QUIZ 1 (Set 1)

Which statement concerning bone fractures is correct? "Bone fractures do not result from low bone density." "Bone fractures may result from repetitive forces or twisting." "A bone fracture can be the direct result of excess pressure in the fibrous membrane or fascia." "Diseases such as neoplasms do not cause bone fractures."

"Bone fractures may result from repetitive forces or twisting."

Which statement from the client regarding cast care requires additional teaching by the nurse? 'I can use plastic shields around the cast while showering or bathing." "If the edges become rough and irritating, I can remove the rough edges." "I can apply ice to the cast and elevate my arm to prevent swelling." "I should never place objects in the cast to relieve itching."

"If the edges become rough and irritating, I can remove the rough edges."

The nurse instructs the client with a right BKA to lie on the stomach for at least 30 minutes a day. The client asks the nurse, "Why do I need to lie on my stomach?" Which statement is the most appropriate statement by the nurse? "This position will help vour lungs expand better." "Lying on your stomach will help prevent contractures." "Many times this will help decrease pain in the limb." "The position will take pressure off your backside."

"Lying on your stomach will help prevent contractures."

Nursing care of a client with a fractured hip should include the assessment of pedal pulses. The nurse should assess for which important characteristics of the pedal pulses? Contractility and rate Color of skin and rhvthm Amplitude and symmetry Local temperature and visible pulsations

Amplitude and symmetry

The nurse is assessing the passive range of motion of a patient's shoulder. The patient complains of pain during circumduction when the nurse moves the arm behind the patient. Which question should the nurse ask? A. "Do you ever have trouble making it to the toilet?" B. "Do you have difficulty in putting on a jacket?" C. "Are you able to feed yourself without difficulty?" D. "How well are you able to sleep at night?"

Answer: B Rationale: The patient's pain will make it more difficult to accomplish tasks like putting on a shirt or jacket. This pain should not impact the patient's ability to feed himself or herself or use the toilet because these tasks do not involve moving the arm behind the patient. The arm will not usually be positioned behind the patient during sleeping. Cognitive Level: Application Text Reference: pp. 1620-1622 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

The male nurse is helping his friend cut wood with an electric saw. His friend cuts two fingers of his left hand off with the saw. Which action should the nurse implement first? Wrap the left hand with towels and apply pressure. Instruct the friend to hold his hand above his head. Apply pressure to the radial artery of the left hand. Go into the friend's house and call for medical assistance

Apply pressure to the radial artery of the left hand.

The nurse is teaching a group of older adults about risk factors related to hip fractures. Which information should the nurse exclude in the presentation? Arthritis Lack of physical activity Osteoporosis Tobacco use

Arthritis

A client who has sustained a crush injury to the right lower leg reports numbness and tingling of the affected extremity. The skin of the right leg appears pale. Which is the nurse's first intervention? Assess pedal pulses. Increase the IV flow rate. Apply oxygen by nasal cannula. Document the finding

Assess pedal pulses.

The 62-year-old client diagnosed with type 2 diabetes who has a gangrenous right toe is being admitted for a below-the-knee amputation. Which nursing intervention should the nurse implement? Assess the client's nutritional status. Refer the client to an occupational therapist. Determine if the client is allergic to IVP dye. Start a 22-gauge Angiocath in the right arm.

Assess the client's nutritional status.

When should the nurse begin the process of rehabilitation when a client is scheduled for an amputation? Before the surgery During the convalescent phase On discharge from the hospital When it is time for a prosthesis

Before the surgery

The nurse assesses an older adult woman and determines the client is at high risk for osteoporosis and hip fractures. Based on these findings, which test should the nurse request from the healthcare provider? Computerized tomography (CT) scan Bone density testing Magnetic resonance imaging (MRI) scan X-ray

Bone density testing

A client is admitted with acute gouty arthritis. Which medication does the nurse anticipate the health care provider may prescribe to prevent and treat an acute attack of gout? Ibuprofen (Motrin) Colchicine (Colsalide) Probenecid (Benemid) Hydrocortisone (Cortef)

Colchicine (Colsalide)

What is the nurse's primary consideration when caring for a client with rheumatoid arthritis? Surgery Comfort Education Motivation

Comfort

After an open reduction and internal fixation of a fractured hip, what assessments of the clients affected leg is inappropriate? Skin temperature Sensation in the toes Condition of the pins Presence of pedal pulse

Condition of the pins

What should the nurse consider as the goal of therapy when administering allopurinol (Zyloprim) to a client with gout? Increase bone density Decrease synovial swelling Decrease uric acid production Prevent crystallization of uric acid

Decrease uric acid production

A client had an above-the-knee amputation of the left leg because of trauma from a motor vehicle collision. The health care provider orders ambulation with crutches until the residual limb is healed and the client can be fitted with a prosthesis. What should be the nurse's first intervention? Demonstrate the swing-through crutch walking gait. Determine if the client has ever used crutches before. Introduce the client to another client who is using crutches. Provide a pamphlet that has information about using crutches.

Determine if the client has ever used crutches before.

A client has a long leg cast. What instructions should the nurse give the client in preparation for crutch walking? Use the trapeze to strengthen the biceps Keep the affected limb in extension and abduction Sit up straight in a chair to develop the back muscles Do exercises in bed to strengthen the upper extremities

Do exercises in bed to strengthen the upper extremities in crutch walking the client uses the triceps, trapezius, and latissimus muscles. a client who has been in bed may need to implement an exercise program to strengthen these shoulder & upper arm muscles before initiating crutch walking

A nurse is caring for a client who had a total hip replacement. What nursing action should be incorporated into the plan of care to prevent thrombus formation? Turning the client from side to side Encouraging the client to perform ankle exercises. Getting the client up to sit in a chair for as long as tolerated Ambulating the client when the effects of anesthesia subside

Encouraging the client to perform ankle exercises

The nurse is teaching an older adult client about preventing hip fractures. Which information should the nurse exclude? Obtaining a screening to test for osteoporosis Maintaining adequate intake of calcium and vitamin D Ensuring throw rugs are placed throughout the home Performing weight-bearing exercises daily

Ensuring throw rugs are placed throughout the home

A nurse suspects the development of compartment syndrome for a client who has sustained blunt trauma to the forearm. For which early sign of compartment syndrome should the nurse assess the client? Warm skin at site of injury Escalating pain in the fingers Rapid capillary refill in affected hand Bounding radial pulse in the injured arm

Escalating pain in the fingers elevated tissue pressure restricts blood flow, causing increasing ischemia & increasing pain; it is the cardinal early symptom of compartment syndrome

What should be included in the nurse's instructions to help a client prepare for walking with crutches? Use of the trapeze to strengthen the biceps muscles Exercises with or without weights to strengthen the muscles of the upper extremities The importance of keeping the affected limb in extension and abduction to prevent contractures Isometric exercises of the hamstring muscles while sitting in a chair until circulatory status is stable

Exercises with or without weights to strengthen the muscles of the upper extremities

On the first postoperative day after a total hip replacement a client asks for assistance onto the bedpan. What should the nurse instruct the client to do? Use the elbows and hands to lift the pelvis off the bed. Extend both legs and pull on the trapeze to lift the pelvis. Turn gently toward the operative side while lifting the pelvis off the bed. Flex the knee on the unoperated leg and pull on the trapeze to lift the pelvis

Flex the knee on the unoperated leg and pull on the trapeze to lift the pelvis the pelvis is elevated by actions involving the unaffected upper extremities and unoperated leg

Which crutch gait should the nurse teach the client wearing a prosthesis after a single-leg amputation? Tripod Four-point Three-point Swing-through

Four-point

Which nursing action is contraindicated when caring for a client with a newly applied long leg cast? Elevating the cast on a pillow Drying the cast by using a fan Leaving the cast exposed to air Handling the cast with fingertips

Handling the cast with fingertips Rationale Handling the cast with fingertips before it is dried may create indentations that can cause pressure. Elevating the casted extremity on a pillow will help reduce edema. Drying the cast with a fan and leaving the cast exposed to the air will increase air flow that facilitates drying of the cast.

When preparing an individualized teaching plan for a client with rheumatoid arthritis, which topic should the nurse omit from the generalized teaching plan for clients with arthritis? Ulnar drift Heberden nodes Swan neck deformity Boutonnière deformity

Heberden nodes

A regimen of rest, exercise, and physical therapy is ordered for a client with rheumatoid arthritis. What should the nurse explain is the intended purpose of this regimen? Prevent arthritic pain Halt the inflammatory process Help prevent the crippling effects of the disease Provide for the return of joint motion after prolonged loss

Help prevent the crippling effects of the disease

The nurse is assessing a client's risk for sustaining a hip fracture. Which information should the nurse obtain when obtaining the health history? History of osteoporosis Skin integrity Age History of falls

History of osteoporosis

The nurse questions a client with rheumatoid arthritis about pain. When should the nurse expect the client to experience increased pain and limited movement of the joints? After assistive exercise When the room is cool In the morning on awakening When the latex fixation test is positive

In the morning on awakening

A client is admitted with a fracture of the neck of the femur. In what position should the nurse maintain the client's affected extremity? Internal rotation with flexion of the knee and hip External rotation with flexion of the knee and hip Internal rotation with extension of the knee and hip External rotation with extension of the knee and hip

Internal rotation with extension of the knee and hip

A client who had an open reduction and internal fixation of a fractured ankle is being discharged. Which behavior indicates the need for further instruction about the use of crutches? Advancing both crutches with the weaker leg Leaning axillae on the crutches to support the body's weight. Transferring the crutches into one hand when sitting in a chair Moving the crutches before the unaffected leg when descending stairs

Leaning axillae on the crutches to support the body's weight.

A client has an amputation of a lower limb. What instructions should the nurse give the client to prevent a hip flexion contracture? Turn from side to side every 1 to 2 hours. Sit in a chair for 30 minutes three times a day. • Lie on the abdomen 30 minutes four times daily. Perform quadriceps muscle setting exercises twice daily

Lie on the abdomen 30 minutes four times daily.

Which foods should the nurse teach a client with gout to avoid to limit painful attacks? Eggs Liver Cheese Salmon

Liver

A nurse is caring for a client who developed aseptic necrosis after a fracture of the head of the femur. The nurse understands that aseptic necrosis is associated with which factor? Infection at the site of the wound Weight-bearing before the fracture is healed Immobilization after reduction of the fracture Loss of blood supply to the head of the femur

Loss of blood supply to the head of the femur

What should the nurse do to prevent deformities of the knee in a client with an exacerbation of arthritis? Maintain a knee brace on the leg. Keep the client on a regimen of bed rest. Maintain joints in functional alignment when resting Immobilize the joint with pillows until pain subsides

Maintain joints in functional alignment when resting

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

No deformity or crepitation.

A client sustained a radial fracture, and a cast was just applied. The client states that there is unrelieved pain and numbness in the fingers on the affected side. Which intervention should be a priority? Notifying the healthcare provider for cast removal Elevating the extremity Preparing for fasciotomy Performing frequent neurovascular checks

Notifying the healthcare provider for cast removal

Which position should a nurse avoid placing a client who had surgery for a total hip replacement? Supine Lateral Orthopneic Semi-Fowler

Orthopneic this position involves hip flexion greater than 90 degrees. this puts stress on the operative site & may dislodge the prosthesis

A patient complains that her amputated foot itches and feels hot. This represents which of the following? Poor psychological adjustment Early symptoms of infection Phantom limb sensation Denial of the amputation

Phantom limb sensation

Which is an example of the principles of body mechanics that the nurse uses when caring for immobilized clients? Bending at the waist to provide the power for lifting Placing the feet apart to increase the stability of the body Keeping the body straight when lifting to reduce pressure on the abdomen Relaxing the abdominal muscles while using the extremities to prevent strain

Placing the feet apart to increase the stability of the body

A client who has intermittently been having painful, swollen knee and wrist joints during the past 3 months is diagnosed with rheumatoid arthritis. What type of diet should the nurse expect the health care provider to order? Salt-free, low-fiber diet High-calorie, low-cholesterol diet High-protein diet with minimal calcium Regular diet with vitamins and minerals

Regular diet with vitamins and minerals

A client with a fractured hip is placed in traction until surgery can be performed. What should the nurse explain is the purpose of the traction? Relieve muscle spasm and pain. Prevent contractures from developing. Keep the client from turning and moving in bed. Maintain the limb in a position of external rotation

Relieve muscle spasm and pain. traction may be used in the treatment of a fractrued hip to align the bones (reduction of fracture). if such traction is not employed, the muscles may go into spasm, shifting the bone fragments & causing pain.

A client is recovering from a fractured radius that occurred 7 weeks ago. Which process of bone healing should the nurse anticipate the client to be experiencing? Reparative phase Inflammatory phase Remodeling phase Bony union phase

Reparative phase

What should the nurse do to control edema of the residual limb 1 week after a client has an above-the-knee amputation? Administer the prescribed diuretic. Restrict the client's oral fluid intake. Rewrap the elastic bandage as necessary. Keep the residual limb elevated on a pillow.

Rewrap the elastic bandage as necessary. elastic bandages compress the residual limb, preventig edema & promoting residual limb shrinkage & molding; the bandage must be rewrapped when it loosens.

A person's right thumb was accidentally severed with an axe. The amputated right thumb was recovered. Which action by the nurse preserves the thumb so it could possibly be reattached in surgery? Place the right thumb directly on some ice. Put the right thumb in a glass of warm water. Wrap the thumb in a clean piece of material. Secure the thumb in a plastic bag and place on ice

Secure the thumb in a plastic bag and place on ice

Which clinical indicator should the nurse expect to identify when assessing a client with a fracture of the neck of the femur? Adduction with internal rotation Abduction with external rotation Shortening of the affected extremity with external rotation Lengthening of the affected extremity with internal rotation

Shortening of the affected extremity with external rotation

A nurse provides discharge teaching for a client who had a total hip replacement. Which activities to avoid identified by the client indicate an understanding of the teaching? Climbing stairs Sitting in a low chair Stretching exercises Lying prone for 30 minutes

Sitting in a low chair

A nurse is caring for a client who had an open reduction and internal fixation of a femoral neck fracture. The client has an order for ambulation with slight weight-bearing on the affected extremity. During the physical assessment the nurse identifies that the client has kyphosis and strong upper arm strength. What assistive devise does the nurse expect the health care provider to order for this client? Crutches Quad cane Straight cane Standard walker

Standard walker

For what clinical findings of compromised circulation should the nurse assess in a client with a long leg cast? Foul odor Swelling of the toes Drainage on the cast Increased temperature

Swelling of the toes

A client experiences a traumatic amputation of a leg in a motor vehicle accident. Which nursing intervention initially should receive the lowest priority? Teaching residual limb care Monitoring hemoglobin levels Maintaining the compression dressing Using therapeutic interviewing techniques

Teaching residual limb care this is not a priority at this point. the client is too traumatized to learn. it will assume priority as the client's recovery progresses

The nurse is assigned to care for a client who experienced a recent fall. Which manifestation indicates that the client's hip is fractured? Complaints of stiffness when transferring to chair The affected leg is shorter than the other and turned outward Bruising noted to the injured hip and leg Discomfort when performing range of motion exercises

The affected leg is shorter than the other and turned outward

Which statement by the nurse describes a comminuted fracture to the client? The ends of the broken bones are forced together." The bone is breaking through the skin." The bone is broken into many pieces." A fragment of the bone is separated from the rest of the bone."

The bone is broken into many pieces."

Which principle should the nurse consider when assisting a client with crutches to learn the four-point gait? Elbows should be kept in rigid extension. Most of the weight should be supported by axillae. The client must be able to bear weight on both legs. The affected extremity should be kept off the ground.

The client must be able to bear weight on both legs.

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 ordered. How does the nurse increase the countertraction? Elevate the head of the bed Add more weight to the traction Use a slight Trendelenburg position Tie a chest restraint around the client

Use a slight Trendelenburg position

Which of the following is the most common cause of lower extremity amputation? Trauma Tumors Vascular disease Congenital defects

Vascular disease

A nurse plans care to prevent deformities in a client with rheumatoid arthritis. Which intervention should be alternated with periods of rest? Active exercise Passive massage Bracing of joints Isometric exercises

active exercise

Which medication should the nurse anticipate the health care provider will prescribe to relieve the pain experienced by a client with rheumatoid arthritis? Aspirin Codeine Meperidine Alprazolam

aspirin

The nurse is caring for a client with a fractured fibula. Which assessment prompts immediate action by the nurse? A. Reported pain of 4 on a scale of 0 to 10 B. Numbness and tingling in the extremity. C. Swollen extremity where the injury occurred. D. Reports of being cold in bed

b. Numbness and tingling in extremity The client with numbness and tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of possible decreased circulation. Moderate pain and swelling is an expected assessment after a fracture. These findings can be treated with comfort measures. Being cold can be treated with additional blankets or by increasing the temperature of the room.

In teaching a patient scheduled for a total ankle replacement, it is important to tell the patient that after surgery he should avoid lifting heavy objects. sleeping on the back. abduction exercises of the affected ankle. bearing weight on the affected leg for 6 weeks

bearing weight on the affected leg for 6 weeks.

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

changes in balance

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

changes in urine output

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

connect bone to muscle

An indication of a neurovascular problem noted during assessment of the patient with a fracture is exaggeration of strength with movement. increased redness and heat below the injury. decreased sensation distal to the fracture site. purulent drainage at the site of an open fracture.

decreased sensation distal to the fracture site.

While obtaining subjective assessment data related to the musculoskeletal system, it is particularly important to ask a patient about other medical problems such as hypertension. thyroid problems. diabetes mellitus. chronic bronchitis.

diabetes mellitus. The nurse should question the patient about past medical problems because certain illnesses are known to affect the musculoskeletal system directly or indirectly. These diseases include tuberculosis, poliomyelitis, diabetes mellitus, parathyroid problems, hemophilia, rickets, soft tissue infection, and neuromuscular disabilities.

During the postoperative period, the nurse instructs the patient with an above the knee amputation that the residual limb should not be routinely elevated because this position promotes hip flexion contractures skin irritation and breakdown clot formation at the incision site increased risk of wound dehiscence

hip flexion contractures

A client has a total knee replacement, and a continuous passive motion device is being used. The nurse concludes that the teaching was effective when the client states, "The goal of this therapy is to: improve joint flexion " maintain muscle tone." prevent tissue breakdown." avoid formation of a blood clot."

improve joint flexion " a continuous passive motion device is most commonly used after knee replacement to gradually increase knee flexion without weight-bearning or strain

A patient with rheumatoid arthritis is experiencing articular involvement of the joints. The nurse recognizes that these characteristic changes include bamboo-shaped fingers. noninflammatory pain in large joints. asymmetric involvement of small joints morning stiffness lasting 60 minutes or more

morning stiffness lasting 60 minutes or more

The bone cells that function in the resorption of bone tissue are called osteoids. osteoclasts. osteocytes. osteoblasts

osteoclasts

A checkout clerk in a grocery store has muscle and tendon tears that have become inflamed, causing pain and weakness in the left hand and elbow. The nurse identifies these symptoms as related to muscle spasms. repetitive strain injury. meniscus injury. carpal tunnel syndrome

repetitive strain injury.

A patient with osteoarthritis is scheduled for a total hip arthroplasty. The nurse explains that the purpose of this procedure is to fuse the joint. replace the joint. prevent further damage. improve or maintain ROM

replace the joint.

The nurse suspects an ankle sprain when a patient at the urgent care center relates being hit by another soccer player during a game. having ankle pain after sprinting around the track. dropping a 10-Ib weight on his lower leg at the health club twisting his ankle while running bases during a baseball game

twisting his ankle while running bases during a baseball game

A client is in skin traction while awaiting surgery for repair of a fractured femur. The client reports leg discomfort and asks the nurse to release the traction. Which is the nurse's best initial response? "I can't because the weights are needed to keep the bone aligned." "I will remove half of the weights and notify your health care provider." "I'll get your prescribed pain medication to help relieve your discomfort." "I have to follow the health care provider's directions, and releasing weights is not ordered."

"I can't because the weights are needed to keep the bone aligned."

The nurse is caring for four clients. Which client should the nurse identify as having the highest risk for sustaining a hip fracture if they sustain a fall? 60-year-old man admitted for treatment of pneumonia 80-year-old man admitted for benign prostatic hypertrophy 50-vear-old woman with a history of osteoarthritis 70-year-old woman who consumes 800 mg calcium/day

70-year-old woman who consumes 800 mg calcium/day

A patient with comminuted fractures of the tibia and fibula is treated with open reduction and application of an external fixator. The next day, the patient complains of severe pain in the leg, which is unrelieved by ordered analgesics. The patient's toes are pink, but the patient complains of numbness and tingling. The most appropriate action by the nurse is to A. Notify the patient's health care provider. B. Check the patient's blood pressure. C. Assess the external fixator pins for redness or drainage. D. Elevate the extremity and apply ice over the wound site.

A. Notify the patient's healthcare provider. The patient's clinical manifestations point to compartment syndrome and delay in diagnosis, and treatment may lead to severe functional impairment. There is no reason to suspect that patient's symptoms are caused by hypotension or hypertension or by infection at the pin sites. Elevation of or ice application to the leg will decrease arterial flow and further reduce perfusion.

During assessment of the musculoskeletal system of a 74-year-old woman, the nurse notes that the patient has lost 1 inch in height since the previous visit two years ago. The nurse will plan to teach the patient about: A. diskography studies. B. magnetic resonance imaging (MRI). C. dual-energy x-ray absorptiometry (DEXA). D. myelographic testing

Answer: C Rationale: The decreased height and the patient's age suggest that the patient may have osteoporosis and that bone density testing is needed. Diskography, MRI, and myelography are typically done for patients with current symptoms caused by musculoskeletal dysfunction and are not the initial diagnostic test for osteoporosis. Cognitive Level: Application Text Reference: pp. 1619, 1625 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

A nurse is caring for a client with rheumatoid arthritis. Based on the client's diagnosis, the nurse should review the result of which laboratory test? Pancreatic lipase Bence Jones protein Antinuclear antibody Alkaline phosphatase

Antinuclear antibody

The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. The nurse's response is based on the understanding that: A. A bone fragment has injured the nerve supply in the area. B. An injured artery causes impaired arterial perfusion through the compartment. C. Bleeding and swelling cause increased pressure in an area that cannot expand. D. The fascia expands with injury, causing pressure on underlying nerves and muscles.

C. Bleeding and swelling cause increased pressure in an area that cannot expand. Compartment syndrome is caused by bleeding and swelling within a compartment, which is lined by fascia that does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms.

A patient is seen at the urgent care center after falling on the right arm and shoulder. It will be most important for the nurse to determine A. whether there is bruising at the shoulder area. B. whether the right arm is shorter than the left. C. the amount of pain the patient is experiencing D. how much range of motion (ROM) is present

Correct Answer: B Rationale: A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. The nurse will expect bruising and pain at the area, even without an injury that requires surgery. The shoulder should be immobilized until it is evaluated by the health care provider.

When administering medications to the patient with gout, the nurse would recognize that which drug is used as a treatment for this disease? A. Colchicine B. Febuxostat C. Sulfasalazine D. Cyclosporine

Correct answer: b Rationale: Febuxostat (Uloric), a selective inhibitor of xanthine oxidase, is administered for long-term management of hyperuricemia in persons with chronic gout. An acute episode of gout is treated with colchicine and nonsteroidal antiinflammatory drugs (NSAIDs).

When counseling an older patient about ways to prevent fractures, which information will the nurse include? A. Tacking down scatter rugs in the home is recommended. B. Occasional weight-bearing exercise will improve muscle and bone strength. C. Most falls happen outside the home D. Buying shoes that provide good support and are comfortable to wear is recommended.

D. Buying shoes that provide good support and are comfortable to wear is recommended

The recovery room nurse is caring for a client who has just had a left BKA. Which intervention should the nurse implement? Assess the client's surgical dressing every two (2) hours. Do not allow the client to see the residual limb. Keep a large tourniquet at the client's bedside. Perform passive range-of-motion exercises to the right leg.

Keep a large tourniquet at the client's bedside.

What instructions should the nurse provide when the client is allowed out of bed after an above-the-knee amputation? Keep the hip in extension and alignment. Keep the hip raised with the residual limb elevated. Lift the shoulder and hip of the affected side when taking a step. Use the ordered crutches until the residual limb is completely healed.

Keep the hip in extension and alignment.

After an above-the-knee amputation of a leg, a client reports pain in the foot that is no longer there. What should the nurse include about phantom limb pain in a discussion with the client? Tactile illusions associated with severed blood vessels. Nerve endings in the limb are still intact and react to stimuli. An unconscious phenomenon to aid with grieving over the lost body part. Hallucinations secondary to emotional symptoms associated with the distress of amputation.

Nerve endings in the limb are still intact and react to stimuli.

A nurse is monitoring a client who is having a computed tomography (CT) scan of the brain with contrast. Which response indicates that the client is having an untoward reaction to the contrast medium? Pelvic warmth Feeling flushed Shortness of breath Salty taste in the mouth

Shortness of breath

A nurse is completing the health history of a client admitted to the hospital with osteoarthritis. Which joints does the nurse least expect the client to report were initially involved? Hips Shoulders Knees Distal interphalengeal joints

Shoulders

The nurse is providing discharge teaching to the family of an older adult client who was treated for a fracture after a fall. Which recommendation should the nurse include in the teaching? Always wear socks when ambulating. Use a step stool when possible. Start a mild exercise program. Remove the rubber mat from tub.

Start a mild exercise program.

Which of the following is the reason a compression dressing or a cast is applied after amputation? To reduce pain To prevent wound contamination To shape the residual limb To prevent stimulation of nerve endings

To shape the residual limb

What should the nurse do to promote early and efficient ambulation after a client has a midthigh amputation? Keep the head of the bed elevated. Place the residual limb on a pillow. Turn the client to the prone position routinely. Encourage the client to lie on the unaffected side

Turn the client to the prone position routinely. flexion contracture of the hip can be prevented by routinely placing the client in a prone postion to extend the hip

A client has a total hip replacement. Which clinical indicators of pulmonary embolism indicate that the plan to prevent postoperative thrombus formation has been ineffective? Flushing of the face Unilateral chest pain Elevation of temperature Pain rating increase from 2 to 8 in the hip

Unilateral chest pain

A client with a fractured hip is helped from the bed to a chair after surgery. The nurse instructs the client to bear most of the weight on the unaffected leg before sitting in a chair. What should the nurse explain is the benefit of bearing most of the weight on the unaffected leg? Can increase circulation in the lower extremities Will help maintain the strength of the unaffected limb Is the quickest method of getting the client to and from the bed Reduces the amount of help necessary to lift the client from the bed to the chair

Will help maintain the strength of the unaffected limb

Based on the nurse's understanding of the physiology of bone and cartilage, the injury that the nurse would expect to heal most rapidly is a a. fracture of the midhumerus. b. torn knee cruciate ligament. c. fractured nose. d. severely sprained ankle.

a. fracture of the midhumerus. Rationale: Bone is dynamic tissue that is continually growing. Nasal fracture, sprains, and ligament tears injure cartilage, tendons, and ligaments, which are slower to heal.

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

adequate alignment cannot be obtained by other nonsurgical methods.

The care plan for a client with a fractured hip includes nursing actions to prevent which type of contracture? Flexion of the hip Abduction of the hip Hyperextension of the hip Internal rotation of the hip

flexion of the hip

The nurse explains to a patient with a fracture of the distal shaft of the humerus who is returning for a week checkup that healing is indicated by formation of callus. complete bony union. hematoma at fracture site presence of granulation tissue

formation of callus.

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

indicate osteophyte formation at the DIP joints. Heberden's nodes are bony deformities in the distal interphalangeal joints that are indicative of osteophyte formation and loss of joint space in osteoarthritis.

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

insertion of small needles into certain muscles

While performing passive range of motion for a patient, the nurse puts the ankle joint through the movements of: inversion and eversion. pronation and supination flexion, extension, abduction, and adduction. pronation, supination, rotation, and circumduction

inversion and eversion.

To prevent muscle atrophy, the nurse teaches the patient with a leg immobilized in traction to perform: flexion contractions. tetanic contractions. isotonic contractions. isometric contractions

isometric contractions

A patient with a stable, closed fracture of the humerus caused by trauma to the arm has a temporary splint with bulky padding applied with an elastic bandage. The nurse suspects compartment syndrome and notifies the physician when the patient experiences increasing edema of the limb. muscle spasms of the lower arm. rebounding pulse at the fracture site. pain when passively extending the fingers

pain when passively extending the fingers. Rationale: One or more of the following are characteristic of compartment syndrome: (1) paresthesia (i.e., numbness and tingling); (2) pain distal to the injury that is not relieved by opioid analgesics and pain on passive stretch of muscle traveling through the compartment; (3) increased pressure in the compartment; (4) pallor, coolness, and loss of normal color of the extremity; (5) paralysis or loss of function; and (6) pulselessness or diminished or absent peripheral pulses. The examination also assesses peripheral edema, especially pitting edema, which may occur with severe injury. Ch. 63 Bridge to NCLEX Examination #5

A client with rheumatoid arthritis has severe pain and swelling of the joints in both hands. Range-of-motion exercises for this client should be: passively performed by the nurse. avoided if the client reports discomfort. preceded by the application of heat or cold. gradually increased to improve mobility and independence.

preceded by the application of heat or cold