Test 4 - Mobility
The nurse is caring for a patient hospitalized with a herniated lumbar disc and an exacerbation of chronic bronchitis. Which breakfast choice would be most appropriate for the patient to select from the breakfast menu? Bran muffin Scrambled eggs Puffed rice cereal Buttered white toast
Bran muffin Each meal should contain one or more sources of fiber to reduce the risk of constipation and straining with defecation, which increases back pain. A patient with chronic breathing difficulties also will benefit from regularity and ease of bowel evacuation. In addition, if lumbar nerve compression is present, bowel and bladder function may be impaired. Bran is a typical high-fiber food choice and is an appropriate selection from the menu. Scrambled eggs, puffed rice cereal, and buttered white toast do not have as much fiber.
The nurse provides instructions to a 30-yr-old office worker who has low back pain. Which statement indicate additional patient teaching is required? "Switching between hot and cold packs may relieve pain and stiffness." "Acupuncture to the lower back would cause irreparable nerve damage." "Smoking may aggravate back pain by decreasing blood flow to the spine." "Sleeping on my side with knees and hips bent reduces stress on my back."
"Acupuncture to the lower back would cause irreparable nerve damage." Acupuncture is a safe therapy when the practitioner has been appropriately trained. Very fine needles are inserted into the skin to stimulate specific anatomic points in the body for therapeutic purposes.
A 24-yr-old male patient has come to the clinic with a gradual onset of pain and swelling in the left knee. The patient is diagnosed with osteosarcoma without metastasis. Chemotherapy is ordered before surgery. How would the nurse explain the reason for preoperative chemotherapy? "The chemotherapy is being used to save your left leg." "Chemotherapy will increase your 5-year survival rate." "Chemotherapy is being used to decrease the tumor size." "Chemotherapy will help decrease the pain before and after surgery."
"Chemotherapy is being used to decrease the tumor size." Preoperative chemotherapy is used to decrease the tumor size before surgery. The chemotherapy will not save his leg if the lesion is too big or there is neurovascular or muscle involvement. Adjunct chemotherapy after amputation or limb salvage has increased 5-year survival rates in people without metastasis. Chemotherapy is not used to decrease pain before or after surgery.
The nurse is admitting a patient who reports the new onset of lower back pain. To distinguish between the pain of a lumbar herniated disc from other causes, what is the best question for the nurse to ask the patient? "Is the pain worse in the morning or in the evening?" "Is the pain sharp and stabbing or burning and aching?" "Does the pain radiate down the buttock or into the leg?" "Is the pain totally relieved by acetaminophen (Tylenol)?"
"Does the pain radiate down the buttock or into the leg?" Lower back pain associated with a herniated lumbar disc is accompanied by radiation along the sciatic nerve. It is often described as traveling through the buttock to the posterior thigh or down the leg. This is because the herniated disc causes compression on spinal nerves as they exit the spinal column. Time of occurrence, type of pain, and pain relief questions do not elicit differentiating data.
A patient who had a long leg cast applied this morning asks to crutch walk before dinner. Which statement explains why the nurse will decline the patient's request? "You must ambulate with a physical therapist for the first few days." "The cast is not dry yet, so 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 hours."
"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. RICE is used for soft tissue injuries, not with long leg casts.
A 66-yr-old man with type 2 diabetes and atrial fibrillation has begun taking glucosamine and chondroitin for osteoarthritis. Which question is most important for the nurse to ask? "Did you have any hypoglycemic reactions?" "Have you noticed any bruising or bleeding?" "Have you had any dizzy spells when standing up?" "Do you have any numbness or tingling in your feet?"
"Have you noticed any bruising or bleeding?" Glucosamine and chondroitin are dietary supplements commonly used to treat osteoarthritis. Both may increase the risk of bleeding. Patients with atrial fibrillation routinely take an anticoagulant to reduce the risk of venous thromboembolism and stroke. Use of glucosamine and chondroitin along with an anticoagulant may precipitate excessive bleeding. Glucosamine may decrease the effectiveness of insulin or other drugs used to control blood glucose, and hyperglycemia may occur.
A 21-yr-old soccer player has injured the anterior crucial ligament (ACL) and is having reconstructive surgery. Which patient statement indicates more teaching is required? "I probably won't be able to play soccer for 6 to 8 months." "They will have me do range of motion with my knee soon after surgery." "I will need to wear an immobilizer and progressively bear weight on my knee." "I can't wait to get this done now so I can play in the soccer tournament next month."
"I can't wait to get this done now so I can play in the soccer tournament next month." The patient does not understand the severity of ACL reconstructive surgery if planning to resume playing soccer soon; safe return will not occur for 6 to 8 months. A physical therapist will oversee initial range of motion, immobilization, and progressive weight bearing.
The nurse obtains a history from a 46-yr-old woman with rheumatoid arthritis. The nurse should follow up on which patient statement? "I perform range of motion exercises at least twice a day." "I use a heating pad for 20 minutes to reduce morning stiffness." "I take a 20-minute nap in the afternoon even if I sleep 9 hours at night." "I restrict fluids to prevent edema when taking methotrexate (Rheumatrex)."
"I restrict fluids to prevent edema when taking methotrexate (Rheumatrex)." Methotrexate can affect renal function. Patients should be well hydrated to prevent nephropathy. Heat application, range of motion, and rest are appropriate interventions to manage rheumatoid arthritis.
The nurse has reviewed proper body mechanics with a patient who has a history of low back pain caused by a herniated lumbar disc. Which patient statement indicates a need for further teaching? "I should sleep on my side or back with my hips and knees bent." "I should exercise at least 15 minutes every morning and evening." "I should pick up items by leaning forward without bending my knees." "I should try to keep one foot on a stool whenever I have to stand for a period of time."
"I should pick up items by leaning forward without bending my knees." The patient should avoid leaning forward without bending the knees. Bending the knees helps to prevent lower back strain and is part of proper body mechanics for lifting. Sleeping on the side or back with hips and knees bent and standing with a foot on a stool will decrease lower back strain. Back strengthening exercises are done twice a day once symptoms subside.
When reinforcing health teaching on managing osteoarthritis, which patient statement indicates additional instruction is needed? "I can use a cane to relieve the pressure on my back and hip." "I should take the Naprosyn as prescribed to help control the pain." "I should try to stay standing all day to keep my joints from becoming stiff." "A warm shower in the morning will help relieve the stiffness I have when I get up."
"I should try to stay standing all day to keep my joints from becoming stiff." Maintaining a balance between rest and activity is important to prevent overstressing joints affected by OA. Naproxen may be used for moderate to severe OA pain. Using a cane and warm shower to help relieve pain and morning stiffness are helpful.
The nurse is delivering teaching to a female patient newly diagnosed with systemic lupus erythematosus (SLE). Which statement demonstrates the patient's need for further teaching about the disease? "I'll try my best to stay out of the sun this summer." "I know that I have a high chance of getting arthritis." "I'm hoping surgery will be an option for me in the future." "I understand I'm going to be vulnerable to getting infections."
"I'm hoping surgery will be an option for me in the future." Surgery is not a key treatment modality for SLE, so this indicates a need for further teaching. SLE carries an increased risk of infection, sun damage, and arthritis.
A patient with acute osteomyelitis asks the nurse how this problem will be treated initially. Which response by the nurse is most appropriate? "IV antibiotics are usually required for several weeks." "Oral antibiotics are often required for several months." "Surgery is almost always necessary to remove the dead tissue that present." "Drainage of the foot and instilling antibiotics into the affected area are the usual therapy."
"IV antibiotics are usually required for several weeks." The standard treatment for acute osteomyelitis consists of several weeks of IV antibiotic therapy. However, as many as 3 to 6 months may be required. Bone is denser and less vascular than other tissues, and it takes time for the antibiotic therapy to eradicate all microorganisms. Surgery may be used for chronic osteomyelitis, to include debridement of the devitalized, infected tissue and irrigation of the affected bone with antibiotics.
A 24-yr-old female patient with systemic lupus erythematosus (SLE) tells the nurse she wants to have a baby and is considering getting pregnant. Which response by the nurse is most appropriate? "Infertility can result from some medications used to control your disease." "Temporary remission of your signs and symptoms is common during pregnancy." "Autoantibodies transferred to the baby during pregnancy will cause heart defects." "The baby is at high risk for neonatal lupus erythematosus being diagnosed at birth."
"Infertility can result from some medications used to control your disease." Infertility may be caused by renal involvement and the previous use of high-dose corticosteroid and chemotherapy drugs. Neonatal lupus erythematosus rarely occurs in infants born to women with SLE. Exacerbation is common after pregnancy during the postpartum period. Spontaneous abortion, stillbirth, and intrauterine growth retardation are common problems with pregnancy related to deposits of immune complexes in the placenta and because of inflammatory responses in the placental blood vessels. There is not an increased risk for heart defects.
A nurse performs discharge teaching for a patient after a left hip arthroplasty using the posterior approach. Which statement 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.
Which statement suggests a need for the nurse to assess the patient for ankylosing spondylitis? "My right elbow has become red and swollen over the last few days." "I wake up stiff every morning, and my knees just don't want to bend." "My husband tells me that my posture has become so stooped this winter." "My lower back pain seems to be getting worse and nothing seems to help."
"My lower back pain seems to be getting worse and nothing seems to help." AS primarily affects the axial skeleton. Based on this, symptoms of inflammatory spine pain are often the first clues to a diagnosis of AS. Knee or elbow involvement is not consistent with the typical course of AS. Back pain is likely to precede the development of kyphosis.
The nurse receives report from the licensed practical nurse (LPN/VN) about care provided to patients on the orthopedic surgical unit. It is most important for the nurse to follow up on which statement? "The patient who had a spinal fusion 12 hours ago has hypoactive bowel sounds and is not passing flatus." "The patient who had cervical spine surgery 2 days ago wants to wear her soft cervical collar when out of bed." "The patient who had spinal surgery 3 hours ago is reporting a headache and has clear drainage on the dressing." "The patient who had a laminectomy 24 hours ago is using patient-controlled analgesia with morphine for pain management."
"The patient who had spinal surgery 3 hours ago is reporting a headache and has clear drainage on the dressing." After spinal surgery, there is potential for cerebrospinal fluid (CSF) leakage. Severe headache or leakage of CSF (clear or slightly yellow) on the dressing should be reported immediately. The drainage is CSF if a dipstick test is positive for glucose. Patients after spinal surgery may experience interference with bowel function for several days. Postoperatively most patients require opioids such as morphine IV for 24 to 48 hours. Patient-controlled analgesia is the preferred method for pain management during this time. After cervical spine surgery, patients often wear a soft or hard cervical collar to immobilize the neck.
The nurse teaches 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 for wound dehiscence.
A Flexion contractures may delay the rehabilitation process after amputations. The most common and debilitating contracture is hip flexion. To prevent flexion contractures, patients should avoid sitting in a chair for more than 1 hour with hips flexed or with pillows under the surgical extremity. Unless specifically contraindicated, patients should lie on the abdomen for 30 minutes three or four times each day and position the hip in extension while prone.
A patient with a pelvic fracture should be monitored for •a. changes in urine output. •b. petechiae on the abdomen. •c. a palpable lump in the buttock. •d. sudden increase in blood pressure.
A Pelvic fractures may cause serious intraabdominal injury, such as hemorrhage, and laceration of the urethra, bladder, or colon. Patients may survive the initial pelvic injury, only to die of sepsis, FES, or VTE. Because a pelvic fracture can damage other organs, the nurse should assess bowel and urinary elimination and distal neurovascular status.
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 Bone goes through a remarkable reparative process of self-healing (i.e., union) that occurs in stages. The third stage is callus formation. As minerals (i.e., calcium, phosphorus, and magnesium) and new bone matrix are deposited in the osteoid, an unorganized network of bone is formed that is woven about the fracture parts. Callus is composed primarily of cartilage, osteoblasts, calcium, and phosphorus. It usually appears by the end of the second week after injury. Evidence of callus formation can be verified on x-rays.
The nurse is caring for patients in a primary care clinic. Which patient is most at risk to develop osteomyelitis caused by Staphylococcus aureus? A 22-yr-old female patient with gonorrhea who is an IV drug user A 48-yr-old male patient with muscular dystrophy and acute bronchitis A 32-yr-old male patient with type 1 diabetes and stage 4 pressure injury A 68-yr-old female patient with hypertension who had a knee arthroplasty 3 years ago
A 32-yr-old male patient with type 1 diabetes and stage 4 pressure injury Osteomyelitis caused by S. aureus is usually associated with a pressure ulcer or vascular insufficiency related to diabetes. Osteomyelitis caused by Staphylococcus epidermidis is usually associated with indwelling prosthetic devices from joint arthroplasty. Osteomyelitis caused by Neisseria gonorrhoeae is usually associated with gonorrhea. Osteomyelitis caused by Pseudomonas is usually associated with IV drug use. Muscular dystrophy is not associated with osteomyelitis.
A patient presents to the clinical after tripping on a curb and spraining the right ankle. Which initial care measures are appropriate? (Select all that apply.) Apply ice directly to the skin. Apply heat to the ankle every 2 hours. Administer anti-inflammatory medication. Compress ankle using an elastic bandage. Rest and elevate the ankle above the heart. Perform passive and active range of motion.
Administer anti-inflammatory 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). Anti-inflammatory 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.
The patient developed acute gout while hospitalized for a heart attack. Because the patient takes aspirin for its antiplatelet effect, what should the nurse recommend in preventing future attacks of gout? Decrease fluid intake Drink a glass of wine daily Administration of probenecid Administration of allopurinol
Administration of allopurinol To prevent future attacks of gout, the urate-lowering drug allopurinol may be administered. Increased fluid will be encouraged to prevent precipitation of uric acid in the renal tubules. This patient will not be able to take the uricosuric drug probenecid because the patient's aspirin will inactivate its effect, resulting in urate retention. Dietary restrictions that limit alcohol and foods high in purine help minimize uric acid production.
The patient with frostbite on the distal toes of both feet is scheduled for amputation of the damaged tissue. Which assessment finding or diagnostic study is most objective in determining tissue viability? Arteriogram showing blood vessels Peripheral pulse palpation bilaterally Patches of black, indurated, cold tissue Bilateral pale, cool skin below the ankles
Arteriogram showing blood vessels Arteriography determines viable tissue for salvage based on blood flow observed in real time and is considered the gold standard for evaluating arterial perfusion. Only arteriography determines where tissue perfusion stops, and amputation needs to occur. Bilateral peripheral pulse assessment and areas of black, indurated, cold, and pale skin indicate ischemia.
When administering medications to the patient with chronic gout, the nurse recognizes which drug is used as a treatment for this disease? •a. Colchicine •b. Allopurinol •c. Sulfasalazine •d. Cyclosporine
B
The nurse is admitting a patient with a history of a herniated lumbar disc and low back pain. Which action would likely aggravate the pain? Bending or lifting Application of warm moist heat Sleeping in a side-lying position Sitting in a fully extended recliner
Bending or lifting Back pain related to a herniated lumbar disc is aggravated by events and activities that increase stress and strain on the spine, such as bending or lifting, coughing, sneezing, and lifting the leg with the knee straight (straight leg-raising test). Moist heat, sleeping position, and ability to sit in a fully extended recliner do not aggravate the pain of a herniated lumbar disc.
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 proteolytic enzymes
B Bouchard's nodes are bony deformities of the proximal interphalangeal joints that indicate osteophyte formation and loss of joint space in osteoarthritis.
A patient with osteomyelitis undergoes surgical debridement with implantation of antibiotic beads. When the patient asks why the beads are used, the nurse answers (select all that apply) •a. "Oral or IV antibiotics are not effective in most cases of bone infection." •b. "The beads are an adjunct to debridement and antibiotics for deep infections." •c. "The beads are used to deliver antibiotics directly to the site of the infection." •d. "This is the safest method to deliver long-term antibiotic therapy for bone infection." •e. "Ischemia and bone death related to osteomyelitis are impenetrable to IV antibiotics."
B, C
A patient with osteoarthritis is scheduled for total hip arthroplasty. The nurse explains the purpose of this procedure is to (select all that apply) •a. fuse the joint. •b. replace the joint. •c. prevent further damage. •d. improve or maintain ROM. •e. decrease the amount of destruction in the joint.
B, D Arthroplasty is the reconstruction or replacement of a joint. This surgical procedure is performed to relieve pain, improve or maintain range of motion, and correct deformity. Total hip arthroplasty (THA) provides significant relief of pain and improvement of function for a patient with osteoarthritis (OA).
The nurse suspects a neurovascular problem based on assessment of •a. exaggerated strength with movement. •b. increased redness and heat below the injury. •c. decreased sensation distal to the fracture site. •d. purulent drainage at the site of an open fracture.
C Musculoskeletal injuries have the potential for causing changes in the neurovascular condition of an injured extremity. Application of a cast or constrictive dressing, poor positioning, and physiologic responses to the injury can cause nerve or vascular damage, usually distal to the injury. The neurovascular assessment consists of peripheral vascular evaluation (i.e. color, temperature, capillary refill, peripheral pulses, and edema) and peripheral neurologic evaluation (i.e. sensation and motor function).
A patient with longstanding Raynaud's phenomenon currently reports red spots on the hands, forearms, palms, face, and lips. Which additional findings would the nurse expect? (Select all that apply.) Calcinosis Weight loss Sclerodactyly Difficulty swallowing Weakened leg muscles Skin thickening below the elbow and knee
Calcinosis Sclerodactyly Difficulty swallowing Skin thickening below the elbow and knee This patient is at risk for scleroderma. The acronym CREST represents the manifestations. C: calcinosis, painful calcium deposits in the skin; R: Raynaud's phenomenon; E: esophageal dysfunction, difficulty swallowing; S: sclerodactyly, tightening of skin on fingers and toes; and T: telangiectasia. Weight loss and weakened leg muscles are associated with polymyositis and dermatomyositis, not scleroderma.
The public health nurse is providing community education to increase the number of people who seek care after a tick bite. What priority information should the nurse provide to people at risk for tick bites? The best therapy for the acute illness is IV antibiotics. Check for an enlarging reddened area with a clear center. Surveillance is necessary during the summer months only. Antibiotics will prevent Lyme disease if taken for 10 days.
Check for an enlarging reddened area with a clear center. After a tick bite, the expanding "bull's eye rash" is the most characteristic symptom that usually occurs in 3 to 30 days. Flu-like symptoms and migrating joint and muscle pain also may be present. Active lesions are treated with oral antibiotics for 2 to 3 weeks; doxycycline is effective in preventing Lyme disease when given within 3 days after the bite of a deer tick. IV therapy is used with neurologic or cardiac complications. Although ticks are most prevalent during summer months, residents of high-risk areas should check for ticks whenever they are outdoors. No vaccine is available.
A nurse is working with a 73-yr-old patient with osteoarthritis. Which description of the disorder should be included in the teaching plan? Joint destruction caused by an autoimmune process Degeneration of articular cartilage in synovial joints Overproduction of synovial fluid resulting in joint destruction Breakdown of tissue in non-weight-bearing joints by enzymes
Degeneration of articular cartilage in synovial joints OA is a degeneration of the articular cartilage in diarthrodial (synovial) joints from damage to the cartilage. The condition has also been referred to as degenerative joint disease. OA is not an autoimmune disease. There is no overproduction of synovial fluid causing destruction or breakdown of tissue by enzymes.
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 •a. the patient is unable to tolerate prolonged immobilization. •b. the patient cannot tolerate the surgery for a closed reduction. •c. other nonsurgical methods cannot achieve adequate alignment. •d. a temporary cast would be too unstable to provide normal mobility.
D A comminuted fracture has more than two bone fragments. Open reduction with internal fixation (ORIF) is indicated for a comminuted fracture and is used to realign and maintain bony fragments. Other nonsurgical methods can result in a failure to obtain satisfactory reduction. Internal fixation reduces the hospital stay and the complications associated with prolonged bed rest.
A patient with a stable, closed humeral fracture has a temporary splint with bulky padding applied with an elastic bandage. The nurse notifies the provider of possible early compartment syndrome when the patient has •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 One or more of the following are characteristic of compartment syndrome: (1) paresthesia (i.e., numbness and tingling sensation); (2) pain distal to the injury that is not relieved by opioid analgesics and, on passive stretch of muscle, pain that travels 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 includes assessment of peripheral edema, especially pitting edema, which may occur with severe injury.
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.
The nurse is caring for a patient with bilateral knee osteoarthritis. Which measure should the nurse recommend to slow progression of the disease? Use a wheelchair to avoid walking as much as possible. Sit in chairs that cause the hips to be lower than the knees. Eat a well-balanced diet to maintain a healthy body weight. Use a walker for ambulation to relieve the pressure on the hips.
Eat a well-balanced diet to maintain a healthy body weight. Because maintaining an appropriate load on the joints is essential to the preservation of articular cartilage integrity, the patient should maintain an optimal overall body weight or lose weight if overweight. Walking is encouraged. The best chairs for this patient have a higher seat and armrests to facilitate sitting and rising from the chair. Relieving pressure on the hips is not important for knee disease.
The nurse teaches a 64-yr-old man with gouty arthritis about food that may be consumed on a low-purine diet. The patient's choice of which food item indicates an understanding of the instructions? Eggs Liver Salmon Chicken
Eggs Gout is caused by an increase in uric acid production, underexcretion of uric acid by the kidneys, or increased intake of foods containing purines, which are metabolized to uric acid by the body. Liver is high in purine, and chicken and salmon are moderately high in purine.
A patient who has low back pain from a herniated lumbar disc is having muscle spasms. Which nursing intervention would be most appropriate? Provide gentle ROM to the lower extremities. Elevate the head of the bed 20 degrees and flex the knees. Place a small pillow under the patient's upper back to gently flex the lumbar spine. Place the bed in reverse Trendelenburg with the patient's feet against the footboard.
Elevate the head of the bed 20 degrees and flex the knees. To reduce pain, the nurse should elevate the head of the bed 20 degrees and have the patient flex the knees to avoid extension of the spine. The slight flexion provided by this position often is comfortable for a patient with a herniated lumbar disc. ROM to the lower extremities will be limited to prevent extremes of spinal movement. Reverse Trendelenburg and a pillow under the patient's upper back will more likely increase pain.
A patient has a plaster cast applied to the right arm for a Colles' fracture. Which nursing action is most appropriate? Elevate the right arm on 2 pillows for 24 hours. Apply heating pad to reduce muscle spasms and pain. Limit movement of the thumb and fingers on the right hand. Place arm in a sling to prevent movement of the right shoulder.
Elevate the right arm on 2 pillows for 24 hours. The casted extremity should be elevated at or above heart level for 24 hours to reduce swelling or inflammation. The cast should be supported on pillows during the drying period to prevent denting and flattening of the cast. Ice (not heat) should be applied for the first 24 to 36 hours to reduce swelling or inflammation. Active movement of the thumb and fingers should be encouraged to reduce edema and increase venous return. A sling may be used to support and protect the extremity after the cast is completely dry, but the patient should perform active movements of the shoulder to prevent stiffness or contracture.
The nurse determines that an older adult patient recovering from left total knee arthroplasty has impaired physical mobility from decreased muscle strength. What nursing intervention is appropriate? Promote vitamin C and calcium intake in the diet. Provide passive range of motion to all the joints every 4 hours. Keep the left leg in extension and abduction to prevent contractures. Encourage isometric quadriceps-setting exercises at least 4 times a day.
Encourage isometric quadriceps-setting exercises at least 4 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 nurse is reinforcing health teaching about osteoporosis with a 72-yr-old patient admitted to the hospital. What should the nurse explain to the patient? With a family history of osteoporosis, you cannot prevent or slow bone resorption. Estrogen therapy must be maintained to prevent rapid progression of the osteoporosis. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.
Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise. The rate of progression of osteoporosis can be slowed if the patient takes calcium supplements or foods high in calcium and engages in regular weight-bearing exercise. Corticosteroids interfere with bone metabolism. Estrogen therapy is no longer used to prevent osteoporosis because of the associated increased risk of heart disease and breast and uterine cancer.
The patient brought to the emergency department after a car accident 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 is caring for a patient with osteoarthritis scheduled for total left knee arthroplasty. Preoperatively, the nurse assesses for which contraindication to surgery? Pain Left knee stiffness Left knee infection Left knee instability
Left knee infection The patient must be free of infection before total knee arthroplasty. An infection in the joint could lead to even greater pain and joint instability, requiring more extensive surgery. The nurse must assess the patient for signs of infection, such as redness, swelling, fever, and elevated white blood cell count. Pain, knee stiffness, or instability are typical of osteoarthritis
The home care nurse visits a 74-yr-old man diagnosed with Parkinson's disease who fell while walking this morning. What observation is of most concern to the nurse? 2 × 6 cm right calf abrasion with sanguineous drainage Left leg externally rotated and shorter than the right leg Stooped posture with a shuffling gait and slow movements Mild pain and minimal swelling of the right ankle and foot
Left leg externally rotated and shorter than the right leg Manifestations of hip fracture include external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness in the region of the fracture site. Expected clinical manifestations of Parkinson's disease include a stooped posture, shuffling gait, and slow movements. An abrasion is a soft tissue injury. Mild pain and minimal swelling may occur with a sprain or strain.
A patient underwent amputation below the knee on the left leg after a traumatic accident. Which intervention should the nurse include in the plan of care? Sit in a chair for 1 to 2 hours three times each day. Lie prone with hip extended for 30 minutes 4 times per day. Dangle the residual limb for 20 to 30 minutes every 6 hours. Elevate the residual limb on a pillow for 4 to 5 days after surgery.
Lie prone with hip extended for 30 minutes 4 times per day. To prevent hip flexion contractures, the patient should lie on the abdomen for 30 minutes 3 or 4 times each day and position the hip in extension while prone. The patient should avoid sitting in a chair for more than 1 hour with hips flexed or having pillows under the surgical extremity. The patient should avoid dangling the residual limb over the bedside to minimize edema.
The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. When completing a focused assessment, which symptom should the nurse expect? Nausea and vomiting Localized pain and warmth Paresthesia in the affected extremity Generalized bone pain throughout the leg
Localized pain and warmth Osteomyelitis is an infection of bone and bone marrow that can occur with trauma, surgery, or spread from another part of the body. Because it is an infection, the patient will exhibit typical signs of inflammation and infection, including localized pain and warmth. Nausea and vomiting and paresthesia of the extremity are not expected to occur. Pain occurs, but it is localized rather than generalized throughout the leg.
An older adult is diagnosed with Paget's disease. Which finding would indicate improvement in the condition? Waddling gait Curvature in affected bones Lower serum alkaline phosphatase Uptake of radiolabeled bisphosphonate in affected bones
Lower serum alkaline phosphatase Paget's disease is characterized by excessive bone resorption and replacement of normal marrow with vascular, fibrous connective tissue. A normalizing alkaline phosphatase indicates bone resorption has slowed or stopped. Additional characteristics of the disease include bone pain, a waddling gait, loss of stature, and curved bones. Uptake of radiolabeled bisphosphonate indicates a bone is affected.
The nurse is completing discharge teaching with a 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.
A patient with fibromyalgia has pain at 12 of the 18 identified tender sites, including the neck, upper back, and knees. The patient reports nonrefreshing sleep, depression, and anxiety when dealing with multiple tasks. Which treatments would be included in the plan of care? (Select all that apply.) Massage therapy Low-impact aerobic exercise Relaxation strategy (biofeedback) Antiseizure drug pregabalin (Lyrica) Morphine sulfate extended-release tablets Serotonin reuptake inhibitor (e.g., sertraline [Zoloft])
Massage therapy Low-impact aerobic exercise Relaxation strategy (biofeedback) Antiseizure drug pregabalin (Lyrica) Serotonin reuptake inhibitor (e.g., sertraline [Zoloft]) Massage will improve blood flow and relaxation. Low-impact aerobic exercise will prevent muscle atrophy without increasing pain at the knees. Relaxation using biofeedback may decrease the patient's stress and anxiety. Because the treatment of fibromyalgia is symptomatic, this patient will preferably be prescribed a nonopioid pain medication, an antiseizure medication such as pregabalin to help with widespread pain, and a serotonin reuptake inhibitor for depression. Long-acting opioids such as morphine are avoided unless other medications do not relieve pain.
During a health screening event, which assessment finding in a 61-yr-old patient would alert the nurse to the possible presence of osteoporosis? Presence of bowed legs Measurable loss of height Poor appetite and aversion to dairy products Development of unstable, wide-gait ambulation
Measurable loss of height A gradual but measurable loss of height and the development of kyphosis ("dowager's hump") are indicative of the presence of osteoporosis. Bowed legs may be caused by abnormal bone development or rickets but are not indicative of osteoporosis. Lack of calcium and Vitamin D intake may cause osteoporosis but are not indicative of its presence. A wide gait is used to support balance and does not indicate osteoporosis.
The nurse is caring for a patient placed in Buck's traction before open reduction and internal fixation of a left hip fracture. Which care can be delegated to the LPN/VN? Assess skin integrity around the traction boot. Determine correct body alignment to enhance traction. Remove weights from traction when turning the patient. Monitor pain intensity and administer prescribed analgesics.
Monitor pain intensity and administer prescribed analgesics. The LPN/VN can monitor pain intensity and administer analgesics. Assessment of skin integrity and determining correct alignment to enhance traction are within the RN scope of practice. Removing weights from the traction should not be delegated or done. Removal of weights can cause muscle spasms and bone misalignment and should not be delegated or done.
A 58-yr-old woman with breast cancer is admitted for severe back pain related to a vertebral compression fracture. The patient's laboratory values include serum potassium of 4.5 mEq/L, serum sodium of 144 mEq/L, and serum calcium of 14.3 mg/dL. Which signs and symptoms would the nurse expect the patient to exhibit? Anxiety, irregular pulse, and weakness Muscle stiffness, dysphagia, and dyspnea Hyperactive reflexes, tremors, and seizures Nausea, vomiting, and altered mental status
Nausea, vomiting, and altered mental status Breast cancer can metastasize to the bone, with vertebrae as a common site. Pathologic fractures at the site of metastasis are common because of a weakening of the involved bone. High serum calcium results as calcium is released from damaged bones. Normal serum calcium is 8.6 to 10.2 mg/dL. Manifestations of hypercalcemia include nausea, vomiting, and altered mental status (e.g., lethargy, decreased memory, confusion, personality changes, psychosis, stupor, coma). Manifestations of hypomagnesemia include hyperactive reflexes, tremors, and seizures. Symptoms of hyperkalemia include anxiety, irregular pulse, and weakness. Symptoms of hypocalcemia include muscle stiffness, dysphagia, and dyspnea.
A patient with a fracture of the proximal left tibia in a long leg cast reports of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which nursing action is a priority? Notify the health care provider immediately. Elevate the left leg above the level of the heart. Administer prescribed morphine sulfate intravenously. Apply ice packs to the left proximal tibia over the cast.
Notify the health care provider immediately. Notify the health care provider immediately of this change in patient's condition, which suggests development of compartment syndrome. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Changes in sensation (tingling) also suggest compartment syndrome. Because elevation of the extremity may lower venous pressure and slow arterial perfusion, the extremity should not be elevated above heart level. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome. Administration of morphine may be warranted, but it is not the first priority.
The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis. Which finding should the nurse expect when examining the patient's knees? Ulnar drift Pain with joint movement Reddened, swollen affected joints Stiffness that increases with movement
Pain with joint movement Osteoarthritis is characterized predominantly by joint pain upon movement and is a classic feature of the disease. Ulnar drift occurs with rheumatoid arthritis, not osteoarthritis. Local inflammation (red, swollen joints) is unlikely with osteoarthritis. Stiffness decreases with movement.
A 67-yr-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges and elevation of the affected foot on 2 pillows. The nurse would place the highest priority on which intervention? Ambulate the patient to the bathroom every 2 hours. Ask the patient about preferred activities to relieve boredom. Allow the patient to dangle legs at the bedside every 2 to 4 hours. Perform frequent position changes and range-of-motion exercises.
Perform frequent position changes and range-of-motion exercises. The patient is at risk for atelectasis of the lungs and contractures because of prescribed bed rest. For this reason, the nurse should place the priority on changing the patient's position frequently to promote lung expansion and performing range-of-motion exercises to prevent contractures. Assisting the patient to the bathroom will keep the patient safe as the patient is in pain, but it may not be needed every 2 hours. Providing activities to relieve boredom will assist the patient to cope with the bed rest. Dangling the legs every 2 to 4 hours may be too painful.
Which nursing intervention is most appropriate when turning a patient after spinal surgery? Having the patient turn to the side by grasping the side rails to help turn Placing a pillow between the patient's legs and turning the body as a unit Elevating the head of bed 30 degrees and having the patient extend the legs while turning Turning the patient's head and shoulders and then the hips, keeping the patient's body centered in the bed
Placing a pillow between the patient's legs and turning the body as a unit Placing a pillow between the legs and turning the patient as a unit (logrolling) helps to keep the spine in good alignment and reduces pain and discomfort after spinal surgery. The other interventions will not maintain proper spine alignment and may cause spinal damage.
Four patients have been newly diagnosed with connective tissue disorders. The nurse is concerned with safety issues and interstitial lung involvement for the patient with which diagnosis? Polymyositis Reactive arthritis Sjögren's syndrome Systemic lupus erythematosus (SLE)
Polymyositis Polymyositis is an inflammatory disease affecting striated muscle and resulting in muscle weakness that increases the patient's risk of falls and injury. Weakened pharyngeal muscles also increase the risk for aspiration, with interstitial lung disease in up to 65% of patients. Safety concerns and interstitial lung involvement are not associated with reactive arthritis (Reiter's syndrome) or Sjögren's syndrome. Safety may be an issue later in disease progression of SLE.
A nurse assesses a patient with joint pain and stiffness who was diagnosed with stage III rheumatoid arthritis (RA). Which additional characteristics should the nurse expect? (Select all that apply.) Presence of nodules Consistent muscle strength Localized disease symptoms No destructive changes on x-ray Subluxation of joints without fibrous ankyloses Joint space narrowing and formation of osteophytes
Presence of nodules Subluxation of joints without fibrous ankyloses In stage III severe RA, extraarticular soft tissue lesions or nodules may be present along with subluxation without fibrous or bony ankylosis. Muscle strength is decreased because of extensive muscle atrophy. Manifestations are systemic rather than localized. There is x-ray evidence of cartilage and bone destruction in addition to osteoporosis. Joint space narrowing with osteophytes is consistent with osteoarthritis.
The nurse is caring for a patient who had a left total knee arthroplasty to relieve the pain of severe osteoarthritis. What care would be expected postoperatively? Progressive leg exercises to obtain 90-degree flexion Early ambulation with full weight bearing on the left leg Bed rest for 3 days with the left leg immobilized in extension Immobilization of the left knee in 30-degree flexion to prevent dislocation
Progressive leg exercises to obtain 90-degree flexion The patient is encouraged to engage in progressive leg exercises until 90-degree flexion is possible; continuous passive motion also may be used based on surgeon preference. Early ambulation is implemented, sometimes the day of surgery, but orders are likely to indicate weight bearing as tolerated rather than full weight bearing. Immobilization and bed rest are not indicated. The patient's knee is unlikely to dislocate.
A nurse is assessing the recent health history of a 63-yr-old patient with osteoarthritis. Which activity pattern should the nurse recommend? Bed rest with bathroom privileges Daily high-impact aerobic exercise Regular exercise program of walking Frequent rest periods with minimal exercise
Regular exercise program of walking A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in patients with osteoarthritis. A balance of rest and activity is needed. High-impact aerobic exercises would cause stress to affected joints and further damage.
When the patient is diagnosed with muscular dystrophy, what information should the nurse include in the teaching plan? Use prolonged bed rest to decrease fatigue. Continuous positive airway pressure will facilitate sleeping. An orthotic jacket will limit mobility and may contribute to deformity. Remain active to prevent skin breakdown and respiratory complications.
Remain active to prevent skin breakdown and respiratory complications. With muscular dystrophy, the patient must remain active for as long as possible. Prolonged bed rest should be avoided because immobility leads to further muscle wasting. An orthotic jacket may be used to provide stability and prevent further deformity. Continuous positive airway pressure (CPAP) may be used as respiratory function decreases before mechanical ventilation is needed to sustain respiratory function.
The nurse determines dietary teaching for a 75-yr-old patient with osteoporosis has been successful when the patient selects which meal as highest in calcium? Chicken stir fry with 1 cup each onions and green peas, and 1 cup of steamed rice Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple Sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk A 2-egg omelet with 2 oz of American cheese, 1 slice of whole wheat toast, and a half grapefruit
Sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk The highest calcium content is present in the lunch containing milk and milk products (yogurt) and small fish with bones (sardines). Chicken, onions, green peas, rice, ham, whole wheat bread, broccoli, apple, eggs, and grapefruit each have less than 75 mg of calcium per 100 g of food. Swiss cheese and American cheese have more calcium but not as much as the sardines, yogurt, and milk.
Which nursing intervention is appropriate for a patient with Sjögren's syndrome? Ambulate with assistive devices. Use lubricating eyedrops frequently. Administer acetaminophen as needed. Apply ice or heat compresses to affected areas.
Use lubricating eyedrops frequently. Sjögren's syndrome is an autoimmune disorder in which lymphocytes attack moisture-producing glands. Treatment is symptomatic, including adding moisture to eyes and increasing intake of fluids, especially with meals.
The nurse is planning health promotion teaching for a 45-yr-old patient with asthma who has low back pain from herniated lumbar disc. What activity would the nurse include in an individualized exercise plan for the patient? Yoga Walking Calisthenics Weightlifting
Walking The patient would benefit from an aerobic exercise that considers the patient's health status and fits the patient's lifestyle. The best exercise is walking, which builds strength in the back and leg muscles without putting undue pressure or strain on the spine. If the patient has exercise-induced asthma, the nurse would recommend use of a rescue inhaler prior to exercise. Yoga, calisthenics, and weightlifting would all put pressure on or strain the spine.
