Exam 3 Musculoskeletal and Integumentary

A nurse is assessing a client who is bedridden and was admitted from home. The nurse notes a shallow crater in the epidermis of the client sacral area. The nurse should document that the client has a pressure ulcer at which of the following stages? A. IV (full thickness loss, tissue necrosis, damage to muscle, bone and tunneling), blanchable B. I (skin is intact, non- blanchable redness, warm or cool) C. III ((full thickness tissue loss with necrosis and subcut tissue, deep crater) D. II (abrasion, blister, shallow crater)

D

A nurse is assessing a client who is in skeletal muscle traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? A. serosanguineous drainage B. Mild erythema C. warmth D. Fever

D

A nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mm Hg. Which of the following actions should the nurse take first? A. administer hydralazine via IV bolus B. Loosen the clients clothing C. Empty the clients bladder D. elevate the head of the client's bed

D

A nurse in an emergency room is assessing a client who reports sudden, severe eye pain with blurry vision. The provider determines that the client has primary angle-closure glaucoma. Which of the followung medications should the nurse expect to adminster? A. Osmotic diuretics via IV bolus B. Mydriatic opthalmic drops C. Corticosteriod opthalmic drops D. epinephrine

A

A nurse is developing a teaching plan for a client who has Meniere's disease. Which of the following instructions should the nurse include? A. move your head slowly to decrease veritgo B. apply warm pack to the affected ear during attacks C. increase you intake of foods and fluid high in salt D. take corticosteriods during acute attacks

A

Caring for a client who is 24 hr post op following an open reduction and internal fixation to repair a fracture of the femur. Which of the following assessment findings is an early manifestation of acute compartment? A. Dyspnea B. Red-brown petechiae C. Headache D. Agitation

A

A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect? A unilateral joint involvement B. ulnar deviation C. fractures of the spine

B

A nurse is caring for a client immediately following application of a plaster cast. The nurse should monitor for and report which of the following findings as an indication of compartment syndrome? A. Sensation of heat on the surface of the cast B. Paresthesias of the extremity , numbness tingling, weakness, and pain that doesn't go away even after medication C. Pruritus of the extremity D. Musty odor noted from cast

B

A nurse is caring for a client who is in balanced suspension skeletal traction and reports intermittent muscle spasms. Which of the following actions should the nurse take first? A. reposition the client B. check the position of the weights and ropes C. administer a muscle relaxant D. provide distraction

B

A nurse is caring for a client who is in skeletal traction following a femur fracture. The nurse finds the client has slid down toward the foot of the bed and the traction weight os resting on the floor. Which of the following actions should the nurse take? A. Remove the weight temp to reposition the client to the correct alignment B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely C. Lift the rope off the pulley while the client rocks back and forth to reposition

B

A nurse is receiving a client who is immediately postoperative following hip arthroplasty. Which of the following medications should the nurse plan to administer for DVT prophylaxis? A. Aspirin PO B. Enoxaparin subcut C. Heparin iv D. Warfarin PO

B

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make? A. Turn the screws on the device once each day B. The purpose of this device is to immobilize the cervical spine C. Apply talcum powder under the vest to limit friction D. The purpose f this device is to allow for neck movement during the healing process

B

Who is at risk for primary osteoporosis? Which is a risk factor for the development of osteoporosis? A. Obesity B. Sedentary lifestyle C. Long term use of diuretics D. Prolonged stress

B

a nurse is teaching a client who has osteoporosis and has a new prescription for alondronate. Which of the following information should the nurse include in the teaching? A. Take this medication with 8 ounces of milk B. remain upright for 30 mins after take medication C. wait 1 hr after taking other medications to take D. Tale vitamin c to promote absorption of this medication

B

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take? A. assess the clients neurological status every 8 hr B. initiate droplet precautions C. Check the cap refill at least every 4 hr D. place the client in a well-lit environment

C

A nurse is caring for a client who is 72 hr post op following an above the knee amputation and reports phantom lim pain. Which of the following actions should the nurse take? A. remind the client that the surgery removed the limb B. change the dressing on the client residual arm C. request a prescription for gabapentin for the client D. elevate the client's residual limb above heart level

C

A nurse is performing medication reconciliation for a newly admitted client who has rheumatoid arthritis (RA). which of the following medications should the nurse identify as the treatment for this condition? A. Misoprostol B. Dantrolene C. Celecoxib D. Colchicine

C

A nurse is providing preoperative teaching for a client who is scheduled for a total knee arthroplasty. Which of the following statements by the client should the nurse identify as understanding of the teaching? A. I will wear a continuous movement machine on my knee for 24 hrs a day B. I should avoid taking NSAID medications for pain after surgery C. I should wear elastic stocking on both of my legs D. I will begin exercising my legs the day after my surgery

C

A nurse is caring for a client who is wheel chair bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include? A. Move between the bed and the wheelchair once every 2 hrs B. Make sure that your caregiver massages your skin daily C. Use a rubber ring when sitting at the bedside D. Shift your weight in the wheelchair every 15 mins

D

A nurse is discussing the plan of care with a client who has osteomyelitis of an open wound on his heel. Which of the following information should nurse include? A. You will need to apply a cold pack to the site at least 3 times a day B. Your provider might ask you to walk frequently to increase circulation to the area C. You will need to limit consumption of high protein D. Your provider might prescribe a central line for long term antibiotic therapy

D

A nurse is teaching a client who has a new prescription for alendronate for treatment of osteoporosis. Which of the following statements by the client indicates understanding of the teaching? A. I will take this medication in the evening B. I will drink this medication with a full glass of milk C. I will take this medication at mealtime D. I will sit upright after taking the medication

D