Exam 4
A client sustained a femur fracture while skiing. After the client undergoes surgery to stabilize the fracture, what does the nurse determine will assist with healing of this fracture?
formation of new bone tissue
A nurse is gathering data to determine fall risk for a client. What information is most important for the nurse collect? Select all that apply.
functional level muscular strength gait and balance visual acuity
The nurse is collecting a health history from a client who is exhibiting signs of gout. Which of the client's joints would the nurse expect to be most commonly affected?
great toe
The infection control team has identified a 25% infection rate on the orthopedic floor. The nursing staff members are asked to record their care activities by recording them in a log to help identify the cause of the high infection rate. Which of the following care activities should be recorded in the activity log?
hand washing between client contacts
A client with a stroke in evolution and a history of coronary artery disease is brought to the medical-surgical floor. The client's medications include heparin and isosorbide. The nurse should monitor the client for which condition?
hypotension
The nurse educator presents an in-service on how to formulate a nursing diagnosis of Risk for imbalanced body temperature for a client who suffers a stroke after surgery. The expected outcomes incorporate assessment of the client's temperature to detect abnormalities. The educator will include in the lecture that the thermoregulatory centers are located in which part of the brain?
hypothalamus
A client who was casted for a recent fracture of the right ulna reports severe pain, numbness, and tingling of the right arm. What would be the nurse's most appropriate response?
immediately report the client's symptoms
At the scene of a trauma, which nursing intervention is appropriate for a child with a suspected fracture?
immobilize the extremity and move the child to a safe place
The parents of a child newly diagnosed with pseudohypertrophic muscular dystrophy ask the nurse to describe this disease. What does the nurse include in the response?
increased muscle hypertrophy second to fat infilteration
A client has a history of osteoarthritis. Which signs and symptoms would the nurse expect to find when gathering data on the client?
joint pain, crepitus, Heberden's nodes
A nurse is providing nutritional information to a client with a diagnosis of gout. Which of the client's favorite foods should be limited?
liver
After a traumatic spinal cord injury, a client requires skeletal traction. When caring for this client, the nurse must:
maintain traction continuously to ensure its effectiveness
A client is undergoing an extensive diagnostic workup for suspected muscular dystrophy. The nurse knows that muscular dystrophy has many forms, but that one data collection finding is common to all forms. Which finding belongs in this category?
muscle weakness
A client with a T1 spinal cord injury arrives at the emergency department with a blood pressure of 82/40 mm Hg, pulse rate of 34 beats/minute, dry skin, and flaccid paralysis of the lower extremities. Which condition would most likely be suspected?
neurogenic shock
A nurse gathers data from a client with suspected bacterial meningitis. Which documented finding of meningeal irritation suggests this diagnosis? Select all that apply.
nuchal rigidity positive Brudzinski's sign positive Kernig's sign photophobia
A nurse is educating the parents of a 1-year-old infant with otitis media. Which statement regarding predisposing factors for otitis media would be most accurate for the nurse to make?
"Eustachian tubes are short, wide, and straight and lie in a horizontal plane."
The nurse is preparing to administer carbamazepine oral suspension, 150 mg by mouth. The pharmacy has dispensed carbamazepine suspension 100 mg/5 mL. How many milliliters of carbamazepine should the nurse administer to the client? Record your answer using one decimal place.
7.5
A school nurse is performing a scoliosis screening on a group of students. Which student would most commonly develop this condition?
A 13 year old girl
A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning this client's care, the nurse should include which measure?
Administering large doses of I.V. antibiotics as prescribed
A client is admitted for closed spine surgery to repair a herniated disk. The nurse is discussing the surgery with the client. Which instruction should the nurse reinforce in the preoperative education?
An endoscope is used to perform the surgery
A client, age 21, is admitted with bacterial meningitis. Which hospital room would be the appropriate choice for this client?
An isolation room close to the nurses' station
The nurse is reinforcing teaching about aspirin therapy with a client diagnosed with transient ischemic attacks (TIA). Which statement made by the client indicates understanding?
Aspirin will help prevent me from having a stroke
A client diagnosed with a brain tumor experiences a generalized seizure while sitting in a chair. How should the nurse intervene first?
Assist the client to a side-lying position on the floor, and protect her with linens.
A client is admitted with a possible diagnosis of osteomyelitis. Based on the documentation shown, which laboratory result is the priority for the nurse to report to the health care provider?
Blood culture
The nurse is reinforcing education on cast care for a client with a cast on the arm. How should the nurse instruct the client to place the casted limb, if there is swelling?
above the level of the heart
A child has just returned to the room with a cast on the leg after open reduction of a fractured femur. What is the most appropriate action for a nurse to take when a 6 cm by 10 cm area of blood is noted on the cast?
Call the healthcare provider
The nurse is caring for a client diagnosed with a cerebral aneurysm, who reports a severe headache. Which action should the nurse perform first?
Call the physician immediately
A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:
Carefully move him to a flat surface and turn him on his side
A client with skeletal fracture to the right leg reports severe right leg pain. Which action should the nurse take first?
Check the client's alignment in bed
A client with skeletal fracture to the right leg reports severe right leg pain. Which action should the nurse take first?
Check the clients alignment in bed.
A client is receiving nutritional counseling following application of a plaster cast for a fracture. Why would it be important for the nurse to promote the intake of Vitamin D?
absorption and use of calcium and phosphorus
The nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)?
Elevate the head of the bed to 30 degrees
A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative plan of care?
Elevating the stump for the first 24 hours.
After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway, attends to the client's immediate needs, and then prepares to perform a neurologic assessment. Because the client is unstable and in critical condition, the examination must be brief but will include which nursing intervention?
Evaluation of the corneal reflex response
A 22-year-old client with an external fixation device attached to his left thigh is unable to bear weight on his left leg. He asks a nurse if he can take a shower on his third postoperative day. After a review of the physician's orders, the nurse notes an order stating, "Client may shower ten (10) days after surgery." In order to meet the client needs, what appropriate action will the nurse take?
Explain that he is not permitted to shower, but the nursing assistant can help him with a sponge bath.
The nurse is reinforcing education for the parents of a child scheduled for a closed reduction of a fracture. Which statement should the nurse include?
Fracture reduction restores alignment
Which finding should alert a nurse to a potential complication in a client with a cast following fracture of the radius?
GI upset and metallic taste
A client is admitted with Ménière's disease. Which instruction should the nurse reinforce in client teaching?
Get up slowly, turning the entire body.
A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?
Helicopod
A client has a long leg cast applied for a tibia fracture. Which statement made by the client would indicate to the nurse that compartment syndrome may be developing?
I am having a decrease sensation of my toes
The nurse is reinforcing education for a client on preventing complications of primary osteoporosis. Which statement made by the client indicates an understanding of the education provided?
I will be sure to take my calcium supplements
A nurse has reinforced instruction for a client to accurately measure the circumference of both calves each morning and to report any increase in circumference. Which client statement indicates that the education has been effective?
I'll use a measuring tape to check circumference
A nurse cares for a client diagnosed with osteoarthritis. To minimize injury to this client, what education should be reinforced?
Install safety devices in your home
The nurse is caring for a client with a cast on his left arm. Which data collection finding is most significant for this client?
Intact skin around the cast edges
A client undergoes hip-pinning surgery to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative plan of care?
Keeping a pillow between the client's legs at all times.
The nurse is preparing to reinforce discharge instructions for a client who was diagnosed with osteoarthritis. Which discharge instruction about home activity should be given to this client?
Learn to pace activity
A nurse is providing discharge instructions on phenytoin to a female client with tonic-clonic seizure disorder. Which instructions should the nurse include? Select all that apply.
Monitor the body for any skin rash. Perform good oral hygiene, including daily brushing and flossing. Receive necessary periodic blood work. Report any problems with walking or coordination, slurred speech, or nausea.
After a person experiences a closure of the epiphyses, which of the following is true?
No further increase in bone length occurs
After a physician describes the surgical procedure for lumbar spinal fusion and its associated risks, the nurse provides a consent form for the client to sign. The client asks the nurse what the term "fusion" means and whether he'll lose a lot of blood during the procedure. Which action should the nurse take?
Notify the physician of the client's questions about the procedure before having the client sign the informed consent form.
A client who experienced a severe stroke develops a fever and a cough that produces thick, yellow sputum. A nurse observes sediment in the client's urine in the indwelling urinary catheter tubing. Based on these findings, which action should the nurse take?
Notify the physician of the findings
A 69-year-old client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct? You Selected:
OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints.
Which finding should alert a nurse to a potential complication in a client with a cast following fracture of the radius?
Pain occurs over bony prominence
A client is experiencing nonchronic gout. Which clinical manifestation reported by the client would lead the nurse to suspect this form of gout?
Painful attacks with pain free periods
The nurse educator is presenting an in-service on falls and notes that elderly clients are most at risk for a particular type of fracture. Which type of fracture, if identified by the nursing staff, would indicate to the educator that the in-service was effective?
Pelvic fracture
Which nursing intervention is essential in caring for a client with compartment syndrome?
Removing all external sources of pressure, such as clothing and jewelry
The nurse is giving instructions to a client who's going home with a cast on his leg. Which point is most critical?
Reporting signs of impaired circulation
A client with Alzheimer's disease is admitted for hip surgery after falling and fracturing the right hip. The spouse tells the nurse of feeling guilty for letting the accident happen and reports not sleeping well because the spouse has been getting up at night and doing odd things. Which nursing diagnosis is most appropriate for the client's spouse?
Risk for caregiver role strain related to increased client care needs
A client has developed a right torticollis with side bending to the right and rotation to the left. Which exercises may assist in reduction of the torticollis?
Rotation exercises to the right
A child is brought to the school nurse with the index finger of the left hand partially amputated and hanging by a shred of skin. What is the appropriate action by the nurse?
Securely wrap the hand and finger and place them in a cold water-filled baggie.
The nurse is reinforcing instruction with a female client regarding collection of a urine culture. Which instruction will the nurse include?
Separate the labia, one at a time clean from front to back with the three wipes provided in the kit, and then start to void in the toilet. Stop voiding, then continue to void into the sterile container.
On a visit to the family physician, a client reports painful swelling on the lateral side of the great toe, at the metatarsophalangeal joint. After determining that the swelling is a bunion, the physician injects an intra-articular corticosteroid. The client asks the nurse what causes bunions. Which answer is correct?
Some bunions are congenital; others are caused by wearing shoes that are too short or narrow.
During data collection of a newly admitted client, the nurse observes a reddened area on the left heel. The nurse applies pressure to the reddened area and notes that it does not blanch when pressure is relieved. When documenting the findings, which appropriate stage would the nurse assign to this pressure sore?
Stage 1
A client is admitted to an acute care facility with osteomyelitis. Which organism usually causes this infection?
Staphylococcus aureus
A client with a fractured femur is in Russell's traction and asks the nurse to help with back care. Which nursing action is most appropriate?
Telling the client to use the trapeze to life his back off the bed.
A child with bilateral fractured femurs is scheduled for a double hip spica cast and says to the nurse, "Only 3 more months, and I can go home." Further investigation reveals that the child and family believe hospitalization is required until the cast comes off. What should the nurse explain to the family?
The child will go home 2-4 days after casting
The nurse is unable to detect a dorsalis pedal pulse on the left foot. What is the priority action by the nurse?
Verify the findings with a handheld doppler
A client is 2 weeks post op from knee replacement surgery and has been on warfarin therapy. The client's most recent INR blood level was 5.6. What should the nurse prepare to administer to the client?
Vitamin K
A client is recovering from an attack of gout. When reinforcing education, the nurse should include the need to lose weight for which reason?
Weight loss will decrease uric acid levels and decrease stress on joints
A middle-age client recovering from major back surgery must wear a back brace and walk with a cane after experiencing leg weakness. During routine care, the client tells a nurse, "I'm sorry I had this operation. Before surgery I didn't look like I had a problem, but now I do." Which response by the nurse is appropriate?
You sound concerned about your appearance. In what way are you worse off than before?
A client underwent a bipolar hip replacement after a fracture. Which interventions would help prevent deep vein thrombosis (DVT) after surgery? Select all that apply.
administration of subcutaneous heparin application of pneumatic compression boots
The nurse is providing care for a child in traction. Which nursing action is a priority?
assessing the pin sites every shift as needed
A client with long-standing rheumatoid arthritis has frequent reports of joint pain. The plan of care should be based on the understanding that chronic pain is most effectively relieved when analgesics are administered in which way?
at regularly scheduled intervals
The nurse monitors a client receiving enoxaparin, 30 mg subQ b.i.d after hip replacement surgery. Which adverse reaction is the client most likely to experience?
bleeding
A client experienced a stroke that damaged the hypothalamus and was admitted to an acute unit. Which body function would the nurse anticipate that the client has problems with and assess as needed?
body temperature control
Which information is the priority to include in the discharge plan for a client leaving the hospital in a leg cast?
cast care, neurovascular checks and hygiene measures
A client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from the ears and nose. Which nursing intervention is appropriate?
checking fluid for glucose with a dipstick
The nurse is reinforcing education for the family of a child with seizures. When should the nurse inform them to call emergency medical services in the event of a seizure?
continuous vomiting for 30 minutes after the seizure
A client who has been recently diagnosed with gout asks the nurse to explain why they need to take colchicine. What should the nurse base the response on?
decreases inflammation
A child in skeletal traction for a fracture of the right femur reports new and constant left calf pain. Also, the nurse notes that the child's left calf is 1 inch larger than the right and that he has nonpitting edema below the left knee. The nurse knows these signs are most consistent with which condition?
deep vein thrombosis DVT
A nurse is caring for a child with severe scoliosis. For which complication should the nurse closely monitor the child?
diminished vital capacity
A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:
electromyography (EMG).
A client is brought to the emergency department with a painful swollen ankle. Which is the nurse's most appropriate action?
elevate the ankle
A client has undergone a total hip replacement on the right side. After surgery, how often should the nurse turn the client?
every 1 to 2 hours from the unaffected side to the back
A client has developed compartment syndrome from full thickness burns on both arms. What treatment will the nurse prepare the client for?
fasciotomy
A client is diagnosed with a long bone fracture. What potential complication related to this form of fracture should the nurse carefully monitor?
fat emboli
A client is admitted with Bell palsy. What should the nurse and health care team include in the plan of care?
provide eye care
An older adult client reports pain in the lower back and is diagnosed with osteoporosis. What education should the nurse reinforce to prevent complications?
safety precautions to prevent fractures
The nurse is caring for a client who underwent a stapedectomy. Which position would have the greatest benefit for prevention of complications and promotion of comfort?
on the unaffected side
A client is brought to the emergency department after injuring his right arm in a bicycle accident. The orthopedic surgeon tells the nurse that the client has a greenstick fracture of the arm. What does this mean?
one side of the bone is broken and the other side is bent
A client with gouty arthritis is prescribed a low-purine diet. When reviewing the diet plan with this client, which items should the nurse instruct the client to avoid? Select all that apply.
organ meats and alcohol
A client asks for information about osteoarthritis. Which statement should the nurse include when reinforcing education for the client on this condition?
osteoarthritis is the most common form of arthritis
The nurse is caring for a female client with osteoarthritis who is being discharge to home. Which items would the nurse reinforce the use of in order to assist the client to dress independently at home? Select all that apply.
skirts with elastic waists jackets with Velcro closures bras with front closure
The parents of a child newly diagnosed with developmental dysplasia of the hip (DDH) ask the nurse how their child developed this condition. The nurse explains that the greatest number of cases are caused by which condition?
subluxation
The health care provider has ordered sulfasalazine for a child with juvenile rheumatoid arthritis. The nurse questions the order when reading that the client has an allergy to what medication?
sulfamethoxazole-trimethoprim
The nurse is assisting the health care provider in applying a cast. Which intervention should be provided during immediate cast care?
support the cast with the palms of her hand
A client presents with pain and warmth in his big toe and reduced urine output. The health care provider suspects gouty arthritis. The nurse can expect the health care provider to confirm this diagnosis by ordering which diagnostic tests?
synovial fluid analysis and serum uric acid level
When gathering data from a child suspected of having scoliosis, what structures will the nurse focus on during the screening process? Select all that apply.
thoracic spine lumbar spine cervical spine
A client with new-onset seizures of unknown cause is started on phenytoin, 750 mg IV now and 100 mg P.O. t.i.d. Which statement best describes the purpose of the loading dose?
to more quickly attain therapeutic levels
A client asks the reason for being placed in traction prior to surgery. Which response by the nurse is most appropriate?
traction helps prevent trauma and over come muscle spasms
A child with muscular dystrophy has lost complete control of his lower extremities. There is some strength bilaterally in the upper extremities, but poor trunk control. Which mechanism would be the most important to have on the wheelchair?
wheelchair belt
