Med-Surg Ch. 44

An older client is distressed at body changes related to kyphosis. What response by the nurse is appropriate? A. Ask the client to explain more about these feelings. B. Explain that these changes are irreversible. C. Offer to help select clothes to hide the deformity. D. Tell the client that safety is more important than looks.

ANS: A Reason: Assessment is the first step of the nursing process, and the nurse would begin by getting as much information about the client's feelings as possible. Explaining that the changes are irreversible discounts the client's feelings. Depending on the extent of the deformity, clothing will not hide it. While safety is more objectively important than looks, the client is worried about looks and the nurse needs to address this issue.

The client's electronic health record indicates genu varum. What does the nurse understand this term to mean? A. Bow-legged B. Fluid accumulation C. Knock-kneed D. Spinal curvature

ANS: A Reason: Genu varum is a bow-legged deformity. A fluid accumulation is an effusion. Genu valgum is knock-kneed. A spinal curvature could be kyphosis or lordosis.

A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to be pale and cool, with a 1+ pedal pulse. What action would the nurse perform first? A. Assess the neurovascular status of the right leg. B. Document the findings in the patient's chart. C. Elevate the left leg on at least two pillows. D. Notify the primary health care provider immediately.

ANS: A Reason: The nurse would compare findings of the two legs as these findings may be normal for the client. If a difference is observed, the nurse would then notify the primary health care provider. Documentation would occur after the nurse has all the data. Elevating the left leg will not improve perfusion if there is a problem.

The nurse takes a history on a male client reporting chronic back pain. Which factor(s) in the client's history may have contributed to his pain? (Select all that apply.) A. Had a motor vehicle crash 10 years ago. B. Played football in college and high school. C. Has installed carpet and other flooring for 30 years. D. Typically takes walks 3 to 4 days each week. E. Eats two servings of dark, green leafy vegetables daily.

ANS: A,B,C Reason: A history of trauma caused by an accident, occupation, or contact sports can result in chronic back pain. Regular exercise and diet helps to promote bone health.

A female client is preparing to have open magnetic resonance imaging (MRI) of the spine. What action(s) by the nurse is (are) most important to assess before the test? (Select all that apply.) A. Ask if the client has a history of kidney disease. B. Ask the client if she could possibly be pregnant. C. Ensure that the patient has no metal or electronic implants. D. Assess the client for the ability to communicate. E. Assess the client for a history of claustrophobia.

ANS: A,B,C,D Reason: The contrast agent that is used for an MRI is gadolinium which can cause complications if the client is pregnant or has kidney disease. The client needs to be able to communicate and should not have any metal or electronic implants due to the magnetic nature of the machine. For an open MRI, claustrophobia is not an issue because the client is not encased in the device.

When assessing gait, what feature(s) would the nurse inspect? (Select all that apply.) A. Balance B. Ease of stride C. Goniometer readings D. Length of stride E. Steadiness

ANS: A,B,D,E Reason: To assess gait, look at balance, ease and length of stride, and steadiness. Goniometer readings assess flexion and extension or joint range of motion.

The nurse is teaching assistive personnel (AP) about the risk for osteoporosis associated with race or ethnicity. Which population typically has a decreased incidence of osteoporosis when compared to Euro-Americans? A. Irish Americans B. African Americans C. American Indians D. Asian Americans

ANS: B Reason: African Americans usually have more bone mass when compared to Euro-Americans which makes them at a decreased risk for osteoporosis.

The nurse is teaching assistant personnel (AP) about care of an older ambulatory adult who has osteopenia. Which statement by the AP indicates understanding of the teaching? A. "I will tell the client to change positions frequently to prevent pressure injury." B. "I will remind the client to take frequent walks to strengthen bones." C. "I will assist the client with activities of daily living as needed." D. "I will apply warm compresses to the joints to relieve pain."

ANS: B Reason: The ambulatory client who has osteopenia has experienced bone loss. Therefore, taking walks as a weight-bearing exercise helps to prevent further bone loss. The client does not have joint pain and does not need assistance or position changes because the client is ambulatory and probably independent.

An older client's serum calcium level is 8.7 mg/dL (2.18 mmol/L). What possible etiology(ies) does the nurse consider for this result? (Select all that apply.) A. Good dietary intake of calcium and vitamin D B. Normal age-related decrease in serum calcium C. Possible occurrence of osteoporosis or osteopenia D. Potential for metastatic cancer or Paget disease E. Recent bone fracture in a healing stage

ANS: B,C Reason: This slightly low calcium level could be an age-related decrease in serum calcium or could indicate a metabolic bone disease, such as osteoporosis or osteopenia. A good dietary intake would be expected to produce normal values. Metastatic cancer, Paget disease, or healing bone fractures will elevate calcium.

The nurse is teaching a client who had a left humeral biopsy about home care. Which statement by the client indicates understanding of the nurse's teaching? A. "I will take my opioids only when I have severe pain." B. "I will keep my left arm elevated for 24 hours." C. "I will watch for tenderness and warmth around the biopsy site." D. "I will report any discomfort to my primary health care provider immediately."

ANS: C Reason: Bone biopsy is an ambulatory procedure which can cause some discomfort but not severe pain. The client can use the affected arm soon after the procedure but should watch for tenderness and warmth which could indicate infection.

A hospitalized client's strength of the upper extremities is rated at a 4. What does the nurse understand about this client's ability to perform activities of daily living (ADLs)? A. The client is able to perform ADLs but not lift some items. B. The client is unable to perform ADLs alone. C. No difficulties are expected with ADLs. D. The client would need almost total assistance with ADLs.

ANS: C Reason: This rating indicates good muscle strength with full range of motion.

The nurse is reviewing the laboratory profile for a client who has muscular dystrophy. Which laboratory value(s) would the nurse expect to be elevated? (Select all that apply.) A. Calcium (Ca) B. Phosphate (PO4) C. Creatine kinase (CK) D. Lactic dehydrogenase (LDH) E. Aspartate aminotransferase (AST) F. Aldolase (ALD)

ANS: C,D,E,F Reason: Muscular dystrophy causes elevations in muscle enzymes and does not affect minerals like calcium and phosphorus.

The nurse is taking a history from an older client who reports having frequent falls. Which dietary habit could be contributing to the client's problem? A. Consumes high-protein foods. B. Eats few concentrated sweets. C. Limits fatty or greasy foods. D. Avoids dairy products.

ANS: D Reason: Falls can occur when older adults have inadequate calcium and Vitamin D because they are at risk for osteopenia and osteoporosis. Dairy products have a high concentration of both calcium and Vitamin D and this client avoids those foods. High-protein foods are recommended to help prevent osteopenia and sweets and fatty/greasy foods have no impact on bone health.

The nurse is caring for an older client who has kyphosis and a widened gait. For which health problems is the client at risk? A. Osteoporosis B. Contracture C. Osteopenia D. Falls

ANS: D Reason: Kyphosis is caused by bone loss and causes the client to bend forward which changes the center of gravity leading to problems with balance. Older adults who have balance issues are at risk for falls.