adult health muscoskeletal
A client immobilized in skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse identifies which client problem as the priority? 1. Lack of control 2. Lack of physical mobility 3. Inability to entertain self 4. Inability to maintain health
Inability to entertain self A manifestation of the inability to entertain self is expression of boredom by the client. The question does not identify difficulties with coordination, range of motion, or muscle strength, which would indicate lack of physical mobility. The question also does not relate to client feelings of inability to take responsibility for meeting basic health practices (inability to maintain health) or to lack of control.
The nurse is caring for a client with a hip fracture who has just been placed in Buck's traction. What intervention is most important for the nurse to perform? 1. Ensure that the weight used as a pulling force is at least 20 lb (9 kg). 2. Ensure that the weights rest on the floor and are not freely hanging. 3. Inspect the skin at least every 8 hours for signs of irritation or inflammation. 4. Remove the weights for at least 5 minutes every hour to give the client a rest.
Inspect the skin at least every 8 hours for signs of irritation or inflammation. It is important for the skin to be assessed at least every 8 hours. Weights should be no more than 5 to 10 lb (2.3 to 4.5 kg) to prevent injury to the skin and should always be freely hanging. Additionally, the amount of weight is prescribed by the health care provider. Once traction is applied, a correct balance is maintained at all times. Weights are not removed on a scheduled basis and are never removed without a prescription to do so.
A client has Buck's extension traction applied to the right leg. Which intervention should the nurse plan to prevent complications of the device? 1. Give pin care once a shift. 2. Inspect the skin on the right leg. 3. Massage the skin of the right leg with lotion. 4. Release the weights on the right leg for daily range-of-motion exercises.
Inspect the skin on the right leg. Buck's extension traction is a type of skin traction. The nurse inspects the skin of the limb in traction at least once every 8 hours for irritation or inflammation. There are no pins to care for with skin traction. Massaging the skin with lotion is not indicated. The nurse never releases the weights of traction unless specifically prescribed by the health care provider.
The nurse is preparing a client for an arthroscopy of the knee. When providing teaching, which information is essential for the nurse to include? 1. It will drain fluid that has accumulated below the knee. 2. It is used to obtain a muscle biopsy for pathology studies. 3. It will determine the degree of range of motion of the joint. 4. It will identify if there is joint injury and provide a route for surgical repair if indicated.
It will identify if there is joint injury and provide a route for surgical repair if indicated. Arthroscopy is used to diagnose acute and chronic conditions of the joint. In addition, surgical repairs can be done during this procedure. This procedure does not quantitate the degree of range of motion of the joint. Obtaining a muscle biopsy is not performed through an arthroscope, nor is this invasive procedure necessary to remove fluid from below the knee.
The nurse has given activity guidelines to a client with chronic low back pain. The nurse determines that the client understands the instructions if the client states to do which activities? Select all that apply. 1. Lying prone 2. Sitting using a lumbar roll or pillow 3. Standing with one foot on a step or stool 4. Lying on the side, with knees and hips straight 5. Lift objects that need to be carried above elbow level. 6. Lean forward to reach objects, keeping the legs and knees straight.
Sitting using a lumbar roll or pillow Standing with one foot on a step or stool The client should avoid positions or activities that place strain on the lower back. The client should not sleep on the abdomen (prone) or on the side if the hips and knees are straight. It may be helpful for the client to stand with a foot elevated on a stool or to sit using a form of lumbar support. The client should not lean forward without bending the knees, stand in one position for long periods, or lift anything above elbow level.
The nurse develops a plan of care for a client with a spica cast that covers a lower extremity and documents that the client is at risk for constipation. When planning for bowel elimination needs, the nurse should include which in the plan of care? 1. Administer an enema daily. 2. Use a fracture pan for bowel elimination. 3 Use a bedside commode for all elimination needs. 4. Use a regular bedpan to prevent spilling of contents in the bed.
Use a fracture pan for bowel elimination. A fracture pan is designed to be used for clients with body or leg casts. A client with a spica cast (body cast) involving a lower extremity cannot bend at the hips to sit up; therefore, a regular bedpan and a commode would be inappropriate. Daily enemas are not a part of routine care.
A client is being discharged to home after spinal fusion with insertion of instrumentation (rod). The unit nurse should consult with the continuing care nurse regarding the need for modification of the home environment if the client makes which statement? 1. "The bathroom has hand railings in the shower." 2. "There are three steps to get up to the front door." 3. "My family has rented a commode for me to use." 4. "My bedroom and bathroom are on the second floor of my home."
"My bedroom and bathroom are on the second floor of my home." Stair climbing may be restricted or limited for several weeks after spinal fusion with instrumentation. If stairs need to be climbed to reach a bathroom, hand rails should be installed and the area kept free of clutter. The nurse ensures that resources are in place before discharge so that the client may sleep and perform all activities of daily living on a single living level. From the options provided, options 1, 2, and 3 do not indicate a need for modification of the environment.
A client who has been taking high doses of acetylsalicylic acid to relieve pain from osteoarthritis now has more generalized joint pain and an elevated temperature. The nurse should assess for which complication to determine whether the client has other signs of aspirin toxicity? 1. Diarrhea 2. Constipation 3. Double vision 4. Ringing in the ears
Ringing in the ears Mild intoxication with acetylsalicylic acid, called salicylism, commonly occurs when the daily dosage is more than 4 g. Tinnitus (ringing in the ears) is the most frequent effect noted with intoxication. Hyperventilation also may occur because a salicylate stimulates the respiratory center. Fever may result because a salicylate interferes with the metabolic pathways coupling oxygen consumption and heat production. The remaining options are not signs of aspirin toxicity.
The clinic nurse is performing an assessment on a client with a diagnosis of rheumatoid arthritis (RA). The nurse checks for which assessment finding that is associated with RA? 1. Age of onset is generally 65 years of age or older 2. Complaints of pain that is more severe after activity 3. Systemic symptoms such as fatigue, anorexia, and weight loss 4. Joint pain is asymmetrical and associated with past injuries to the joint
Systemic symptoms such as fatigue, anorexia, and weight loss In clients diagnosed with RA, systemic symptoms such as fatigue, anorexia, weight loss, and nonspecific aching and stiffness may appear before joint manifestations. RA is characterized by chronic joint pain of variable intensity, which is more severe on rising in the morning. The age of onset for RA is most commonly between 30 and 50 years of age. Complaints of pain that is more severe after activity and asymmetrical joint pain associated with past injuries to the joint are more commonly seen in osteoarthritis.
The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding? 1. Temperature of 101.6°F (38.7°C) orally 2. Complaints of discomfort during repositioning 3. Old bloody drainage outlined on the surgical dressing 4. Discomfort during coughing and deep-breathing exercises
Temperature of 101.6°F (38.7°C) orally he nursing assessment conducted after spinal surgery is similar to that done after other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101.6°F (38.7°C) should be reported.
A client has had surgery to repair a fractured left hip. When repositioning the client from side to side in the bed, what should the nurse plan to use as the most important item for this maneuver? 1. Bed pillow 2. Abductor splint 3. Adductor splint 4. Overhead trapeze
abductor splint After surgery to repair a fractured hip, an abductor splint is used to maintain the affected extremity in good alignment. A bed pillow and an overhead trapeze also are used, but neither is the priority item to be used in repositioning the client from side to side.
The nurse provides instructions to a client with bilateral deformities of the joints of the fingers due to rheumatoid arthritis. When providing teaching about the disease process, the nurse should inform the client that the changes are most likely due to what type of response? 1. Allergic 2. Metabolic 3. Endocrine 4. Autoimmune
autoimmune The most likely cause for rheumatoid arthritis is activation of an autoimmune response. This is thought to trigger antigen-antibody responses and release of lysosomes from phagocytic cells, which ultimately attack the cartilage and synovia, with resultant synovitis. Other theories related to the cause of rheumatoid arthritis have been proposed, but the most likely cause is an autoimmune reaction.
The nurse has delegated the ambulation of a client to the unlicensed assistive personnel (UAP). Which actions by the UAP support a clear understanding of the appropriate steps to carry out this task safely? Select all that apply 1. Remove clutter that may interfere with ambulation. 2. Assist client in applying nonskid shoes before ambulation. 3. Instruct client to sit up on the bedside and dangle before ambulation. 4 Observe the client for dizziness during ambulation and report immediately. 5. Understand that the client may experience nausea as a normal expectation during ambulation.
Remove clutter that may interfere with ambulation. Assist client in applying nonskid shoes before ambulation. Instruct client to sit up on the bedside and dangle before ambulation. Observe the client for dizziness during ambulation and report immediately. When delegating the task of ambulation to a UAP, the nurse should ensure that the UAP understands instructions before ambulation, including making sure that clutter is removed in the area of ambulation; assisting the client in applying nonskid socks before ambulation; instructing the client to sit up on the bedside and dangle before ambulation; and observing the client for dizziness and reporting this finding immediately. The client should not experience nausea, dizziness, or diaphoresis or become pale during ambulation under normal conditions.
The home health nurse visits a client who is having an acute attack of gout. The nurse determines that the client needs further instruction regarding the treatment of gout if the client states to take which action? 1. Restricting fluids 2. Maintaining bed rest 3. Eating a low-purine diet 4. Taking nonsteroidal antiinflammatory drugs
restricting fluids Ample fluid intake is encouraged to promote the excretion of uric acid. The client is placed on bed rest during an acute attack until the pain subsides. A diet low in purine normally is prescribed. Nonsteroidal antiinflammatory drugs (NSAIDs) are used to reduce pain and inflammation. Colchicine, which also may be prescribed, reduces the migration of leukocytes to the synovial fluid.
A client with a short-leg plaster cast complains of an intense itching under the cast. The nurse provides instructions to the client regarding relief measures for the itching. Which client statement indicates an understanding of appropriate measures to relieve the itching? 1. "I can use the blunt part of a ruler to scratch the area." 2. "I can trickle small amounts of water down inside the cast." 3. "I need to obtain assistance when placing an object into the cast for the itching." 4. "I can use a hair dryer on the low setting and allow the cool air to blow into the cast."
"I can use a hair dryer on the low setting and allow the cool air to blow into the cast." Itching is a common complaint of clients with casts. Objects should not be put inside a cast because of the risk of scratching the skin, thereby providing a point of entry for bacteria. A plaster cast can break down when wet. Therefore, the best way to relieve itching is with a forceful injection of air inside the cast.
A male client arrives in the hospital emergency department and tells the nurse that he twisted his ankle while jogging. The client is seen by the health care provider and is diagnosed with a sprained ankle. The nurse provides instructions to the client regarding home care for the injury. Which statement, if made by the client, would indicate an understanding of appropriate care measures for the next 24 hours? 1. "I should place hot packs on my ankle." 2. "I should wrap my ankle with blankets." 3. "I should elevate my foot above the level of the heart." 4. "I should try to ambulate at least 10 minutes out of every hour."
"I should elevate my foot above the level of the heart." Soft tissue injuries such as sprains are treated with RICE (rest, ice, compression, and elevation) for the first 24 to 48 hours after the injury, depending on health care provider prescription. Ice is applied intermittently for 20 to 30 minutes at a time. Heat is not used for the first 24 hours because this could cause venous congestion, thereby increasing edema and pain. Blankets would produce heat to the affected area. The client should rest and not walk around, and the foot should be elevated and not placed in a dependent position.
A client has been experiencing muscle weakness over a period of several months. The health care provider suspects polymyositis. Which client statement correctly identifies a confirmation of test results and this diagnosis? 1. "If I have polymyositis, there will be a decrease in elastic tissue." 2. "I will know I have polymyositis if the muscle fibers are inflamed." 3. "The health care provider said there would be more fibers and tissue with polymyositis." 4. "The health care provider said if the muscle fibers were thickened, I would have polymyositis."
"I will know I have polymyositis if the muscle fibers are inflamed." In polymyositis, necrosis and inflammation are seen in muscle fibers and myocardial fibers. Option 1 refers to the decreased elastic tissue in the aorta seen in Marfan syndrome. Option 3 refers to increased fibrous tissue seen in ankylosis. Option 4 is the opposite of what is noted in this disorder.
The nurse is performing an assessment on a client after a closed reduction of a fractured right humerus and application of a plaster cast. To assess for signs of compartment syndrome, the nurse should perform which action? 1 Assess the client's cognitive level. 2. Assess the temperature of the cast. 3. Monitor for the presence of drainage or odors on or beneath the cast. 4. Assess capillary refill, temperature, color, and amount of pain in the right hand.
Assess capillary refill, temperature, color, and amount of pain in the right hand. The major signs and symptoms of compartment syndrome include pallor or cyanosis; pain, even following the administration of opioid analgesics; vascular compromise demonstrated by weakened or absent pulses and poor capillary refill; and edema of the extremity distal to the area of the fracture. Cognitive level, temperature of the cast, and the presence of drainage or odors on or beneath the cast are not assessments related to compartment syndrome.
A client is admitted to the emergency department with an open fracture of the right tibia. What intervention is most appropriate for this client? 1. Remove the client's shoes. 2. Place the client in a semi Fowler's position. 3. Check the neurovascular status of the area distal to the extremity. 4. Apply a tourniquet above the area of bleeding and loosen it every 15 minutes.
Check the neurovascular status of the area distal to the extremity. To prevent further damage, the neurovascular status must be assessed for temperature, color, sensation, movement, and capillary refill. Tourniquets are not used to control hemorrhage in extremities because of the risk of tissue ischemia. Direct pressure is applied at the site and over the proximal artery nearest the fracture if bleeding occurs. Clients need to be kept in a supine position to help prevent hypotension and shock. Shoes are not removed because this action may cause increased trauma.
The nurse is caring for a client who is an athlete and has sustained an injury to the anterior cruciate ligament. The nurse is providing education to the client regarding the potential treatment measures for this injury. What should the nurse include in the teaching? Select all that apply. 1. Physical therapy 2. Knee immobilizer 3. Aspiration of joint fluid 4. Ambulation with a walker 5 Antiinflammatory medications
Physical therapy Knee immobilizer Aspiration of joint fluid Antiinflammatory medications The anterior cruciate ligament (ACL) runs diagonally in the middle of the knee. Injury to the ACL can result in a partial tear, a complete tear, and an avulsion. Treatment measures for this injury include physical therapy, use of a knee immobilizer or hinge brace, aspiration of joint fluid if an effusion occurs, ambulation with crutches, antiinflammatory medications, rest, ice, and possibly reconstructive surgery.
The nurse is caring for a client diagnosed with osteomyelitis. Which data noted in the client's record are supportive of this diagnosis? Select all that apply. 1. Pyrexia 2. Elevated potassium level 3. Elevated white blood cell count 4. Elevated erythrocyte sedimentation rate 5. Bone scan impression indicative of infection
Pyrexia Elevated white blood cell count Elevated erythrocyte sedimentation rate Bone scan impression indicative of infection Osteomyelitis is an infection of the bone, bone marrow, and surrounding tissue. Clinical data indicative of osteomyelitis include pyrexia, elevated white blood cell count, elevated erythrocyte sedimentation rate, and a bone scan, computed tomography scan, or magnetic resonance imaging scan indicative of infection. Elevated potassium level is not specifically associated with osteomyelitis.
The nurse is obtaining a health history from a client and is assessing for risk factors associated with osteoporosis. The nurse would be most concerned if which data were obtained? Select all that apply. 1. The client reports that she doesn't exercise much at all. 2. The client reports that she smokes a few cigarettes a day. 3. The client reports that she is taking phenytoin to treat a seizure disorder. 4. The client reports that she consumes calcium and vitamin foods and supplements daily. 5. The client reports that she takes a daily low dose of prednisone to treat a chronic respiratory condition.
The client reports that she doesn't exercise much at all. The client reports that she smokes a few cigarettes a day. The client reports that she is taking phenytoin to treat a seizure disorder. The client reports that she takes a daily low dose of prednisone to treat a chronic respiratory condition. Risk factors associated with osteoporosis include a sedentary lifestyle, cigarette smoking, excessive alcohol consumption, chronic illness, and long-term use of anticonvulsants and furosemide. Another risk factor associated with osteoporosis includes a diet that is deficient in calcium. Options 1, 2, 3, and 5 are risk factors associated with osteoporosis.
The nurse is planning to teach the client with below-the-knee amputation about care to prevent skin breakdown. Which point should the nurse include in developing the teaching plan? 1. The residual limb is washed gently and dried every other day. 2. The socket of the prosthesis must be dried carefully before it is used. 3. A residual limb sock must be worn at all times and changed twice a week. 4. The socket of the prosthesis is washed with a harsh bactericidal agent daily.
The socket of the prosthesis must be dried carefully before it is used. A residual limb sock must be worn at all times to absorb perspiration and is changed daily. The residual limb is washed, dried, and inspected for breakdown twice each day. The socket of the prosthesis is cleansed with a mild detergent and rinsed and dried carefully each day. A harsh bactericidal agent would not be used.
A client has several fractures of the lower leg, which has been placed in an external fixation device. The client is upset about the appearance of the leg, which is edematous. The nurse documents which client problem in the plan of care? 1. Feeling isolated 2. Body image alteration 3. Inability to perform activities 4. Inability to engage in physical mobility
body image alteration The client experiences an altered image of the body related to a change in the structure and function of the affected leg. No data in the question support a client's problem of feeling isolated or unable to perform activities or engage in physical mobility.
The nurse is caring for a client who was just admitted to the hospital with a diagnosis of a fractured right hip sustained from a fall 5 hours earlier. The nurse creates a plan of care for the client and includes interventions related to monitoring for signs of fat embolism. Which findings should be listed in the care plan as a sign/symptom of fat embolism? 1. Fever and chills 2. Dyspnea and chest pain 3. External rotation of the right leg 4. Pallor, paresthesia, and pulselessness of the right lower leg
dyspnea and chest pain The signs of fat embolism are associated with alterations in respiratory status or neurological status. Dyspnea, petechiae, and chest pain are signs of fat embolism. External rotation of the leg is indicative of the hip fracture itself. Fever and chills indicate signs of infection, and pallor, paresthesia, and pulselessness indicate signs of severe circulatory impairment.
The nurse is caring for a client who has just had a plaster leg cast applied. The nurse should plan to prevent the development of compartment syndrome by performing which action? 1. Elevate the limb slightly. 2. Elevate the limb above heart level. 3. Keep the leg horizontal and cover the limb with bath blankets. 4. Place the leg in a slightly dependent position, and apply ice to the affected leg.
elevate the limb slightly Compartment syndrome is prevented by controlling edema. Elevation of the extremity may lower venous pressure and slow arterial perfusion; thus, the extremity should not be elevated above the heart. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome. It may also be necessary to bivalve or split the cast in half if compartment syndrome is suspected. Covering the limb with bath blankets, and keeping the leg horizontal or in a dependent position would not be beneficial in controlling edema.
The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg. The nurse notes the presence of edema in the foot below the cast. The nurse should make which interpretation about this finding? 1. Arterial insufficiency 2. Impaired venous return 3. Impaired arterial circulation 4. The presence of an infection
impaired venous return Edema in the extremity indicates impaired venous return. Signs of impaired arterial circulation in the limb include coolness and pallor of the skin and a diminished arterial pulse. Signs of infection under a cast area would include odor or purulent drainage from the cast and the presence of "hot spots," which are areas of the cast that feel warmer to the touch than the rest of the cast.
The nurse is caring for a client who sustained an open fracture and is diagnosed with acute osteomyelitis of the right lower extremity. Which intervention should the nurse plan to perform? 1. Apply ice to the affected area. 2. Perform sterile dressing changes. 3. Instruct the client on leg exercises. 4. Measure the leg circumference daily
perform sterile dressing changes Osteomyelitis is a severe infection of the bone, bone marrow, and surrounding soft tissue. Clinical manifestations include constant bone pain unrelieved by rest that worsens with activity; swelling, tenderness, and warmth at the infection site; restricted movement of the affected part; fever, night sweats, chills, restlessness, nausea, and malaise. Option 2 is the correct option, as treatment of osteomyelitis often includes surgical debridement and requires sterile dressing changes. Option 1 is incorrect, as osteomyelitis is an infection and applying ice to the area will not help any swelling and may cause vasoconstriction. Option 3 is incorrect, as movement worsens the pain and some immobilization of the affected limb (e.g., splint, traction) is usually indicated. Option 4, measuring leg circumference daily, is not necessary.
The nurse in the hospital emergency department is assessing a client with an open leg fracture. The nurse should inquire about the last time the client had which done? 1. Tuberculin test 2. Tetanus vaccine 3. Chest radiograph 4 Physical examination
tetanus vaccine With an open fracture, the client is at risk for the development of osteomyelitis, gas gangrene, and tetanus. The nurse assesses for the date of the last tetanus immunization to ensure that the client has tetanus prophylaxis. The remaining options are unrelated to the current situation identified in the question
