EXAM 3 Prep Us

Which is a hallmark sign of compartment syndrome? A.) Motor weakness B.) Edema C.) Pain D.) Weeping skin surfaces

Answer: C.) Pain

A client had a total left hip arthroplasty. What clinical manifestation would indicate to the nurse that the prosthesis is dislocated? A.) The left leg is internally rotated. B.) The leg length is the same as the right leg. C.) The client has discomfort when moving in bed. D.) There are diminished peripheral pulses on the affected extremity.

ANswer: A.) The left leg is internally rotated. Rationale: The nurse must monitor the client for signs and symptoms of dislocation of the prosthesis, which include abnormal external or internal rotation of the affected extremity. The length of the leg with a dislocated prosthesis may be shorter. The client's discomfort will not indicate a dislocation. Diminished peripheral pulse of the affected extremity would be a indication of circulation issues

Which of the following is to be expected soon after a major burn? Select all that apply. - Hypotension - Tachycardia - Anxiety - Hypertension - Bradycardia

Answer: - Hypotension - Tachycardia - Anxiety

A client is being discharged home with a long arm cast. What education should the nurse include to prevent disuse syndrome in the arm? A.) Use of isometric exercises B.) Proper use of a sling C.) Repositioning the arm in the cast D.) Abduction and adduction of the shoulder

Answer: A.) Use of isometric exercises

A patient diagnosed with Addison's disease would be expected to have which of the following skin pigmentations? A.) Orange-green B.) Bronze C.) Yellow D.) Gray

Answer: B.) Bronze

Which type of cast encloses the trunk and a lower extremity? A.) Body cast B.) Hip spica C.) Long-leg D.) Short-leg

Answer: B.) Hip spica

Which factor causes wrinkles among older adults? A.) Decrease in melanin B.) Loss of subcutaneous tissue C.) Decrease in estrogen production D.) Decrease in sebum

Answer: B.) Loss of subcutaneous tissue

A nurse is caring for a client in skeletal leg traction. Which nursing assessment findings indicate the client has met expected outcomes? Select all that apply. - Capillary refill less than 3 seconds - Repositions self with trapeze - Peripheral pulses +2 bilaterally - Right calf warm and swollen - Elbows are free of skin breakdown

Answer: - Capillary refill less than 3 seconds - Repositions self with trapeze - Peripheral pulses +2 bilaterally - Elbows are free of skin breakdown

A nurse is caring for a construction worker who fell from the second story of a building site and fractured the femoral neck. Which nursing diagnosis is a priority for the client? Select all that apply. - Risk for infection - Impaired physical mobility - Risk for injury - Urinary incontinence - Disturbed body image

Answer: - Risk for infection - Impaired physical mobility - Risk for injury

Which of the following topical burn preparations act as wick for sodium and potassium? A.) Silver nitrate solution B.) Silver sulfadiazine (Silvadene) C.) Mafenide acetate (Sulfamylon) D.) Acticoat

Answer: A.) Silver nitrate solution

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? A.) Anemia B.) Gastric ulcers C.) Hyperthyroidism D.) Cardiac arrest

Answer: B.) Gastric ulcers Rationale: The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric (Curling's) ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest.

A variety of complications can occur after a leg amputation. Which is not a possibility in the immediate postoperative period? A.) infection B.) osteomyelitis C.) hematoma D.) hemorrhage

Answer: B.) osteomyelitis

A client has an elevated temperature. The nurse is applying a cool compress to his forehead. This is an example of which of the following types of heat loss? A.) Radiation B.) Evaporation C.) Conduction D.) Convection

Answer: C.) Conduction Rationale: Conduction is the transfer of heat through direct contact. Radiation is the transfer of surface heat in the environment. Evaporation is the loss of moisture or water. Convection is the transfer of hear by means of currents of liquids or gases in which warm air molecules move away from the body.

Colles fracture occurs in which area? A.) Elbow B.) Humeral shaft C.) Clavicle D.) Distal radius

Answer: D.) Distal radius

Which diagnostic test is used to examine cells from herpes zoster? A.) Skin scrapings B.) Patch testing C.) Skin biopsy D.) Tzanck smear

Answer: D.) Tzanck smear

When discussing physical activities with the client who has just undergone a right total hip replacement, which instruction should the nurse provide? A.) "Limit hip flexion to 90 degrees." B.) "Perform rotation exercises each day." C.) "Intermittently cross and uncross your legs several times each day." D.) "Avoid weight bearing until the hip is completely healed."

Answer: A.) "Limit hip flexion to 90 degrees."

A client has Paget's disease. An appropriate nursing diagnosis for this client is: A.) Risk for infection B.) Delayed wound healing C.) Risk for falls D.) Fatigue

Answer: C.) Risk for falls

The nurse is performing a musculoskeletal assessment of a client in a nursing home who had a stroke 2 years ago and who has right-sided hemiplegia. The nurse notes that the girth of the client's right calf is 2 inches less in diameter than the left calf. The nurse attributes the decreased girth to A.) edema in left lower extremity. B.) increased use of left calf muscle. C.) atrophy of right calf muscle. D.) bruising in right lower extremity.

Answer: C.) atrophy of right calf muscle.

The nurse is performing an assessment on an older adult patient and observes the patient has an increased forward curvature of the thoracic spine. What does the nurse understand this common finding is known as? A.) Lordosis B.) Scoliosis C.) Osteoporosis D.) Kyphosis

Answer: D.) Kyphosis

A client with osteoporosis is prescribed a selective estrogen receptor modifier (SERM) as treatment. The nurse would identify which drug as belonging to this class? A.) Alendronate (Fosamax) B.) Calcium gluconate C.) Tamoxifen (Nolvadex) D.) Raloxifene (Evista)

Answer: D.) Raloxifene (Evista) Rationale: An example of a selective estrogen receptor modifier (SERM) is raloxifene (Evista). Alendronate is a bisphosphonate; calcium gluconate is an oral calcium preparation; tamoxifen is an antiestrogen agent.

Which is the primary reason for placing a client in a horizontal position while smothering flames are present? A.) To prevent collapse and further injuries B.) To keep fire and smoke from airway C.) To extinguish flames more quickly D.) To promote blood flow to the brain and vital organs

ANswer: B.) To keep fire and smoke from airway Rationale: The primary reason the client is placed in a horizontal position while smothering flames is to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passages. The stop, drop, and roll method is a quick and efficient means to extinguish flames. If hypovolemic shock occurs, lowering the head will assist in promoting blood flow to the head.

The nurse cares for a 30-year-old client who suffered severe head and facial burn injuries. Which action, if completed by the client, indicates the client is adapting to altered body image? Select all that apply. - Wears hats and wigs - Covers face with a scarf - Participates actively in daily activities - Reports absence of sleep disturbance

Answer: - Wears hats and wigs - Participates actively in daily activities

The nurse is caring for a client with a hip fracture. The physician orders the client to start taking a bisphosphonate. Which medication would the nurse document as given? A.) Alendronate B.) Raloxifene C.) Teriparatide D.) Denosumab

Answer: A.) Alendronate

Which medication directly inhibits osteoclasts, thereby reducing bone loss and increasing BMD? A.) Calcitonin (Miacalcin) B.) Raloxifene (Evista) C.) Teriparatide (Forteo) D.) Vitamin D

Answer: A.) Calcitonin (Miacalcin)

Following a burn injury, the nurse determines which area is the priority for nursing assessment? A.) Pulmonary system B.) Cardiovascular system C.) Pain D.) Nutrition

Answer: A.) Pulmonary system

A client with Paget's disease comes to the hospital and reports difficulty urinating. The emergency department health care provider consults urology. What should the nurse suspect is the most likely cause of the client's urination problem? A.) Renal calculi B.) Urinary tract infection (UTI) C.) Benign prostatic hyperplasia D.) Dehydration

Answer: A.) Renal calculi Rationale: Renal calculi commonly occur with Paget's disease, causing pain and difficulty when urinating. A UTI commonly causes fever, urgency, burning, and hesitation with urination. Benign prostatic hyperplasia is common in men older than age 50; however, because the client has Paget's disease, the nurse should suspect renal calculi, not benign prostatic hyperplasia. Dehydration causes a decrease in urine production, not a problem with urination.

Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? A.) Roll the client in a blanket B.) Cover the client with a wet cloth C.) Place the client with the head positioned slightly below the rest of the body D.) Avoid immediate IV fluid therapy

Answer: A.) Roll the client in a blanket

A client has come to the clinic with foot pain. The physician has described the client's condition as a flexion deformity of the proximal interphalangeal joint. What is the name of this disorder? A.) hammer toe B.) mallet toe C.) hallux valgus (bunion) D.) Heberden's nodes

Answer: A.) hammer toe Rationale: Hammer toe is a flexion deformity of the proximal interphalangeal joint. Mallet toe is a flexion deformity of the distal interphalangeal joint. Bunion is a deformity of the great toe at its metatarsophalangeal joint. Heberden's nodes are bony enlargements of the distal interphalangeal joints.

A nurse is caring for a client with eczema. Which medication would be prescribed when an allergy is a factor causing the skin disorder? A.) Dexamethasone B.) Chlorpheniramine C.) Dicloxacillin D.) Bupivacaine

Answer: B.) Chlorpheniramine

Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis? A.) Superficial partial thickness B.) Deep partial-thickness C.) Full-thickness D.) Fourth degree

Answer: B.) Deep partial-thickness

The diagnosis of a skin disorder is made chiefly by which of the following? A.) Palpation B.) Visual inspection C.) Biopsy D.) Culture

Answer: B.) Visual inspection Rationale: The diagnosis of a skin disorder is made chiefly by visual inspection. Some disorders may involve additional inspection with other diagnostic procedures.

A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction? A.) "Apply ice packs for the first 12 to 18 hours." B.) "Apply heat packs for the first 24 to 48 hours." C.) "Apply ice packs for the first 24 to 48 hours, then apply heat packs." D.) "Apply heat packs for the first 24 hours, then apply ice packs for the next 48 hours."

Answer: C.) "Apply ice packs for the first 24 to 48 hours, then apply heat packs." Rationale: The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing. Applying ice for only 12 to 18 hours may not keep swelling from recurring. Applying heat for the first 24 to 48 hours would worsen, not ease, swelling. Applying ice 48 hours after the injury would be less effective because swelling already has occurred by that time.

A client who has sustained a fracture reports an increase in pain and decreased function of the affected extremity. What will the nurse suspect? A.) Infection B.) Pulmonary embolism C.) Avascular necrosis D.) Hypovolemic shock

Answer: C.) Avascular necrosis Rationale: Avascular necrosis refers to the death of the bone from insufficient blood supply, typically manifested by complaints of increased pain and decreased function. Fever or redness, purulent drainage, and swelling of the site would suggest infection. Respiratory distress would suggest a pulmonary embolism. Changes in vital signs, level of consciousness, and signs and symptoms of fluid loss would suggest hypovolemic shock.

The nurse is assessing the feet of a patient and observes an overgrowth of the horny layer of the epidermis. What does the nurse recognize this condition as? A.) Bunion B.) Clawfoot C.) Corn D.) Hammer Toe

Answer: C.) Corn

The nurse notes that the client's left great toe deviates laterally. This finding would be recognized as A.) Hammertoe B.) Pes cavus C.) Hallux valgus D.) Flatfoot

Answer: C.) Hallux valgus

The nurse is caring for a client who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report if it occurs immediately after burn injury? A.) Hypernatremia B.) Hypokalemia C.) Hyperkalemia D.) Hypercalcemia

Answer: C.) Hyperkalemia

Which term refers to the failure of fragments of a fractured bone to heal together? A.) Dislocation B.) Subluxation C.) Nonunion D.) Malunion

Answer: C.) Nonunion

The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn? A.) Age B.) Weight C.) Preexisting conditions D.) Family history

Answer: C.) Preexisting conditions

A client is having a cast applied for a fractured leg that extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position. What type of cast is the client having applied? A.) Long leg cast B.) Walking cast C.) Short leg cast D.) Hip spica cast

Answer: C.) Short leg cast

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? A.) 18% B.) 27% C.) 30% D.) 36%

Answer: D.) 36%

A female client is at risk for developing osteoporosis. Which action will reduce the client's risk? A.) Living a sedentary lifestyle to reduce the incidence of injury B.) Stopping estrogen therapy C.) Taking a 300-mg calcium supplement to meet dietary guidelines D.) Initiating weight-bearing exercise routines

Answer: D.) Initiating weight-bearing exercise routines Rationale: Performing weight-bearing exercise increases bone health. A sedentary lifestyle increases the risk of developing osteoporosis. Estrogen is needed to promote calcium absorption. The recommended daily intake of calcium is 1,000 mg, not 300 mg.

During a routine physical examination of a client, the nurse observes a flexion deformity of the proximal interphalangeal (PIP) joint of two toes on the right foot. How would the nurse document this finding? A.) Hammer toe B.) Mallet toe C.) Hallux valgus D.) Bunion

Answer: A.) Hammer toe Rationale: Hammer toe is a flexion deformity of the proximal interphalangeal (PIP) joint and may involve several toes. Mallet toe is a flexion deformity of the distal interphalangeal joint (DIP), and also can affect several toes. Hallux valgus, also called a bunion, is a deformity of the great (large) toe at its metatarsophalangeal joint.

Radiographic evaluation of a client's fracture reveals that a bone fragment has been driven into another bone fragment. The nurse identifies this as which type of fracture? A.) Comminuted B.) Compression C.) Impacted D.) Greenstick

Answer: C.) Impacted

Which type of fracture is one in which the skin or mucous membrane wound extends to the fractured bone? A.) Compound B.) Complete C.) Incomplete D.) Simple

Answer: A.) Compound Rationale: A compound fracture is one in which the skin or mucous membrane wound extends to the fractured bone. A complete fracture involves a break across the entire cross section of the bone and is frequently displaced. An incomplete fracture involves a break through only part of the cross section of the bone. A simple fracture is one that does not cause a break in the skin.

The nurse notes several very small, round, red and purple macules on a patient's skin. The patient has a history of anticoagulant use. The nurse records this finding as which of the following? A.) Petechiae B.) Ecchymoses C.) Cherry angiomas D.) Telangiectasias

Answer: A.) Petechiae

Which of the following observations helps the nurse in determining adequate oxygenation? A.) Appearance of lunula B.) Hard keratin C.) Pink nail beds D.) Capillary refill time

Answer: C.) Pink nail beds Rationale: The nurse observes the color of the nail beds. Pink nail beds suggest adequate oxygenation. Lunula does not signify adequate oxygenation. Fingernails and toenails are layers of hard keratin that have a protective function. Hence, hard keratin does not signify adequate oxygenation. Capillary refill time is an assessment for tissue perfusion.

Which laboratory study indicates the rate of bone turnover? A.) Urine calcium B.) Serum calcium C.) Serum phosphorous D.) Serum osteocalcin

Answer: D.) Serum osteocalcin Rationale: Serum osteocalcin (bone GLA protein) indicates the rate of bone turnover. Urine calcium concentration increases with bone destruction. Serum calcium concentration is altered in clients with osteomalacia and parathyroid dysfunction. Serum phosphorous concentration is inversely related to calcium concentration and is diminished in osteomalacia associated with malabsorption syndrome.

Which of the following is an appropriate priority nursing diagnosis for the client following an arthrocentesis? A.) Risk for infection B.) Chronic pain C.) Deficient knowledge: procedure D.) Activity intolerance

Answer: A.) Risk for infection Rationale: The priority nursing diagnosis following an arthrocentesis is risk for infection. The client may experience acute pain. The client needs adequate information before experiencing the procedure. Activity intolerance would not be an expected nursing diagnosis.

A nurse is assigned to support a patient while a cast is being applied to treat a greenstick fracture. The nurse documents that this fracture is classified as what type of fracture? A.) Closed B.) Incomplete C.) Stress D.) Compression

Answer: B.) Incomplete Rationale: A greenstick fracture involves a break through only part of the cross-section of the bone.

Which nerve is being assessed when the nurses asks the client to dorsiflex the ankle and extend the toes? A.) Radial B.) Peroneal C.) Median D.) Ulnar

Answer: B.) Peroneal

A 14-year-old client is treated in the emergency room for an acute knee sprain sustained during a soccer game. The nurse reviews discharge instructions with the client's parent. The nurse instructs the parent that the acute inflammatory stage will last how long? A.) 24 to 48 hours B.) 3 to 4 days C.) 4 to 5 days D.) At least 7 days

Answer: A.) 24 to 48 hours Rationale: Rest and ice applications during the first 24 to 48 hours produce vasoconstriction while decreasing bleeding and edema. After this time, the acute inflammatory stage decreases.

A group of students are reviewing information about cast composition in preparation for a discussion on the advantages and disadvantages of each. The students demonstrate understanding of the topic when they cite which of the following as an advantage of a plaster cast? A.) Better molding to the client B.) Quicker drying C.) Longer-lasting D.) More breathable

Answer: A.) Better molding to the client

After completing a skin assessment of an older adult patient, the nurse documents evidence of lentigines, which indicate which of the following? A.) Freckles B.) Dryness C.) Itchy spots D.) Yellowish waxy deposits

Answer: A.) Freckles Rationale: Lentigines are freckles. Xerosis is dryness. Neurodermatitis is itchy spots. Xanthelasma is the yellowish waxy deposits on the upper and lower eyelids.

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? A.) Full-thickness B.) Superficial C.) Superficial partial-thickness D.) Deep partial-thickness

Answer: A.) Full-thickness

The nurse is caring for a client who sustained rib fractures in an automobile accident. What symptoms does the nurse recognize as a complication of rib fractures and should immediately be reported to the physician? A.) Blood pressure of 140/90 mm Hg B.) Crackles in the lung bases C.) Client complains of pain in the affected rib area when taking a deep breath D.) Heart rate of 94 beats/minute

Answer: B.) Crackles in the lung bases Rationale: Crackles in the lung bases can be an indicator that the client has developed pneumonia from shallow respirations. The blood pressure is high but may be due to pain. It is expected that the client will have pain in the rib area when taking deep breaths. A heart rate of 94 beats/minute is within normal range.

Production of melanin is controlled by a hormone secreted by which of the following? A.) Hypothalamus B.) Thyroid C.) Adrenal D.) Parathyroid

Answer: A.) Hypothalamus Rationale: The production of melanin is controlled by a hormone secreted from the hypothalamus of the brain called melanocyte-stimulating hormone. Production of melanin is not controlled by the thyroid, adrenal, or parathyroid gland.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? A.) Do nothing until the chemical agent is identified. B.) Irrigate the wounds with water. C.) Wash the wounds with soap and water and apply a barrier cream. D.) Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour.

Answer: B.) Irrigate the wounds with water. Rationale: The nurse should begin treatment by irrigating the wounds with water. Delaying treatment until the agent is identified allows the agent to cause further tissue damage. Washing the wounds with soap and water might cause a chemical reaction that may further damage tissue. The client may require I.V. fluid; however, the wounds should be irrigated first.

A client who was in a motor vehicle crash is diagnosed with a stable T7 spinal fracture with no neurologic deficits. Which nursing intervention should the nurse implement? A.) Maintain bed rest with the head of the bed at 20 degrees. B.) Withhold opioid pain medication to prevent ileus. C.) Maintain NPO (nothing by mouth) status for surgical repair. D.) Sit the client upright in a padded chair for meals.

Answer: A.) Maintain bed rest with the head of the bed at 20 degrees. Rationale: The client should maintain limited bed rest with the head of the bed lower than 30 degrees. If the client's pain is not controlled with a lower form of pain medication, then an opioid may be used to treat the pain. The nurse should monitor for an ileus. Stable spinal fractures are treated conservatively and not with surgical repair. The client should avoid sitting until the pain eases.

A client asks the nurse why his residual limb cannot be elevated on a pillow. What is the best response by the nurse? A.) "I am sorry. We ran out of pillows. I can elevate it on a few blankets." B.) "Elevating the leg might lead to a flexion contracture." C.) "You need to turn yourself side to side. If your leg is on a pillow, you would not be able to do that." D.) "Elevating the extremity may increase your chances of compartment syndrome."

Answer: B.) "Elevating the leg might lead to a flexion contracture." Rationale: Elevating the residual limb on a pillow may lead to a flexion contracture; this could jeopardize the client's ability to use a prosthesis. The client does need to turn to both sides but might still be able to do it with the extremity elevated. Elevating the extremity would not increase the risk for compartment syndrome. The limb should not be elevated on pillows or blankets.

Which of the following disorders results in widespread hemorrhage and microthrombosis with ischemia? A.) Disseminated intravascular coagulation (DIC) B.) Avascular necrosis (AVN) C.) Complex regional pain syndrome (CRPS) D.) Fat embolism syndrome (FES)

Answer: A.) Disseminated intravascular coagulation (DIC)

After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis? A.) Compartment syndrome B.) Fat embolism C.) Infection D.) Volkmann's ischemic contracture

Answer: B.) Fat embolism Rationale: Fat embolism is a relatively rare but life-threatening complication of pelvis and long-bone fractures, arising 24 to 48 hours after the injury. It occurs when fat droplets released at the fracture site enter the circulation, become lodged in pulmonary capillaries, and break down into fatty acids. Because these acids are toxic to the lung parenchyma, capillary endothelium, and surfactant, the client may develop pulmonary hypertension. Signs and symptoms of fat embolism include an altered mental status, fever, tachypnea, tachycardia, hypoxemia, and petechiae. Compartment syndrome and infection may complicate any fracture and aren't specific to a pelvis fracture. Volkmann's ischemic contracture is a potential complication of a hand or forearm fracture.

Which nursing intervention is appropriate for a client with a closed-reduction extremity fracture? A.) Encourage participation in ADLs B.) Promote intake of omega-3 fatty acids C.) Use frequent dependent positioning to prevent edema D.) Administer prescribed enema to prevent constipation

Answer: A.) Encourage participation in ADLs Rationale: General nursing measures for a client with a fracture reduction include administering analgesics, providing comfort measures, encouraging participation with ADLs, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing the client for self-care. Omega-3 fatty acids have no implications on the diet of a client with a fracture reduction. Dependent positioning may increase edema because the extremity is below the level of the heart. While some pain medications may contribute to constipation, this intervention would be reserved for a client experiencing constipation and not as a preventative measure.

Arthrodesis is: A.) fusion of a joint (most often the wrist or knee) for stabilization and pain relief. B.) total reconstruction or replacement of a joint (most often the knee or hip) with an artificial joint to restore function and relieve pain. C.) replacement of one of the articular surfaces in a joint, such as the femoral head but not the acetabulum. D.) cutting and removal of a wedge of bone (most often the tibia or femur) to change the bone's alignment, thereby improving function and relieving pain.

Answer: A.) fusion of a joint (most often the wrist or knee) for stabilization and pain relief.

A client has an exaggerated convex curvature of the thoracic spine. What is this condition called? A.) kyphosis B.) lordosis C.) scoliosis D.) diaphysis

Answer: A.) kyphosis Rationale: Kyphosis is an exaggerated convex curvature of the thoracic spine. Lordosis is an excessive concave curvature of the lumbar spine. Scoliosis is a lateral curvature of the spine. Diaphyses are the long shafts of bones in the arms and legs.

Which antimicrobials is not commonly used to treat burns? A.) tetracycline B.) silver sulfadiazine (Silvadene) C.) mafenide (Sulfamylon) D.) silver nitrate (AgNO3) 0.5% solution

Answer: A.) tetracycline Rationale: Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns.

A patient has a long leg cast applied. Where does the nurse understand a common pressure problem may occur? A.) Dorsalis pedis B.) Peroneal nerve C.) Popliteal artery D.) Posterior tibialis

Answer: B.) Peroneal nerve Rationale: The nurse assesses circulation by observing the color, temperature, and capillary refill of the exposed toes. Nerve function is assessed by observing the patient's ability to move the toes and by asking about the sensations in the foot. Numbness, tingling, and burning may indicate peroneal nerve injury resulting from pressure at the head of the fibula.

An adult is swinging a small child by the arms, and the child screams and grabs his left arm. It is determined in the emergency department that the radial head is partially dislocated. What is this partially dislocated radial head documented as? A.) Volkmann's contracture B.) Subluxation C.) Compartment syndrome D.) Sprain

Answer: B.) Subluxation Rationale: A partial dislocation is referred to as a subluxation. A Volkmann's contracture is a claw like deformity that results from compartment syndrome or obstructed arterial blood flow to the forearm and hand. Compartment syndrome is a condition in which a structure such as a tendon or nerve is constricted in a confined space and affects nerve innervation, leading to subsequent palsy. A sprain is injury to the ligaments surrounding the joint.

A patient is having low back pain. What position can the nurse suggest to relieve this discomfort? A.) High-Fowler's to allow for maximum hip flexion B.) Supine, with the knees slightly flexed and the head of the bed elevated 30 degrees C.) Prone, with a pillow under the shoulders D.) Supine, with the bed flat and a firm mattress in place

Answer: B.) Supine, with the knees slightly flexed and the head of the bed elevated 30 degrees Rationale: A medium to firm, not sagging mattress (a bed board may be used) is recommended; there is no evidence to support the use of a firm mattress (National Guideline Clearinghouse, 2010). Lumbar flexion is increased by elevating the head and thorax 30 degrees by using pillows or a foam wedge and slightly flexing the knees supported on a pillow. Alternatively, the patient can assume a lateral position with knees and hips flexed (curled position) with a pillow between the knees and legs and a pillow supporting the head (Fig. 42-1). A prone position should be avoided because it accentuates lordosis.

A client was climbing a ladder, slipped on a rung, and fell on the right side of the chest. X-ray studies reveal three rib fractures, and the client reports pain with inspiration. What is the anticipated treatment for this client? A.) Chest strapping B.) Mechanical ventilation C.) Coughing and deep breathing with pillow splinting D.) Thoracentesis

Answer: C.) Coughing and deep breathing with pillow splinting Rationale: Because these fractures cause pain with respiratory effort, the client tends to decrease respiratory excursions and refrains from coughing. As a result, tracheobronchial secretions are not mobilized, aeration of the lung is diminished, and a predisposition to atelectasis and pneumonia results. To help the client cough and take deep breaths and use an incentive spirometer, the nurse may splint the chest with his or her hands, or may educate the client on using a pillow to temporarily splint the affected site.

A client presents to the emergency department with fever, chills, restlessness, and limited movement of a fractured jaw. What complication should the nurse interpret as the findings? A.) Avascular necrosis B.) Fat embolism C.) Osteomyelitis D.) Compartment syndrome

Answer: C.) Osteomyelitis Rationale: Clinical manifestations of osteomyelitis include signs and symptoms of sepsis and localized infection. A client with avascular necrosis does not have fever and chills. Clients with fat emboli will have a rash and breathing complications. A client with compartment syndrome will have numbness, not a fever.

The nurse teaching the client with a cast about home care includes which instruction? A.) Cover the cast with plastic or rubber B.) Keep the cast below heart level C.) Fix a broken cast by applying tape D.) Dry a wet fiberglass cast thoroughly to avoid skin problems

Answer: D.) Dry a wet fiberglass cast thoroughly to avoid skin problems

A client with low back pain is being seen in the clinic. In planning care, which teaching point should the nurse include? A.) Sleep on the stomach to alleviate pressure on the back. B.) A soft mattress is most supportive by conforming to the body. C.) Avoid twisting and flexion activities. D.) Use the large muscles of the leg when lifting items.

Answer: D.) Use the large muscles of the leg when lifting items.

The nurse is assisting a client with removing shoes prior to an examination and observes that the client has a flexion deformity of several toes on both feet of the proximal interphalangeal (PIP) joints. What can the nurse encourage the client to do? A.) Bind the toes so that they will straighten. B.) Do active range of motion on the toes. C.) Have surgery to fix them. D.) Wear properly fitting shoes.

Answer: D.) Wear properly fitting shoes.

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories. The nurse recognizes this intervention is to promote A.) increased metabolic rate. B.) increased glucose demands. C.) increased skeletal muscle breakdown. D.) decreased catabolism.

Answer: D.) decreased catabolism. Rationale: Burn injuries produce profound metabolic abnormalities fueled by the exaggerated stress response to the injury. The body's response has been classified as hyperdynamic, hypermetabolic, and hypercatabolic. The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.