Musculoskeletal System

observing new grad with burn patient in protective isolation. what causes manager to intervene the new grad a. using sterile sheets and linens b. performing strict hand-washing technique c. wearing gloves and gown only when giving direct care to client d. wearing proper PPE

c

the nurse suspects an ankle sprain when a pt at the UC center describes a. being hit by another soccer player during a game b. having ankle pain after sprinting around the track c. dropping a 10-lb weight on his lower leg at the health club d. twisting his ankle while running bases during a baseball game

d

This morning a 21-yr-old male patient had a long leg cast applied, and he asks to crutch walk before dinner. Which statement explains why the nurse will decline the patient's request? "No one is available to assist and accompany the patient." "The cast is not dry yet, and it may be damaged while using crutches." "Rest, ice, compression, and elevation are in process to decrease pain." "Excess edema and complications are prevented when the leg is elevated for 24

"Excess edema and complications are prevented when the leg is elevated for 24 hours." For the first 24 hours after a lower extremity cast is applied, the leg should be elevated on pillows above heart level to avoid excessive edema and compartment syndrome. A plaster cast will also be drying during this 24-hour period. RICE is used for soft tissue injuries, not with long leg casts.

A nurse performs discharge teaching for a 58-yr-old woman after a left hip arthroplasty using the posterior approach. Which statement by the patient indicates teaching is successful? "Leg-raising exercises are necessary for several months." "I should not try to drive a motor vehicle for 2 to 3 weeks." "I will not have any restrictions now on hip and leg movements." "Blood tests will be done weekly while taking enoxaparin (Lovenox)."

"Leg-raising exercises are necessary for several months." Exercises designed to restore strength and muscle tone will be done for months after surgery. The exercises include leg raises in supine and prone positions. Driving a car is not allowed for 4 to 6 weeks. In the posterior approach hip arthroplasties, extremes of internal rotation and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively. The knees must be kept apart. The patient should never cross the legs or twist to reach behind. To prevent thromboembolism, enoxaparin is administered subcutaneously and can be given at home. Enoxaparin does not require monitoring of the patient's coagulation status.

After a vasectomy, what instruction should be included in discharge teaching? "Some secondary sexual characteristics may be lost after the surgery." "Use an alternative form of contraception until your semen is sperm free." "Erectile dysfunction may be present for several months after this surgery." "You will be uncomfortable, but you may safely have sexual intercourse today."

"Use an alternative form of contraception until your semen is sperm free." Because vasectomies are usually done for sterilization purposes, to safely have sexual intercourse, the patient will need to use an alternative form of contraception until semen examination reveals no sperm. Hormones are not affected, so there is no loss of secondary sexual characteristics or erectile function. Most men experience too much pain to have sexual intercourse on the day of their surgery, so this is not an appropriate comment by the nurse.

The nurse is teaching clinic patients about risk factors for testicular cancer. Which individual is at highest risk for developing testicular cancer? A 30-yr-old white man with a history of cryptorchidism A 48-yr-old African American man with erectile dysfunction A 19-yr-old Asian man who had surgery for testicular torsion A 28-yr-old Hispanic man with infertility caused by a varicocele

A 30-yr-old white man with a history of cryptorchidism Serum PSA level 10 ng/mL The incidence of testicular cancer is four times higher in white men than in African American men. Testicular tumors are also more common in men who have had undescended testes (cryptorchidism) or a family history of testicular cancer or anomalies. Other predisposing factors include orchitis, human immunodeficiency virus infection, maternal exposure to exogenous estrogen, and testicular cancer in the contralateral testis.

Calculate the BSA burned in a patient who has mixed deep partial thickness and full thickness burn injuries to the anterior trunk, and anterior surface of the right arm and anterior surface of the right lower leg using the rule of nines. Calculate the fluid needs for the first 24 hours for the above patient who weighs 60 kg using the Parkland formula.

27 (31.5 if cant separate lower leg %); 6480 mL in 24 hrs (or 7560); 50% in first 8 hrs 18+4.5+4.5 (9) 4x60x27 (31.5)-Parkland Formula: 4 ml/ kg/ %BSA burned

Calculate the BSA burned in a patient who has mixed deep partial thickness and full thickness burn injuries to the posterior trunk, left arm and anterior surface of the left leg using the rule of nines.

36% 18+ 9+ 9

A male patient complains of fever, dysuria, and cloudy urine. What additional information may indicate that these manifestations may be something other than a urinary tract infection (UTI)? E. coli bacteria in his urine A very tender prostate gland Complaints of chills and rectal pain Complaints of urgency and frequency

A very tender prostate gland A tender and swollen prostate is indicative of prostatitis, which is a more serious male reproductive problem because an acute episode can result in chronic prostatitis and lead to epididymitis or cystitis. E. coli in his urine, chills and rectal pain, and urgency and frequency are all present with a UTI and not specifically indicative of prostatitis.

When entering the grocery store, a patient trips on the curb and sprains the right ankle. Which initial care is appropriate (SATA) Apply ice directly to the skin. Apply heat to the ankle every 2 hours. Administer antiinflammatory medication. Compress ankle using an elastic bandage. Rest and elevate the ankle above the heart. Perform passive and active range of motion.

Administer antiinflammatory medication. Compress ankle using an elastic bandage. Rest and elevate the ankle above the heart. Appropriate care for a sprain is represented with the acronym RICE (rest, ice, compression, and elevation). Antiinflammatory medication should be used to decrease swelling if not contraindicated for the patient. After the injury, the ankle should be immobilized and rested. Prolonged immobilization is not required unless there is significant injury. Ice is indicated, but will cause tissue damage if applied directly to the skin. Apply ice to sprains as soon as possible and leave in place for 20 to 30 minutes at a time. Moist heat may be applied 24 to 48 hours after the injury.

A hospitalized older patient reports his foreskin is retracted and will not return to normal. Which action is the priority? Start antibiotics. Apply ice to reduce swelling. Attempt to move the foreskin over the glans. Call the physician to prepare for circumcision.

Attempt to move the foreskin over the glans. Paraphimosis can occur when the foreskin is pulled back during bathing, during catheter insertion, or after intercourse and not returned to the normal position. Attempting to return the foreskin over glans is the priority action. If the nurse is unsuccessful, then ice would be applied to decrease swelling. If the foreskin is not returned to the normal position manually by the health care provider, then circumcision would be indicated. Paraphimosis is considered a urologic emergency because arterial blood flow to the glans penis is impaired.

The nurse is caring for a 62-yr-old man after a transurethral resection of the prostate (TURP). Which instructions should the nurse include in the teaching plan? Avoid straining during defecation. Restrict fluids to prevent incontinence. Sexual functioning will not be affected. Prostate examinations are not needed after surgery.

Avoid straining during defecation. Activities that increase abdominal pressure, such as sitting or walking for prolonged periods and straining to have a bowel movement (Valsalva maneuver), should be avoided in the postoperative recovery period to prevent a postoperative hemorrhage. Instruct the patient to drink at least 2 L of fluid every day. Digital rectal examinations should be performed yearly. The prostate gland is not totally removed and may enlarge after a TURP. Sexual functioning may change after prostate surgery. Changes may include retrograde ejaculation, erectile dysfunction, and decreased orgasmic sensation.

The nurse teaches a 30-yr-old man with a family history of prostate cancer about dietary factors associated with prostate cancer. The nurse determines that teaching is successful if the patient selects which menu? a. Grilled steak, French fries, and vanilla shake b. Hamburger with cheese, pudding, and coffee c. Baked chicken, peas, apple slices, and skim milk d. Grilled cheese sandwich, onion rings, and hot tea

Baked chicken, peas, apple slices, and skim milk A diet high in red meat and high-fat dairy products along with a low intake of vegetables and fruits may increase the risk of prostate cancer.

A 73-yr-old male patient admitted for total knee replacement states during the health history interview that he has no problems with urinary elimination except that the "stream is less than it used to be." The nurse should give anticipatory guidance regarding what condition? A tumor of the prostate Benign prostatic hyperplasia Bladder atony because of age Age-related altered innervation of the bladder

Benign prostatic hyperplasia Benign prostatic hyperplasia is an enlarged prostate gland because of an increased number of epithelial cells and stromal tissue. It occurs in about 50% of men older than age 50 years and 80% of men older than age 80 years. Only about 16% of men develop prostate cancer. Bladder atony and age-related altered innervations of the bladder do not lead to a weakened stream.

Following x-rays of an injured wrist, the patient is informed that it is badly sprained. What should the nurse tell the patient when teaching the patient to care for the injury? a. Apply a heating pad to reduce muscle spasms. b. Wear an elastic compression bandage continuously. c. Use pillows to keep the arm elevated above the heart. d. Gently exercise the joint to prevent muscle shortening.

C Rationale: Elevation of the arm will reduce the amount of swelling and pain. For the first 24 to 48 hours, cold packs are used to reduce swelling. Compression bandages are not left on continuously. The wrist should be rested and kept immobile to prevent further swelling or injury.

A patient is one day postoperative after a transurethral resection of the prostate (TURP). Which event is an unexpected finding? Requires two tablets of Tylenol #3 during the night Complains of fatigue and claims to have minimal appetite Continuous bladder irrigation (CBI) infusing, but output has decreased Expressed anxiety about his planned discharge home the following day

Continuous bladder irrigation (CBI) infusing, but output has decreased A decrease or cessation of output in a patient with CBI requires immediate intervention. The nurse should temporarily stop the CBI and attempt to resume output by repositioning the patient or irrigating the catheter. Complaints of pain, fatigue, and low appetite at this early postoperative stage are not unexpected. Discharge planning should be addressed, but this should not precede management of the patient's CBI.

The nurse completes an admission history for a 73-yr-old man with osteoarthritis scheduled for total knee arthroplasty. Which response is expected when asking the patient the reason for admission? Recent knee trauma Debilitating joint pain Repeated knee infections Onset of frozen knee joint

Debilitating joint pain The most common reason for knee arthroplasty is debilitating joint pain despite exercise, weight management, and drug therapy. Recent knee trauma, repeated knee infections, and onset of frozen knee joint are not primary indicators for a knee arthroplasty.

To monitor the progression of decreased urinary stream, the nurse should encourage which type of regular screening? Uroflowmetry Transrectal ultrasound Digital rectal examination (DRE) Prostate-specific antigen (PSA) monitoring

Digital rectal examination (DRE) DRE is part of a regular physical examination and is a primary means of assessing symptoms of decreased urinary stream, which is often caused by benign prostatic hyperplasia (BPH) in men older than 50 years of age. The uroflowmetry helps determine the extent of urethral blockage and the type of treatment needed but is not done on a regular basis. Transrectal ultrasound is indicated with an abnormal DRE and elevated PSA to differentiate between BPH and prostate cancer. The PSA monitoring is done to rule out prostate cancer, although levels may be slightly elevated in patients with BPH.

The nurse formulates a nursing diagnosis of Impaired physical mobility related to decreased muscle strength for an older adult patient recovering from left total knee arthroplasty. What nursing intervention is appropriate? Promote vitamin C and calcium intake in the diet. Provide passive range of motion to all of the joints q4hr. Keep the left leg in extension and abduction to prevent contractures. Encourage isometric quadriceps-setting exercises at least four times a day.

Encourage isometric quadriceps-setting exercises at least four times a day. Emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the first day after surgery. Vitamin C and calcium do not improve muscle strength, but they will facilitate healing. The patient should be able to perform active range of motion to all joints. Keeping the leg in one position (extension and abduction) may contribute to contractures.

The patient had tibia and fibula fractures repaired using open reduction internal fixation. A fiberglass cast is in place. She wants to know when she can resume exercise classes. To answer this question, the nurse must understand the stages of union occur in what order? (Answer with a letter followed by a comma and a space (e.g. A, B, C, D).) a. Ossification b. Granulation c. Remodeling d. Consolidation e. Callus formation f. Fracture hematoma

F, B, E, A, D, C A fracture hematoma occurs in the first 72 hours after the fracture injury. Granulation produces the basis for new bone substance 3 to 14 days after injury. Callus formation (composed of cartilage, osteoblasts, calcium, and phosphorus) appears by the end of the second week after injury. Ossification of the callus will prevent movement at the fracture when the bones are gently stressed and occurs from 3 weeks to 6 months after the fracture and continues until the fracture is healed. Consolidation occurs when the distance between bone fragments diminishes and there is radiologic evidence of union. Remodeling is the reabsorption of excess bone tissue in the final stage of bone healing; it occurs in response to gradually increased stress on the bone or weight bearing

The nurse understands that patients have the most difficulties with diarthrodial joints. Which joints are included in this group (SATA) Hinge joint of the knee Ligaments joining the vertebrae Gliding joints of the wrist and hand Fibrous connective tissue of the skull Ball and socket joint of the shoulder or hip Cartilaginous connective tissue of the pubis joint

Hinge joint of the knee Gliding joints of the wrist and hand Ball and socket joint of the shoulder or hip The diarthrodial joints include the hinge joint of the knee and elbow, ball and socket joint of the shoulder and hip, pivot joint of the radioulnar joint, and condyloid, saddle, and gliding joints of the wrist and hand. The ligaments and cartilaginous connective tissue joining the vertebrae and pubis joint and the fibrous connective tissue of the skull are synarthrotic joints.

The patient is brought to the emergency department after a car accident and is diagnosed with a femur fracture. What nursing intervention should the nurse implement at this time to decrease risk of a fat embolus? Administer enoxaparin (Lovenox). Provide range-of-motion exercises. Apply sequential compression boots. Immobilize the fracture preoperatively.

Immobilize the fracture preoperatively. The nurse immobilizes the long bone to reduce movement of the fractured bone ends and decrease the risk of a fat embolus development before surgical reduction. Enoxaparin is used to prevent blood clots not fat emboli. Range of motion and compression boots will not prevent a fat embolus in this patient.

The nurse coordinates postoperative care for a 70-yr-old man with osteoarthritis after prostate surgery. Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/LVN) (SATA) Clean around the catheter daily. Increase flow of irrigation solution. Teach the patient how to perform Kegel exercises. Provide instructions to the patient on catheter care. Administer oxybutynin (Ditropan) for bladder spasms. Manually irrigate the urinary catheter to restore catheter flow.

Increase flow of irrigation solution Administer oxybutynin for bladder spasms The nurse may delegate the following to an LPN/LVN: monitor catheter drainage for increased blood or clots, increase flow of irrigating solution to maintain light pink color in outflow, and administer antispasmodics and analgesics as needed. The UAP will clean around the catheter daily. A registered nurse may not delegate teaching, assessments, or clinical judgments to a LPN/LVN.

The nurse is completing discharge teaching with an 80-yr-old male patient who is recovering from a right total hip arthroplasty by posterior approach. Which patient action indicates further instruction is needed? Uses an elevated toilet seat Sits with feet flat on the floor Maintains hip in adduction and internal rotation Verifies need to notify future caregivers about the prosthesis

Maintains hip in adduction and internal rotation The patient should not force hip into adduction or internal rotation because these movements could dislocate the hip prosthesis. Sitting with feet flat on the floor (avoiding crossing the legs), using an elevated toilet seat, and notifying future caregivers about the prosthesis indicate understanding of discharge teaching.

The patient has a history of cardiovascular disease and has developed erectile dysfunction. He is frustrated because he is taking nitrates and cannot take erectogenic medications. What should the nurse do first? Give the patient choices for penile implant surgery. Recommend counseling for the patient and his partner. Obtain a thorough sexual, health, and psychosocial history. Assess levels of testosterone, prolactin, luteinizing hormone, and thyroid hormones.

Obtain a thorough sexual, health, and psychosocial history. The nurse's first action to help this patient is to obtain a thorough sexual, health, and psychosocial history. Alternative treatments for the cardiac disease would then be explored if that had not already been done. Further examination or diagnostic testing would be based on the history and physical assessment, including hormone levels, counseling, or penile implant options.

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incsion. PResence of loop of bowel through incision. Which interventions? SATA a. contact surgeon b. instruct client to remain quiet c. prepare the client for wound closure d. document finding and actions e. place sterile saling dressing and ice pack over wound f. place the client supine position w/o pillow under the head

a, b, c, d

Which task can the nurse delegate to an unlicensed assistive personnel (UAP) in the care of a patient who has recently undergone prostatectomy? a. Assessing the patient's incision b. Irrigating the patient's urinary catheter c. Reporting complaints of pain or bladder spasms d. Evaluating the patient's pain and selecting analgesia

Reporting complaints of pain or bladder spasms Cleaning around the catheter, recording intake and output, and reporting complaint of pain or bladder spasms to the registered nurse are appropriate tasks for delegation to the UAP. Selecting analgesia, irrigating the patient's catheter, and assessing the incision are not appropriate skills or tasks for unlicensed personnel.

A 71-yr-old patient with a diagnosis of benign prostatic hyperplasia (BPH) has been scheduled for a contact laser technique. What is the primary goal of this intervention? Resumption of normal urinary drainage Maintenance of normal sexual functioning Prevention of acute or chronic renal failure Prevention of fluid and electrolyte imbalances

Resumption of normal urinary drainage The most significant signs and symptoms of BPH relate to the disruption of normal urinary drainage and consequent urine retention, incontinence, and pain. A laser technique vaporizes prostate tissue and cauterizes blood vessels and is used as an effective alternative to a TURP to resolve these problems. Fluid imbalances, impaired sexual functioning, and kidney disease may result from uncontrolled BPH, but the central focus remains urinary drainage.

The patient has a low-grade carcinoma on the left lateral aspect of the prostate gland and has been on "watchful waiting" status for 5 years. Six months ago, his last prostate-specific antigen (PSA) level was 5 ng/mL. Which manifestations indicate prostate cancer may be extending and require a change in the plan of care (SATA) Casts in his urine Presence of α-fetoprotein Serum PSA level 10 ng/mL Onset of erectile dysfunction Nodularity of the prostate gland Development of a urinary tract infection

Serum PSA level 10 ng/mL Nodularity of the prostate gland The manifestations of increased PSA level along with the new nodularity of the prostate gland potentially indicate that the tumor may be growing. Casts in the urine, presence of α-fetoprotein, and new onset of erectile dysfunction do not indicate prostate cancer growth. Development of a urinary tract infection may indicate urinary retention or could be related to other issues.

While performing passive ROM for a pt, the nurse puts the ankle joint through the movements of (SATA) a. flexion and extension b. inversion and eversion c. pronation and supination d. flexion, extension, abduction, and adduction e. pronation, supination, rotation, and circumduction

a, b

A 33-yr-old patient noticed a painless lump and heaviness in his scrotum during testicular self-examination. The nurse should provide the patient information on which diagnostic test? Ultrasound Cremasteric reflex Doppler ultrasound Transillumination with a flashlight

Ultrasound When the scrotum has a painless lump, scrotal swelling, and a feeling of heaviness, testicular cancer is suspected, and an ultrasound of the testes is indicated. Blood tests will also be done. The cremasteric reflex and Doppler ultrasound are done to diagnose testicular torsion. Transillumination with a flashlight is done to diagnose a hydrocele.

A normal assessment finding of the musculoskeletal system is a.no deformity or crepitation. b.muscle and bone strength of 4. c.ulnar deviation and subluxation. d.angulation of bone toward midline.

a

A patient with a humeral fracture is returning for a 4-week checkup. The nurse explains that initial evidence of healing on x-ray is indicated by a. formation of callus b. complete bony union c. hematoma at the fracture site d. presence of granulation tissue

a

A patient with a pelvic fracture should be monitored for a. changes in urine output b. petechiae on the abdomen c. palpable lump on the buttock d. sudden increase in blood pressure

a

A patient with tendonitis asks what the tendon does. The nurse's response is based on the knowledge that tendons a.connect bone to muscle. b.provide strength to muscle. c.lubricate joints with synovial fluid. d.relieve friction between moving parts.

a

A therapeutic measure used to prevent hypertrophic scarring during the rehab phase of burn recovery is a. applying pressure garments b. repositioning the pt q 2hrs c. performing active ROM every 4 hours d. massaging the new tissue with water-based moisturizers

a

An 85-year-old patient is assessed to have a score of 16 on the braden scale. Based on this information, how should the nurse plan for this patient's care? a. implement a 1-hr turn schedule with skin assessment b. place Duoderm on sacrum to prevent breakdown c. elevate the head of bed to 90 degrees when supine d. continue with weekly skin assessments with no special precautions

a

Symptoms of BPH are primarily caused by a. obstruction of the urethra. b. untreated chronic prostatitis. c. decreased bladder compliance. d. excessive secretion of testosterone.

a

The increased risk for falls in the older adult is MOST likely due to a. changes in balance b. decrease in bone mass c. loss of ligament elasticity d. erosion of articular cartilage

a

The injury that is least likely to result in a full thickness burn is: a. sunburn b. scald injury c. chemical burn d. electrical injury

a

The nurse instructs the patient with an above-the- knee amputation that the residual limb should not be routinely elevated because this position promotes a. hip flexion contracture b. clot formation at the incision c. skin irritation and breakdown d. increased risk of wound dehiscence

a

To maintain a positive nitrogen balance in a major burn, the patient must a. increase normal caloric intake by about 3 times b. eat a high-protein, low-fat, high-carbohydrate diet. c. eat at least 1500 calories per day in small, frequent meals. d. eat a gluten-free diet for the chemical effect on nitrogen balance

a

What would the nurse expect to find in a patient with full thickness burns in the emergent phase? a. Leathery, dry, hard skin b. Red, fluid filled vesicles c. Massive edema at the injury site d. Serous exudate on a shiny, dark brown wound

a

What would the nurse recognize as a possible difference in the assessment of a gerontologic pt a. slowed rxn time b. quicker reflex response c. decreased joint stiffness d. increased fine motor dexterity

a

the nurse is preparing to care for a burn client scheduled for escharotomy on a 3rd degree circumfrential arm burn. what is anticipated therapeutic outcome? a. return of distal pulses b. brisk bleeding from the site c. decreasing edema formation d. formation of granulation tissue

a

Which of the following changes would cause the nurse to suspect the possibility of sepsis in a burn patient? a. Vital signs b. Urinary output c. Gastrointestinal function d. Burn wound appearance

a tachy, fever, BP

Which safe sun practices would the nurse include in the teaching care plan for a patient who has photosensitivity (select all that apply)? a. wear protective clothing b. apply sunscreen liberally and often c. emphasize the short-term use of a tanning booth d. avoid exposure to the sun, especially during midday e. wear any sunscreen as long as it is purchased at a drugstore

a, b, d

Pain management for the burn pt is most effective when (SATA) a. a pain rating tool is used to monitor the pt's level of pain b. painful dressing changes are delayed until the pt's pain is completely relieved c. the pt is informed about and has some control over the management of the pain d. a multimodal approach is used e. nonpharmacologic therapies replace opioids in the rehab phase of burn injury

a, c, d

Which factors would place a patient at a higher risk for prostate cancer (SATA) a. Older than 65 b. Asian/Native american c. Long-term use of an indwelling catheter d. Father diagnosed and treated for early stage prostate cancer e. previous hx of undescended testicle and testicular cancer

a, d

When assessing a patient with a partial-thickness burn, the nurse would expect (SATA) a. bilster b. exposed fascia c. exposed muscles d. intact nerve endings e. red, shiny, wet appearance

a, d, e

A 78 year old woman has a physiologic change related to aging in her joints. What would be an appropriate nursing diagnosis related to common changes of aging? a. Fatigue b. Risk for falls c. Self care deficit d. Risk for impaired skin integrity

b

A nurse is caring for a patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. How should the nurse anticipate healing to occur? a. tertiary intention b. secondary intention c. regeneration of cells d. remodeling of tissues

b

A patient complains of pain in the foot of a leg that was recently amputated. What does the nurse recognize about the pain? a. That it is caused by swelling at the incision b. That it should be treated with ordered analgesics c. That it will become worse with the use of a prosthesis d. That it can be managed with diversion because it is psychologic

b

A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dresing. The nurse's priority intervention for wound care would be to a. reapply a new dressing w/out disturbing the wound bed b. observe the wound for signs of infection during dressing changes c. apply cool compresses for pain relief in between dressing changes d. wash the wound aggressively with soap and water three times a day

b

A pt is scheduled for an EMG. The nurse explains that this diagnostic test involves a. incision or puncture of the joint capsule b. insertion of small needles into certain muscles c. administration of a radioisotope before the procedure e. placement of skin electrodes to record muscle activity

b

In assessing the joints of a patient with osteoarthritis, the nurse understands that Bouchard's nodes a. are often red, swollen, and tender b. indicate osteophyte formation at the PIP joints c. are the result of pannus formation at the DIP joints d. occur from deterioration of cartilage by protolytic enzymes

b

In caring for a patient after a spinal fusion, the nurse would immediately report which of the following to the surgeon? a. the patient experiences a single episode of emesis b. the patient is unable to move the lower extremities c. the patient is nauseated and has not voided in 4 hr d. the patient complains of pain at the bone graft donor site

b

The nurse is administering fluids IV to client with superficial partia-thickess burns. evaluation of fluid resuscitation, which is MOST reliable indicator of adequecy? a. vitals b. Urine output c. mental status d. peripheral pulses

b

What is important to include in the teaching plan for a patient with osteopenia? a. lose weight b. stop smoking c. eat a high-protein diet d. start swimming for exercise

b

You have just received change-of-shift report for the burn unit. Which patient should you assess first? a. A patient with deep partial thickness burns on both legs who is complaining of severe and continuous leg pain b. A patient who has just arrived from the emergency department with facial burns sustained in a house fire c. A patient who has recently been transferred from the post anesthesia care unit after having skin grafts applied to the anterior chest d. A patient admitted three weeks ago with full thickness leg and buttock burns who ahs been waiting for 2 hours to receive discharge teaching

b airway then A- watch for compartment syndrome

The nurse assesses a surgical patient the morning of the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? a. Notify the health care provider. b. Document the assessment. c. Assess the wound every 2 hours. d. Obtain wound cultures.

b normal signs of wound healing

Inhalation injury suffered: Carbon monoxide 12%. Anticipated S/S a. coma b. flushing c. dizzy e. tacycardia

b 11-20%=flushing, HA, decreased vision, decreased cerebral fxn, breathlessness 21-40%=N/V, dizzy, tinnitus, vertigo, confusion, drowsy, pale-reddish-purple, tachy 41-60%=seizure, coma >60%= death

A 65-year-old stroke patient with limited mobility has a purple area of suspected deep tissue injury on the left greater trochanter. Which nursing diagnoses are MOST appropriate (SATA) a. acute pain r/t tissue damage and inflammation b. impaired skin integrity r/t immobility and decreased sensation c. impaired skin integrity r/t inadequate circulation secondary to pressure d. risk for infection r/t loss of tissue integrity and undernutrition secondary to stroke e. Ineffective peripheral tissue perfusion r/t arteriosclerosis and loss of blood supply to affected area

b, c

A client is brought to ED with partial-thickness burns to face, neck, arms, chest. implement which nursing actions a. restrict fluids b. assess for airway patency c. admin O2 d. place a cooling blanket on client e. elevate extremities if no fractures f. prepare to give Oral pain meds

b, c, e

A patient with osetoarthritis is scheduled for a total hip arthroplasty. The nurse explain the purpose of this procedure is to (SATA) a. fuse the joint b. replace the joint c. prevent further damage d. improve or maintain ROM e. decrease the amt of destruction in the joint

b, d

A patient with rheumatoid arthritis is experiencing articular involvement. The nurse recognizes these characteristic changes include (SATA) a. bamboo-shaped fingers b. metatarsal head dislocation in feet c. noninflammatory pain in lg joints d. asymmetric involvment of small joints e. morning stiffness lasting 60 min or more

b, e

A patient is admitted to the hospital with an infected pressure ulcer on the left buttock. The pressure ulcer is 5 cm long by 2.5 cm wide and is 1.5 cm deep. The base of the wound is yellow and involves subcutaneous tissue. What stage would the nurse classify this ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV

c

A patient is recovering from second-and third-degree burns over 30% of his body and the burn care team is planning for discharge. The first action the nurseshould take when meeting with the pt would be to a. arrange a return-to-clinic appt and prescription for pain meds b. teach the pt and caregiver proper wound care to be performed at home c. review the pt's current health care status and readiness for discharge to home d. give the pt written info and websites for information for burn survivors

c

A patient with a fractured tibia accompanied by extensive soft tissue damage initially had a splint applied and held in place with an elastic bandage. What is an early sign that the patient is developing compartment syndrome? a. Paralysis of the toes b. Absence of peripheral pulses c. Progressive pain unrelieved by usual analgesics d. The skin blanches when the bandage is removed

c

A patient with an extra capsular hip fracture is admitted to the orthopedic unit and placed in Buck's traction. What should the nurse state is the purpose of the traction? a. Prepare for hip replacement b. Stabilize the leg before and after surgery c. Reduce pain and muscle spasms before surgery d. Prevent damage to the blood vessels at the fracture site

c

An 82-year-old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1X2X0.8 cm in depth, and pink subcutaneous tissue is completely visible on teh wound bed. Which stage would the nurse document on the wound assessment form? a. Stage 1 b. stage 2 c. stage 3 d. stage 4

c

Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include a. adherence of albumin to ascular walls b. movement of potassium into the vascular space c. sequestering of Na and water in interstitial fluid d. hemolysis of RBC from large volumes of rapidly administered fluid

c

Fluid replacement for 12 hrs. BP is low, tachy, UO< 20mL/hr. anticipated orders? a. transfuse 1 unit blood b. admin diuretic to increase urine output c. increase LR admin d. change IV LR to D5W

c

Knowing the most common causes of household fired, which prevention strategy would the nurse focus on when teaching about fire safety? a. Set hot water temp at 140F b. use only hardwired smoke detectors c. Encourage regular home fire exit drills d. never permit older adults to cook unattended

c

The bone cells that function in the resorption of bone tissue are called a. osteoids b. osteocytes c. osteoclasts d. osteooblasts

c

The nurse suspects a neuromuscular problem based on assessment of a. exaggerated strength with movement b. increased redness and heat below injury c. decreased sensation distal to the fracture site d. purulent drainage at the site of an open fracture

c

The patient is being discharged after being in the burn unit for six (6) weeks. Which strategies should the nurse identify to promote the patient's mental health? a. Encourage the patient to stay at home as much as possible b. Discuss the importance of not relying on the family for needs c. Tell the patient to remember that changes in lifestyle take time d. Instruct the patient to discuss feelings only with the therapist

c

To decrease the patient's discomfort related to discussing his reproductive organs, the nurse should a. relate his sexual concerns to his sexual partner b. arrange to have male nurses care for the pt c. maintain a nonjudgmental attitude toward his sexual practices d. use technical terminology when discussing reproductive fxn

c

Which one of the orders should a nurse question in the plan of care for an elderly immobile stroke patient with a stage 3 pressure ulcer? a. pack the ulcer with foam dressing b. turn and position the patient every hour c. clean the ulcer every shift with Dakin's solution d. assess for pain and medicate before dressing change

c

Which patient will the nurse see first to evaluate for wound infection? a. The patient with a negative blood culture b. The patient with thin serous drainage c. The patient with a white blood cell count elevation d. The patient with a decrease in wound size

c

While obtaining subjective assessment data related to the musculoskeletal system, the nurse must ask a pt about other medical problems such as a. HTN b. thyroid problems c. DM d. chronic bronchitis

c

following autograft and grafting to right knee, anticipated orders? a. out-of-bed exercises b. bathroom priveleges c. immobilization of affected leg d. placing affected leg in dependent position

c

Which patient information is most essential for the nurse to report to the health care provider before a patient with knee pain undergoes magnetic resonance imaging (MRI)? a. Daily use of aspirin b. Swollen and tender knee c. Presence of a permanent pacemaker d. History of claustrophobia

c Having a permanent pacemaker is a contraindication for MRI because metallic implants are present within the client. Taking a daily dose of aspirin does not affect or interact with the MRI test. A swollen and tender knee does not warrant cancellation of an MRI. A history of claustrophobia should be reported, but does not indicate that cancellation of the MRI is necessary because sedatives can be given to manage claustrophobia.

Burned in explosion- entire face, posterior head, upper half of torso (ant and post), circumfrential burns to lower bilateral arms. Rule of nines to determine % burned a. 18% b. 24% c. 36% d. 48%

c face=4.5 post head= 4.5 upper torso front=9 upper torso back=9 lower arms=9

A client is admitted to the hospital with a diagnosis of BPH and a TURP is performed. 4 hours post-op, the nurse takes the vital signs and empties the urinary drainage bag. Which assessment finding indicated the need to notify the HCP? a. red, bloody urine b. pain rated as 2 (0-10) c. urinary output of 200mL higher than intake d. BP 100/50, HR 130

d

A patient is admitted to the burn center with burns to his head, neck, anterior and posterior chest after explosion in garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next a. encourag the patient to cough and auscultate the lungs again b. obtain vital signs, oxygen saturation, and a STAT arteril blood gas c. Document the findings and continue to monitor the patient's breathing d. anticipate the nedd for ET intubation and notify the physician

d

A patient is scheduled for total ankle replacement. The nurse should tell the patient that after surgery he should avoid a. lifting heavy objects b. sleeping on the back c. abduction exercises of the affected ankle d. bearing weight on the affected leg for 6 wks

d

A patient with a comminuted fracture of the tibia is to have an open reduction with internal fixation (ORIF) of the fracture. The nurse explain that ORIF is indicated when a. the pt is unable to tolerate prolonged immobilization b. the pt cannot tolerate the surgery for a closed reduction c. a temporary cast would be too unstable to provide normal mobility d. adequate alignment cannot be obtained by other nonsurgical methods

d

A patient with a stable, closed humeral fracture has a temporary splint with bulky padding applied with an elastic bandage. The nurse notifies the surgeon of possible early compartment syndrome when the patient experiences a. increasing edema of the limb b. muscle spasms of the lower arm c. bounding pulse at the fracture site d. pain when passively extending the fingers

d

During morning care, a patient with a below-the-knee amputation asks the nursing assistant about prostheses. How will you instruct the nursing assistant to respond? a. "You should get a prosthesis so that you can walk again." b. "Wait and ask your doctor that question the next time he comes in." c. "It's too soon to be worrying about getting a prosthesis." d. "I'll ask the nurse to come in and discuss this with you."

d

Postoperatively, a patient who has had a laser prostatectomy has continuous bladder irrigation with a three-way urinary catheter with a 30-mL balloon. When he complains of bladder spasms with the catheter in place, you should A. deflate the catheter balloon to 10 mL to decrease bulk in the bladder. B. deflate the catheter balloon and then reinflate it to ensure that it is patent. C. encourage the patient to try to have a bowel movement to relieve colon pressure. D. explain that this feeling is normal and that he should not try to urinate around the catheter.

d

The evening nurse review the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stege2 pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area a. intact skin b. full-thickness skin loss c. exposed bone, tendon, muscle d. Partial-thickness skin loss of the dermis

d

The nurse is collecting data from a client. Which symptom described by the client is characteristic of an EARLY symptom of BPH a. nocturia b. scrotal edema c. occasional constipation d. decreased force in the stream in urine

d

The nurse prepares to perform a neurovascular assessment on a patient with closed multiple fractures of the right humerus. Which technique does the nurse use? a. Inspect the abdomen for tenderness and bowel sounds. b. Auscultate lung sounds. c. Assess the level of consciousness and ability to follow commands. d. Assess sensation of the right upper extremity.

d

To prevent muscle atrophy, the nurse teaches the patient with a leg immobilized in traction to perform (select all that apply) a.flexion contractions. b.tetanic contractions. c.isotonic contractions. d.isometric contractions. e.extension contractions.

d

When grading muscle strength, the nurse records a score of 3, which indicates a.no detection of muscular contraction. b.a barely detectable flicker of contraction. c.active movement against full resistance without fatigue. d.active movement against gravity but not against resistance.

d

Which nursing action does the nurse on the orthopedic unit plan to delegate to unlicensed assistive personnel (UAP)? a. Remove the wound drain for a patient who had an open reduction of a hip fracture 3 days ago. b. Assess for bruising on a patient who is receiving warfarin (Coumadin) to prevent deep vein thrombosis. c. Teach a patient with a right ankle fracture how to use crutches when transferring and ambulating. d. Check the vital signs for a patient who was admitted after a total knee replacement 3 hours ago.

d

Which patient's wound will the nurse recommend for surgical management? a. patient with a stage II pressure ulcer with granulation b. patient with a stage III pressure ulcer with a foul odor c. patient with a stage III pressure ulcer with decreased blood flow d. patient with a stage IV pressure ulcer with necrotic tissue

d

a client arrives to ED following burn injury in basement with inhalation injury suspected. Anticipated order? a. 100% O2 aerosol mask b. O2 via NC at 6L/min c. O2 NC at 15L/min d. 100% O2 via tight-fitting nonrebreather mask

d