NCLEX Musculoskeletal #2

The client asks the nurse what his activity limitations are while he is in Buck's traction. The nurse should tell the client: 1. "You can sit up whenever you want." 2. "You must lie flat on your back most of the time." 3. "You can turn your body." 4. "You must lie on your stomach."

1

Which of the following should lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus? 1. Acute respiratory distress syndrome. 2. Migraine-like headaches. 3. Numbness in the right leg. 4. Muscle spasms in the right thigh.

1

The physician has written an order for a client to begin anticoagulant therapy with 5 mg Coumadin (warfarin) orally. In planning care for this client, the nurse should verify that which of the following services have been contacted? Check all that apply. 1. Pharmacy. 2. Dietary. 3. Laboratory. 4. Discharge planning. 5. Chaplain.

1, 2, 3

Which of the following client statements identifies a knowledge deficit about cast care? 1. "I'll elevate the cast above my heart initially." 2. ''I'll exercise my joints above and below the cast." 3. "I can pull out cast padding to scratch inside the cast." 4. "I'll apply ice for 10 minutes to control edema for the first 24 hours."

3

The client has a nursing diagnosis of Self-care deficit related to the confinement of traction. Which of the following would indicate a successful out come for this diagnosis? 1. The client assists as much as possible in his care, demonstrating increased participation over time. 2. The client allows the nurse to complete his care in an efficient manner without interfering. 3. The client allows his wife to assume total responsibility for his care. 4. The client allows his wife to complete his care to promote feelings of usefulness.

1

The nurse is planning to teach the client with spinal cord injury and intermittent nasogastric suctioning about interventions to protect her integumentary system. The nurse should tell the client to: 1. Eat enough calories to maintain desired weight. 2. Stay in cool environments to avoid sweating. 3. Stay in warm environments to avoid chilling. 4. Eat low-sodium foods to avoid edema.

1

When developing a teaching plan for a client who is prescribed acetaminophen (Tylenol) for muscle pain, which information should the nurse expect to include? Select all that apply. 1. The drug can be used if the person is allergic to aspirin. 2. Acetaminophen does not affect platelet aggregation. 3. This drug causes little or no gastric distress. 4. Acetaminophen exerts a strong anti inflammatory effect. 5. The client should have the International Normalized Ratio (INR) checked regularly.

1, 2, 3

The nurse on an orthopedic unit is instituting a falls prevention program. Which of the following personnel should be involved in the program? Select all that apply. 1. Registered nurses. 2. Physicians. 3. Unlicensed personnel. 4. Housekeeping services. 5. Family members. 6. Client.

1, 2, 3, 4, 5, 6

The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, the nurse's documentation should include which of the following? Select all that apply. 1. Nutrition and hydration needs. 2. Capillary refill. 3. Continued need for restraints. 4. Need for medication. 5. Skin integrity.

1, 2, 3, 5

Which of the following interventions would be least appropriate for a client who is in a double hip spica cast? 1. Encouraging the intake of cranberry juice. 2. Advising the client to eat large amounts of cheese. 3. Establishing regular times for elimination. 4. Having the client dangle at the bedside.

2

The client who had an open femoral fracture was discharged to her home where she developed fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg. Which of the following reflects the best interpretation of these findings? 1. Pulmonary emboli. 2. Osteomyelitis. 3. Fat emboli. 4. Urinary tract infection.

2

The client with a fractured femur is upset and agitated about her injury and its treatment. She says, "How can I stay like this for weeks? I can't even move!" Which of the following is the most appropriate nursing diagnosis? 1. Impaired physical mobility related to traction. 2. Ineffective coping related to prolonged immobility. 3. Deficient diversional activity related to pro longed hospitalization. 4. Activity intolerance related to impaired mobility.

2

The nurse is planning care for a client with osteomyelitis. The client is taking an antibiotic, but the infection has not resolved. The nurse should advise the client to do which of the following? 1. Use herbal supplements 2. Eat a diet high in protein and vitamin C 3. Ask the health care provider for a change of antibiotics. 4. Encourage frequent passive range-of-motion to the affected extremity.

2

A client has a Pearson attachment on the traction setup. Which of the following is the purpose of this attachment? 1. To support the lower portion of the leg. 2. To support the thigh and upper leg. 3. To allow attachment of the skeletal pin. 4. To prevent flexion deformities in the ankle and foot.

1

A client has a tibial fracture that required casting. Approximately 5 hours later, the client has increasing pain distal to the left tibial fracture despite the morphine injection administered 30 minutes previously. Which of the following should be the nurse's next assessment? 1. Presence of a distal pulse. 2. Pain with a pain rating scale. 3. Vital sign changes. 4. Potential for drug tolerance.

1

A client returned from surgery with a debrided open tibial fracture and has a three-way drain age system. The nurse should first: 1. Review the results of culture and sensitivity testing of the wound. 2. Look for the presence of a pressure dressing over the wound. 3. Determine if the client has increased pain from exposed nerve endings. 4. Check the client's blood pressure for hypoten sion resulting from additional vessel bleeding.

1

Because a client has a Thomas splint, the nurse should assess the client regularly for which of the following? 1. Signs of skin pressure in the groin area. 2. Evidence of decreased breath sounds. 3. Skin breakdown behind the heel. 4. Urine retention.

1

The nurse prepares a teaching plan for a client about crutch walking using a two-point gait pattern. Which of the following should the nurse include? 1. Advance a crutch on one side and then advance the opposite foot; repeat on the opposite side. 2. Advance a crutch on one side and simultaneously advance and bear weight on the opposite foot; repeat on the opposite side. 3. Advance both crutches together and then follow by lifting both lower extremities to the level of the crutches. 4. Advance both crutches together and then follow by lifting both lower extremities past the level of the crutches.

2

A client has a leg immobilized in traction. Which of the following activities demonstrated by the client indicate that the client understands actions to take to prevent muscle atrophy? 1. The client adducts the affected leg every 2 hours. 2. The client rolls the affected leg away from the body's midline twice per day. 3. The client performs isometric exercises to the affected extremity three times per day. 4. The client asks the nurse to add a 5-lb weight to the traction for 30 minutes/day.

3

A client is in balanced suspension traction using a half-ring Thomas splint with a Pearson attachment that suspends the lower extremity and applies direct skeletal traction for a hip fracture. Which of the following nursing assessments would not be appropriate? 1. Greater trochanter skin checks. 2. Pin site inspection. 3. Neurovascular checks proximal to the splint. 4. Foot movement evaluation.

3

A client who has been taking carisoprodol (Soma) at home for a fractured arm is admitted with a blood pressure of 80/50 mm Hg, a pulse rate of 115 bpm, and respirations of 8 breaths/minute and shallow. The nurse interprets these findings as indicating which of the following? 1. Expected common adverse effects. 2. Hypersensitivity reaction. 3. Possible habituating effect. 4. Hemorrhage from gastrointestinal irritation.

3

A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, "Why can't I stop talking about these things? I know those days are gone forever." Which of the following responses by the nurse conveys the best understanding of the client's behavior? 1. "Be patient. It takes time to adjust to such a massive loss." 2."Talking about the past is a form of denial. We have to help you focus on today." 3. "Reviewing your losses is a way to help you work through your grief and loss." 4. "It's a simple escape mechanism to go back and live again in happier times."

3

During the period of spinal shock, the nurse should expect the client's bladder function to be which of the following? 1. Spastic. 2. Normal. 3. Atonic. 4. Uncontrolled.

3

The client in balanced suspension traction is transported to surgery for closed reduction and internal fixation of his fractured femur. Which of the following should the nurse do when transporting the client to the operating room? 1. Transfer the client to a cart with manually suspended traction. 2. Call the surgeon to request an order to temporarily remove the traction. 3. Send the client on his bed with extra help to stabilize the traction. 4. Remove the traction and send the client on a cart.

3

The client with a fractured tibia has been taking methocarbamol (Robaxin). Which of the following indicate that the drug is having the intended effect? 1. Lack of infection. 2. Reduction in itching. 3. Relief of muscle spasms. 4. Decrease in nervousness.

3

The client with a spinal cord injury asks the nurse why the dietitian has recommended to decrease the total daily intake of calcium. Which of the following responses by the nurse would provide the most accurate information? 1. "Excessive intake of dairy products makes constipation more common." 2. "Immobility increases calcium absorption from the intestine." 3. "Lack of weight bearing causes demineralization of the long bones." 4. "Dairy products likely will contribute to weight gain."

3

The nurse on the orthopedic unit is going to lunch and is conducting a "hand-off" to the charge nurse. The goal of the "hand-off" communication is to do which of the following? 1. To insure the charge nurse understands that the nurse is going to lunch. 2. To be sure the charge nurse assigns someone else to take care of the client. 3. To provide accurate information about client's care to the next caregiver. 4. To provide in-depth information about the client's history.

3

The nurse unit manager is making rounds on a team of clients and notices a client who is wearing red slipper socks and a color-coded armband that indicates the client is at risk for falling walking down the hall unassisted. The nurse should do which of the following first? 1. Encourage the client to keep walking until he becomes tired. 2. Walk with the client back to his room and assist him to get in bed. 3. Accompany the client while using the lapel microphone to call for the unlicensed nursing personnel (UAP) to walk with the client. 4. Instruct the client to walk only in his room.

3

When admitting a client with a fractured extremity, the nurse should first focus the assessment on which of the following? 1. The area proximal to the fracture. 2. The actual fracture site. 3. The area distal to the fracture. 4. The opposite extremity for baseline comparison.

3

When planning to move a person with a possible spinal cord injury, the nurse should direct the team to: 1. Limit movement of the arms by wrapping them next to the body. 2. Move the person gently to help reduce pain. 3. Immobilize the head and neck to prevent further injury. 4. Cushion the back with pillows to ensure comfort.

3

A client with a fracture develops compartment syndrome. Which of the following signs should alert the nurse to impending organ failure? 1. Crackles. 2. Jaundice. 3. Generalized edema. 4. Dark, scanty urine.

4

A client with a fractured right femur has not had any immunizations since childhood. Which of the following biologic products should the nurse administer to provide the client with passive immunity for tetanus? 1. Tetanus toxoid. 2. Tetanus antigen. 3. Tetanus vaccine. 4. Tetanus antitoxin.

4

After 1 month of therapy, the client in spinal shock begins to experience muscle spasms in his legs. He calls the nurse in excitement to report the leg movement. Which of the following responses by the nurse would be the most accurate? 1. "These movements indicate that the damaged nerves are healing." 2. "This is a good sign. Keep trying to move all the affected muscles." 3. "The return of movement means that eventually you should be able to walk again." 4. "The movements occur from muscle reflexes that can't be initiated or controlled by the brain."

4

After teaching the client with a femoral fracture about the purpose of treatment with skeletal traction, which of the following, if stated by the client, would indicate the need for additional teaching? 1. To align injured bones. 2. To provide long-term pull. 3. To apply 25 lb of traction. 4. To pull weight with a boot.

4

The nurse is planning care for the client with a femoral fracture who is in balanced suspension traction. Which of the following would the nurse be least likely to include in the plan of care? 1. Use of a fracture bedpan. 2. Checks for redness over the ischial tuberosity. 3. Elevation of the head of bed no more than 25 degrees. 4. Personal hygiene with a complete bed bath.

4

Which of the following should the nurse use as the best method to assess for the development of deep vein thrombosis in a client with a spinal cord injury? 1. Homans' sign. 2. Pain. 3. Tenderness. 4. Leg girth.

4