Chapter 40 - Med Surg
A nurse is caring for an older adult who has been diagnosed with geriatric failure to thrive. This patient's prolonged immobility creates a risk for what complication? A) Muscle clonus B) Muscle atrophy C) Rheumatoid arthritis D) Muscle fasciculations
Ans: B Feedback: If a muscle is in disuse for an extended period of time, it is at risk of developing atrophy, which is the decrease in size. Clonus is a pattern of rhythmic muscle contractions and fasciculation is the involuntary twitch of muscle fibers; neither results from immobility. Lack of exercise is a risk factor for rheumatoid arthritis.
A patient injured in a motor vehicle accident has sustained a fracture to the diaphysis of the right femur. Of what is the diaphysis of the femur mainly constructed? A) Epiphyses B) Cartilage C) Cortical bone D) Cancellous bone
Ans: C Feedback: The long bone shaft, which is referred to as the diaphysis, is constructed primarily of cortical bone.
A nurse is taking a health history on a new patient who has been experiencing unexplained paresthesia. What question should guide the nurse's assessment of the patient's altered sensations? A) How does the strength in the affected extremity compare to the strength in the unaffected extremity? B) Does the color in the affected extremity match the color in the unaffected extremity? C) How does the feeling in the affected extremity compare with the feeling in the unaffected extremity? D) Does the patient have a family history of paresthesia or other forms of altered sensation?
Ans: C Feedback: Questions that the nurse should ask regarding altered sensations include "How does this feeling compare to sensation in the unaffected extremity?" Asking questions about strength and color are not relevant and a family history is unlikely.
A patient is receiving ongoing nursing care for the treatment of Parkinson's disease. When assessing this patient's gait what finding is most closely associated with this health problem? A) Spastic hemiparesis gait B) Shuffling gait C) Rapid gait D) Steppage gait
Ans: B Feedback: A variety of neurologic conditions are associated with abnormal gaits, such as a spastic hemiparesis gait (stroke), steppage gait (lower motor neuron disease), and shuffling gait (Parkinson's disease). A rapid gait is not associated with Parkinson's disease.
A clinic nurse is caring for a patient with a history of osteoporosis. Which of the following diagnostic tests best allows the care team to assess the patient's risk of fracture? A) Arthrography B) Bone scan C) Bone densitometry D) Arthroscopy
Ans: C Feedback: Bone densitometry is used to detect bone density and can be used to assess the risk of fracture in osteoporosis. Arthrography is used to detect acute or chronic tears of joint capsule or supporting ligaments. Bone scans can be used to detect metastatic and primary bone tumors, osteomyelitis, certain fractures, and aseptic necrosis. Arthroscopy is used to visualize a joint.
A nurse is performing a musculoskeletal assessment of a patient with arthritis. During passive range-of-motion exercises the nurse hears an audible grating sound. The nurse should document the presence of which of the following? A) Fasciculations B) Clonus C) Effusion D) Crepitus
Ans: D Feedback: Crepitus is a grating, crackling sound or sensation that occurs as the irregular joint surfaces move across one another, as in arthritic conditions. Fasciculations are involuntary twitching of muscle fiber groups. Clonus is the rhythmic contractions of a muscle. Effusion is the collection of excessive fluid within the capsule of a joint.
The nurse's musculoskeletal assessment of a patient reveals involuntary twitching of muscle groups. How would the nurse document this observation in the patient's chart? A) Tetany B) Atony C) Clonus D) Fasciculations
Ans: D Feedback: Fasciculation is involuntary twitching of muscle fiber groups. Clonus is a series of involuntary, rhythmic, muscular contractions and tetany is involuntary muscle contraction, but neither is characterized as "twitching." Atony is a loss of muscle strength.
An older adult patient has symptoms of osteoporosis and is being assessed during her annual physical examination. The assessment shows that the patient will require further testing related to a possible exacerbation of her osteoporosis. The nurse should anticipate what diagnostic test? A) Bone densitometry B) Hip bone radiography C) Computed tomography (CT) D) Magnetic resonance imaging (MRI)
Ans: A Feedback: Bone densitometry is considered the most accurate test for osteoporosis and for predicting a fracture. As such, it is more likely to be used than CT, MRI, or x-rays.
A patient is undergoing diagnostic testing for suspected Paget's disease. What assessment finding is most consistent with this diagnosis? A) Altered serum magnesium levels B) Altered serum calcium levels C) Altered serum potassium levels D) Altered serum sodium levels
Ans: B Feedback: Serum calcium levels are altered in patients with osteomalacia, parathyroid dysfunction, Paget's disease, metastatic bone tumors, or prolonged immobilization. Paget's disease is not directly associated with altered magnesium, potassium, or sodium levels.
A nurse is caring for a patient who has just had an arthroscopy as an outpatient and is getting ready to go home. The nurse should teach the patient to monitor closely for what postprocedure complication? A) Fever B) Crepitus C) Fasciculations D) Synovial fluid leakage
Ans: A Feedback: Following arthroscopy, the patient and family are informed of complications to watch for, including fever. Synovial fluid leakage is unlikely and crepitus would not develop as a postprocedure complication. Fasciculations are muscle twitches and do not involve joint integrity or function.
A nurse is caring for a patient whose cancer metastasis has resulted in bone pain. Which of the following are typical characteristics of bone pain? A) A dull deep ache that is "boring" in nature B) Soreness or aching that may include cramping C) Sharp, piercing pain that is relieved by immobilization D) Spastic or sharp pain that radiates
Ans: A Feedback: Bone pain is characteristically described as a dull, deep ache that is "boring" in nature, whereas muscular pain is described as soreness or aching and is referred to as "muscle cramps." Fracture pain is sharp and piercing and is relieved by immobilization. Sharp pain may also result from bone infection with muscle spasm or pressure on a sensory nerve.
A patient's fracture is healing and callus is being deposited in the bone matrix. This process characterizes what phase of the bone healing process? A) The reparative phase B) The reactive phase C) The remodeling phase D) The revascularization phase
Ans: A Feedback: Callus formation takes place during the reparative phase of bone healing. The reactive phase occurs immediately after injury and the remodeling phase builds on the reparative phase. There is no discrete revascularization phase.
A patient has been experiencing an unexplained decline in knee function and has consequently been scheduled for arthrography. The nurse should teach the patient about what process? A) Injection of a contrast agent into the knee joint prior to ROM exercises B) Aspiration of synovial fluid for serologic testing C) Injection of corticosteroids into the patient's knee joint to facilitate ROM D) Replacement of the patient's synovial fluid with a synthetic substitute
Ans: A Feedback: During arthrography, a radiopaque contrast agent or air is injected into the joint cavity to visualize the joint structures such as the ligaments, cartilage, tendons, and joint capsule. The joint is put through its range of motion to distribute the contrast agent while a series of x-rays are obtained. Synovial fluid is not aspirated or replaced and corticosteroids are not administered.
A nurse is providing care for a patient whose pattern of laboratory testing reveals longstanding hypocalcemia. What other laboratory result is most consistent with this finding? A) An elevated parathyroid hormone level B) An increased calcitonin level C) An elevated potassium level D) A decreased vitamin D level
Ans: A Feedback: In the response to low calcium levels in the blood, increased levels of parathyroid hormone prompt the mobilization of calcium and the demineralization of bone. Increased calcitonin levels would exacerbate hypocalcemia. Vitamin D levels do not increase in response to low calcium levels. Potassium levels would likely be unaffected.
A patient has just had an arthroscopy performed to assess a knee injury. What nursing intervention should the nurse implement following this procedure? A) Wrap the joint in a compression dressing. B) Perform passive range of motion exercises. C) Maintain the knee in flexion for up to 30 minutes. D) Apply heat to the knee.
Ans: A Feedback: Interventions to perform following an arthroscopy include wrapping the joint in a compression dressing, extending and elevating the joint, and applying ice or cold packs. Passive ROM exercises, static flexion, and heat are not indicated.
Diagnostic tests show that a patient's bone density has decreased over the past several years. The patient asks the nurse what factors contribute to bone density decreasing. What would be the nurse's best response? A) "For many people lack of nutrition can cause a loss of bone density." B) "Progressive loss of bone density is mostly related to your genes." C) "Stress is known to have many unhealthy effects, including reduced bone density." D) "Bone density decreases with age, but scientists are not exactly sure why this is the case."
Ans: A Feedback: Nutrition has a profound effect on bone density, especially later life. Genetics are also an important factor, but nutrition has a more pronounced effect. The pathophysiology of bone density is well understood and psychosocial stress has a minimal effect.
A child is growing at a rate appropriate for his age. What cells are responsible for the secretion of bone matrix that eventually results in bone growth? A) Osteoblasts B) Osteocytes C) Osteoclasts D) Lamellae
Ans: A Feedback: Osteoblasts function in bone formation by secreting bone matrix. Osteocytes are mature bone cells and osteoclasts are multinuclear cells involved in dissolving and resorbing bone. Lamellae are circles of mineralized bone matrix.
A nurse on the orthopedic unit is assessing a patient's peroneal nerve. The nurse will perform this assessment by doing which of the following actions? A) Pricking the skin between the great and second toe B) Stroking the skin on the sole of the patient's foot C) Pinching the skin between the thumb and index finger D) Stroking the distal fat pad of the small finger
Ans: A Feedback: The nurse will evaluate the sensation of the peroneal nerve by pricking the skin centered between the great and second toe. None of the other listed actions elicits the function of one of the peripheral nerves.
A nurse is taking a health history on a patient with musculoskeletal dysfunction. What is the primary focus of this phase of the nurse's assessment? A) Evaluating the effects of the musculoskeletal disorder on the patient's function B) Evaluating the patient's adherence to the existing treatment regimen C) Evaluating the presence of genetic risk factors for further musculoskeletal disorders D) Evaluating the patient's active and passive range of motion
Ans: A Feedback: The nursing assessment of the patient with musculoskeletal dysfunction includes an evaluation of the effects of the musculoskeletal disorder on the patient. This is a vital focus of the health history and supersedes the assessment of genetic risk factors and adherence to treatment, though these are both valid inclusions to the interview. Assessment of ROM occurs during the physical assessment, not the interview.
The nurse is performing an assessment of a patient's musculoskeletal system and is appraising the patient's bone integrity. What action should the nurse perform during this phase of assessment? A) Compare parts of the body symmetrically. B) Assess extremities when in motion rather than at rest. C) Percuss as many joints as are accessible. D) Administer analgesia 30 to 60 minutes before assessment.
Ans: A Feedback: When assessing bone integrity, symmetric parts of the body, such as extremities, are compared. Analgesia should not be necessary and percussion is not a clinically useful assessment technique. Bone integrity is best assessed when the patient is not moving.
A nurse is explaining a patient's decreasing bone density in terms of the balance between bone resorption and formation. What dietary nutrients and hormones play a role in the resorption and formation of adult bones? Select all that apply. A) Thyroid hormone B) Growth hormone C) Estrogen D) Vitamin B12 E) Luteinizing hormone
Ans: A, B, C Feedback: The balance between bone resorption and formation is influenced by the following factors: physical activity; dietary intake of certain nutrients, especially calcium; and several hormones, including calcitriol (i.e., activated vitamin D), parathyroid hormone (PTH), calcitonin, thyroid hormone, cortisol, growth hormone, and the sex hormones estrogen and testosterone. Luteinizing hormone and vitamin B12 do not play a role in bone formation or resorption.
The nurse is assessing a patient for dietary factors that may influence her risk for osteoporosis. The nurse should question the patient about her intake of what nutrients? Select all that apply. A) Calcium B) Simple carbohydrates C) Vitamin D D) Protein E) Soluble fiber
Ans: A, C Feedback: A patient's risk for osteoporosis is strongly influenced by vitamin D and calcium intake. Carbohydrate, protein, and fiber intake do not have direct effect on the development of osteoporosis.
A patient is scheduled for a bone scan to rule out osteosarcoma of the pelvic bones. What would be most important for the nurse to assess before the patient's scan? A) That the patient completed the bowel cleansing regimen B) That the patient emptied the bladder C) That the patient is not allergic to penicillins D) That the patient has fasted for at least 8 hours
Ans: B Feedback: Before the scan, the nurse asks the patient to empty the bladder, because a full bladder interferes with accurate scanning of the pelvic bones. Bowel cleansing and fasting are not indicated for a bone scan and an allergy to penicillins is not a contraindication.
A bone biopsy has just been completed on a patient with suspected bone metastases. What assessment should the nurse prioritize in the immediate recovery period? A) Assessment for dehiscence at the biopsy site B) Assessment for pain C) Assessment for hematoma formation D) Assessment for infection
Ans: B Feedback: Bone biopsy can be painful and the nurse should prioritize relevant assessments. Dehiscence is not a possibility, since the incision is not linear. Signs and symptoms of infection would not be evident in the immediate recovery period and hematoma formation is not a common complication.
A nurse is assessing a patient who is experiencing peripheral neurovascular dysfunction. What assessment findings are most consistent with this diagnosis? A) Hot skin with a capillary refill of 1 to 2 seconds B) Absence of feeling capillary refill of 4 to 5 seconds, and cool skin C) Pain, diaphoresis, and erythema D) Jaundiced skin, weakness, and capillary refill of 3 seconds
Ans: B Feedback: Indicators of peripheral neurovascular dysfunction include pale, cyanotic, or mottled skin with a cool temperature; capillary refill greater than 3 seconds; weakness or paralysis with motion; and paresthesia, unrelenting pain, pain on passive stretch, or absence of feeling. Jaundice, diaphoresis, and warmth are inconsistent with peripheral neurovascular dysfunction.
A public health nurse is organizing a campaign that will address the leading cause of musculoskeletal-related disability in the United States. The nurse should focus on what health problem? A) Osteoporosis B) Arthritis C) Hip fractures D) Lower back pain
Ans: B Feedback: The leading cause of musculoskeletal-related disability in the United States is arthritis.
A nurse is performing a nursing assessment of a patient suspected of having a musculoskeletal disorder. What is the primary focus of the nursing assessment with a patient who has a musculoskeletal disorder? A) Range of motion B) Activities of daily living C) Gait D) Strength
Ans: B Feedback: The nursing assessment is primarily a functional evaluation, focusing on the patient's ability to perform activities of daily living. The nurse also assesses strength, gait, and ROM, but these are assessed to identify their effect on functional status rather than to identify a medical diagnosis.
When assessing a patient's peripheral nerve function the nurse uses an instrument to prick the fat pad at the top of the patient's small finger. This action will assess which of the following nerves? A) Radial B) Ulnar C) Median D) Tibial
Ans: B Feedback: The ulnar nerve is assessed for sensation by pricking the fat pad at the top of the small finger. The radial, median, and tibial nerves are not assessed in this manner.
A nurse is caring for a patient with a diagnosis of cancer that has metastasized. What laboratory value would the nurse expect to be elevated in this patient? A) Bilirubin B) Potassium C) Alkaline phosphatase D) Creatinine
Ans: C Feedback: Alkaline phosphatase is elevated during early fracture healing and in diseases with increased osteoblastic activity (e.g., metastatic bone tumors). Elevated bilirubin, potassium, and creatinine would not be expected in a patient with metastatic bone tumors.
A patient has been experiencing progressive increases in knee pain and diagnostic imaging reveals a worsening effusion in the synovial capsule. The nurse should anticipate which of the following? A) Arthrography B) Knee biopsy C) Arthrocentesis D) Electromyography
Ans: C Feedback: Arthrocentesis (joint aspiration) is carried out to obtain synovial fluid for purposes of examination or to relieve pain due to effusion. Arthrography, biopsy, and electromyography would not remove fluid and relieve pressure.
The human body is designed to protect its vital parts. A fracture of what type of bone may interfere with the protection of vital organs? A) Long bones B) Short bones C) Flat bones D) Irregular bones
Ans: C Feedback: Flat bones, such as the sternum, provide vital organ protection. Fractures of the flat bones may lead to puncturing of the vital organs or may interfere with the protection of the vital organs. Long, short, and irregular bones do not usually have this physiologic function.
The nurse's comprehensive assessment of an older adult involves the assessment of the patient's gait. How should the nurse best perform this assessment? A) Instruct the patient to walk heel-to-toe for 15 to 20 steps. B) Instruct the patient to walk in a straight line while not looking at the floor. C) Instruct the patient to walk away from the nurse for a short distance and then toward the nurse. D) Instruct the patient to balance on one foot for as long as possible and then walk in a circle around the room.
Ans: C Feedback: Gait is assessed by having the patient walk away from the examiner for a short distance. The examiner observes the patient's gait for smoothness and rhythm. Looking at the floor is not disallowed and gait is not assessed by observing balance on one leg. Heel-to-toe walking ability is not gauged during an assessment of normal gait.
A nurse is caring for a patient who has been scheduled for a bone scan. What should the nurse teach the patient about this diagnostic test? A) "The test is brief and requires that you drink a calcium solution 2 hours before the test." B) "You will not be allowed fluid for 2 hours before and 3 hours after the test." C) "You'll be encouraged to drink water after the administration of the radioisotope injection." D) "This is a common test that can be safely performed on anyone."
Ans: C Feedback: It is important to encourage the patient to drink plenty of fluids to help distribute and eliminate the isotopic after it is injected. There are important contraindications to the procedure, include pregnancy or an allergy to the radioisotope. The test requires the injection of an intravenous radioisotope and the scan is preformed 2 to 3 hours after the isotope is injected. A calcium solution is not utilized.
A nurse's assessment of a teenage girl reveals that her shoulders are not level and that she has one prominent scapula that is accentuated by bending forward. The nurse should expect to read about what health problem in the patient's electronic health record? A) Lordosis B) Kyphosis C) Scoliosis D) Muscular dystrophy
Ans: C Feedback: Scoliosis is evidenced by an abnormal lateral curve in the spine, shoulders that are not level, an asymmetric waistline, and a prominent scapula, accentuated by bending forward. Lordosis is the curvature in the lower back; kyphosis is an exaggerated curvature of the upper back. This finding is not suggestive of muscular dystrophy.
The results of a nurse's musculoskeletal examination show an increase in the lumbar curvature of the spine. The nurse should recognize the presence of what health problem? A) Osteoporosis B) Kyphosis C) Lordosis D) Scoliosis
Ans: C Feedback: The nurse documents the spinal abnormality as lordosis. Lordosis is an increase in lumbar curvature of the spine. Kyphosis is an increase in the convex curvature of the spine. Scoliosis is a lateral curvature of the spine. Osteoporosis is the significant loss of bone mass and strength with an increased risk for fracture.
A nurse is assessing a child who has a diagnosis of muscular dystrophy. Assessment reveals that the child's muscles have greater-than-normal tone. The nurse should document the presence of which of the following? A) Tonus B) Flaccidity C) Atony D) Spasticity
Ans: D Feedback: A muscle with greater-than-normal tone is described as spastic. Soft and flabby muscle tone is defined as atony. A muscle that is limp and without tone is described as being flaccid. The state of readiness known as muscle tone (tonus) is produced by the maintenance of some of the muscle fibers in a contracted state.
A nurse is caring for a patient who has an MRI scheduled. What is the priority safety action prior to this diagnostic procedure? A) Assessing the patient for signs and symptoms of active infection B) Ensuring that the patient can remain immobile for up to 3 hours C) Assessing the patient for a history of nut allergies D) Ensuring that there are no metal objects on or in the patient
Ans: D Feedback: Absolutely no metal objects can be present during MRI—their presence constitutes a serious safety risk. The procedure takes up to 90 minutes. Nut allergies and infection are not contraindications to MRI.
While assessing a patient, the patient tells the nurse that she is experiencing rhythmic muscle contractions when the nurse performs passive extension of her wrist. What is this pattern of muscle contraction referred to as? A) Fasciculations B) Contractures C) Effusion D) Clonus
Ans: D Feedback: Clonus may occur when the ankle is dorsiflexed or the wrist is extended. It is characterized as rhythmic contractions of the muscle. Fasciculation is involuntary twitching of muscle fiber groups. Contractures are prolonged tightening of muscle groups and an effusion is the pathologic escape of body fluid.
An older adult patient has come to the clinic for a regular check-up. The nurse's initial inspection reveals an increased thoracic curvature of the patient's spine. The nurse should document the presence of which of the following? A) Scoliosis B) Epiphyses C) Lordosis D) Kyphosis
Ans: D Feedback: Kyphosis is the increase in thoracic curvature of the spine. Scoliosis is a deviation in the lateral curvature of the spine. Epiphyses are the ends of the long bones. Lordosis is the exaggerated curvature of the lumbar spine.
A patient has had a cast placed for the treatment of a humeral fracture. The nurse's most recent assessment shows signs and symptoms of compartment syndrome. What is the nurse's most appropriate action? A) Arrange for a STAT assessment of the patient's serum calcium levels. B) Perform active range of motion exercises. C) Assess the patient's joint function symmetrically. D) Contact the primary care provider immediately.
Ans: D Feedback: This major neurovascular problem is caused by pressure within a muscle compartment that increases to such an extent that microcirculation diminishes, leading to nerve and muscle anoxia and necrosis. Function can be permanently lost if the anoxic situation continues for longer than 6 hours. Therefore, immediate medical care is a priority over further nursing assessment. Assessment of calcium levels is unnecessary.
