pelvic fractures and bilateral femur fractures. The client's blood pressure has fallen from 120/76 to 60/40, and the heart rate has risen from 82 to 121. Which does the nurse recognize as the most likely reason for the assessment findings?1Cardiogenic shock2Hypervolemic shock3Hemorrhagic shock4Septic shock
3
A client is suspected of having myasthenia gravis. What are the most significant initial nursing assessments that should be performed?1Ability to chew and speak distinctly2Capacity to smile and close the eyelids3Effectiveness of respiratory exchange and ability to swallow4Degree of anxiety and concern about the suspected diagnosis
3
A client returns from the postanesthesia care unit after a right rotator cuff repair. What should the nurse do when performing a neurovascular assessment?1Monitor for a pulse deficit.2Obtain hourly blood pressure readings.3Assess for capillary refill in the nail beds.4Place the shoulder through range-of-motion exercises.
3
A client with a chest tube is to be transported via a stretcher. When transporting the client, what should the nurse do?1Keep collection device attached to mechanical suction2Keep chest tube clamped distal to the water-seal chamber3Keep collection device below the level of the client's chest4Keep chest tube end covered with sterile gauze pads taped to the client
3
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?1Lack of a productive cough 2 days postoperatively2Rectal temperature of 100.2° F (37.9° C) 3 days postoperatively3Complaints of right-sided chest pain 6 days postoperatively4Fatigue in the leg on the unaffected side 5 days postoperatively
3
On the first postoperative evening after a lumbar laminectomy, a client states, "My feet are as numb as they were before the operation." Which is the nurse's best response?1"Let me elevate your feet so the numbness will decrease more quickly."2"That's important to know. I will inform your healthcare provider about the numbness."3"Continue to let me know how you feel. It often takes time before this feeling subsides."4"There is no cause for concern because the numbness will disappear as soon as the anesthesia wears off."
3
To reduce a hip fracture, the client is placed in traction before surgery for an open reduction and internal fixation. Because the client keeps slipping down in bed, increased countertraction is prescribed. How does the nurse increase the countertraction?1Elevate the head of the bed.2Add more weight to the traction.3Raise the foot of the bed slightly.4Tie a chest restraint around the client.
3
What is the main reason a nurse raises three of the four side rails on the bed of a 63-year-old client who had surgery for a fractured hip?1As a safety measure because of the client's age2Because clients older than 60 years of age should use side rails3To be used as handholds to facilitate the client's ability to move in bed4Because older adults often are disoriented for several days after anesthesia
3
Which joint surgery is used as a prophylactic measure and as a palliative treatment for clients with rheumatoid arthritis (RA)?1Osteotomy2Arthrodesis3Synovectomy4Debridement
3
Which principle should the nurse consider when assisting a client with crutches to learn the four-point gait?1Elbows should be kept in rigid extension.2Most of the weight should be supported by axillae.3The client must be able to bear weight on both legs.4The affected extremity should be kept off the ground.
3
A client reports mild tenderness and swelling near the ankle while running. Which nursing instruction would best benefit the client?1"Do vigorous endurance exercises."2"Complete your activity with a balancing exercise."3"Perform strengthening exercises in between your activity."4"Do warm-up muscle exercises before performing an activity."
4
A nurse is caring for a client with scoliosis of the thoracic spine and lumbar spine. Which risk does the nurse suspect in the client?1Osteoarthritis2Muscle spasticity3Intervertebral disc prolapse4Cardiac function impairment
4
The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when making which statement?a. "Patients must have a trapeze over the bed to move properly."b. "Patients should move themselves in bed to prevent immobility."c. "Patients should always have a two-person assist to move in bed."d. "Patients must be moved correctly in bed to prevent shearing."
D
