Chapter 43: Care of the Patient with a Musculoskeletal Disorder

46. The nurse administering the drug colchicine for gout will give 0.5 mg hourly for hours.

ANS: 12 Colchicine is given orally in a dose of 0.5 mg for a period of 12 hours or until relief from pain is achieved or diarrhea occurs. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1354 OBJ: 8 TOP: Colchicine KEY: Nursing Process Step: Implementation

43. The division of the skeletal system that comprises the skull, hyoid, vertebral column, and thorax is the division.

ANS: axial The axial division of the skeletal system is comprised of the skull, hyoid, vertebral column, and the throat. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1336 OBJ: 2 TOP: Skeletal divisions KEY: Nursing Process Step: Implementation

24. The 14-year-old boy who is scheduled for left leg amputation says to the nurse, "What in the world am I going to do with only one leg?" What is the nurse's most therapeutic response? a. "What are you thinking about right now?" b. "With a prosthesis, you will be as good as new." c. "It is way too early to be concerned about that now." d. "When my brother had his leg removed, he did great!"

ANS: A The patient's concern should be acknowledged and the patient encouraged to express feelings. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1394 OBJ: 20 TOP: Fracture of hip KEY: Nursing Process Step: Implementation

40. The characteristics of osteoarthritis that should be included in a teaching plan would include that osteoarthritis (select all that apply): a. will cause the formation of Heberden nodes. b. can involve other organs. c. results from wear and tear. d. may affect only one side of the body. e. may cause constitutional symptoms of fatigue and fever. f. will cause marked erythema and edema of hands.

ANS: A, C, D Osteoarthritis is a disease caused by wear and tear of the joints, causing the appearance of Heberden nodes on the fingers without marked edema or erythema. The disease may only affect one side of the body and does not cause constitutional symptoms. PTS: 1 DIF: Cognitive Level: Application REF: Page 1344, Table 43-4 OBJ: 10 TOP: Osteoarthritis KEY: Nursing Process Step: Planning

48. The nurse takes into consideration that a healing fracture progresses through several healing stages. Place the stages in order of healing. (Separate letters by a comma and space as follows: A, B, C, D) a. Development of fibrin meshwork b. Collagen fibers collect calcium c. Osteoblasts home fracture site form d. Callus e. Formation of hematoma f. Clot formation g. Vascularization

ANS: F, E, A, C, G, B, D The healing stages of a fracture start with a clot formation, which leads to a hematoma. The development of a fibrin meshwork, which traps osteoblasts to keep the fracture site firm, vascularization, collagen fibers collect calcium to make the callus. Topic: Fracture healing Nursing Process Step: Planning Objective: 15 Cognitive Level: Analysis NCLEX: Physiological Integrity Text Reference: Page 4-64 PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1371 OBJ: 15 TOP: Fracture healing KEY: Nursing Process Step: Planning

47. The nurse explains that the use of the brace allows a person with a cervical fracture to be mobile.

ANS: halo Halo braces attach to the skull with pins, which stabilize a cervical vertebral fracture, allowing the patient to be mobile. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1372, Figure 43-21 OBJ: 15 TOP: Halo brace KEY: Nursing Process Step: Implementation

44. A patient's patellar-femoral cartilage has deteriorated due to arthritis. The medial and lateral cartilage is undamaged. This patient is likely to undergo knee replacement surgery.

ANS: partial, unicompartmental Unicompartmental knee arthroplasty is also referred to as partial knee replacement and is performed on patients who have only one of the compartments of the knee affected by arthritis. Topic: Partial knee replacement Nursing Process Step: Planning Objective: 10 Cognitive Level: Comprehension NCLEX: Physiological Integrity Text Reference: Page 4-46 PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1361 OBJ: 10 TOP: Partial knee replacement KEY: Nursing Process Step: Planning

45. The emergency department nurse assesses the two cardinal signs of a hip fracture in a newly admitted patient, which are the of the injured leg and the rotation of that same leg.

ANS: shortening, external The two cardinal signs of a fractured hip are the appearance of the shortening of the affected leg and the external rotation of that same leg. PTS: 1 DIF: Cognitive Level: Application REF: Page 1366 OBJ: N/A TOP: Signs of hip fracture KEY: Nursing Process Step: Assessment

1. What is the movement of an extremity away from the midline of the body called? a. Abduction b. Adduction c. Flexion d. Extension

ANS: A Abduction is movement of an extremity away from the midline of the body. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1339 OBJ: 6 TOP: Movements KEY: Nursing Process Step: Implementation

12. Which finding would delay a computed tomography (CT) scan? a. Patient's allergy to shellfish b. Patient in first trimester of a pregnancy c. Patient's allergy to milk products d. Patient's gluten intolerance

ANS: A Allergy to shellfish predicts an allergy to the contrast media used in the CT scan. PTS: 1 DIF: Cognitive Level: Application REF: Page 1342 OBJ: 7 TOP: CT scan KEY: Nursing Process Step: Assessment

19. When the patient with rheumatoid arthritis complains about the daily exercise, the nurse encouragingly reminds the patient that exercises: a. keeps the joints from "freezing." b. will ensure better sleep. c. should be vigorous for joint stimulation. d. need not be done daily.

ANS: A Daily gentle exercises keep the joints from "freezing" and keep the muscles from weakening. PTS: 1 DIF: Cognitive Level: Application REF: Page 1349 OBJ: 8 TOP: Rheumatoid arthritis KEY: Nursing Process Step: Assessment

34. Certain foods may increase the pain associated with gout. Which foods have the highest concentration of purines? a. Brain, liver, kidney b. Lettuce, corn, potatoes c. Beef, pork, chicken d. Fruits and fruit juices

ANS: A Foods high in purines, such as brain, kidney, liver, and heart should be avoided, as well as alcohol. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1354 OBJ: 8 TOP: Gout KEY: Nursing Process Step: Assessment

23. A 16-year-old male patient presents in the emergency room with a pathologic fracture of the left femur and complains of pain on weight bearing. These are cardinal indicators of: a. osteogenic sarcoma. b. osteoporosis. c. rheumatoid arthritis. d. osteochondroma.

ANS: A Osteogenic sarcoma occurs in young men aged 10 to 25. They are malignant bone tumors that can cause a pathologic fracture and they are accompanied by pain on weight bearing. Osteochondromas are benign and usually do not cause fractures. PTS: 1 DIF: Cognitive Level: Application REF: Page 1393 OBJ: 20 TOP: Bone tumor KEY: Nursing Process Step: Assessment

27. What should the nurse stress to a post-hip replacement patient in quadriceps setting exercises? a. Push knee down to mattress and raise heel off the bed b. Flex knee and extend foot c. Adduct leg and flex foot d. Lift leg and heel off the bed

ANS: A Pushing the knee down into the mattress and raising the heel will strengthen the quadriceps muscles. PTS: 1 DIF: Cognitive Level: Application REF: Page 1367, Patient Teaching OBJ: 14 TOP: Quad setting KEY: Nursing Process Step: Implementation

31. How is rheumatoid arthritis distinguished from osteoarthritis? a. Rheumatoid arthritis is an autoimmune, systemic disease; osteoarthritis is a degenerative disease of the joints. b. Rheumatoid arthritis is an autoimmune, degenerative disease; osteoarthritis is a systemic inflammatory disease. c. People with osteoarthritis are considered to be genetically predisposed; there is no known genetic component to rheumatoid arthritis. d. Osteoarthritis is often caused by a virus; viruses play no part in the pathogenesis of rheumatoid arthritis.

ANS: A RA is thought to be an autoimmune disorder. Degenerative joint disease is also known as osteoarthritis. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1344, Table 43-4 OBJ: 8 TOP: Rheumatoid arthritis KEY: Nursing Process Step: Assessment

14. What is the first priority nursing intervention for an impending fat embolism? a. Administer oxygen in a respiratory emergency b. Increase intravenous fluids c. Position in flat position to ease decreased blood pressure d. Cover with warm blanket

ANS: A The airway is always the first priority. If hypoxia is present, the physician will order the administration of oxygen. It is important for the nurse to check the liter flow of oxygen and educate patients and their families as to safety precautions necessary when oxygen is administered. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1377 OBJ: 17 TOP: Fat embolism KEY: Nursing Process Step: Implementation

11. What should the nurse include in the plan of care for a patient following a myelogram? a. Position in a semi-Fowler position for 8 hours to reduce potential of headache b. Place patient flat on back to compress puncture site c. Ambulate for brief periods to lessen postmyelogram headache d. Limit fluids to increase absorption of the dye

ANS: A The patient should be positioned in the semi-Fowler position for 8 hours to encourage the dye to stay in the lower spine and to reduce headache. PTS: 1 DIF: Cognitive Level: Application REF: Page 1340 OBJ: 7 TOP: Myelogram KEY: Nursing Process Step: Implementation

33. The patient, age 58, is diagnosed with osteoporosis after densitometry testing. She has been menopausal for 5 years and has been concerned about her risk for osteoporosis because her mother has osteoporosis. In teaching her about her osteoporosis, which information does the nurse include? a. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise. b. Estrogen replacement therapy must be started to prevent rapid progression of her osteoporosis. c. With a family history of osteoporosis, there is no way to prevent or slow bone reabsorption. d. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis.

ANS: A To prevent osteoporosis, women are advised to have an adequate daily intake of calcium and vitamin D; exercise regularly; avoid smoking; decrease coffee intake; decrease excess protein in the diet; and engage in regular moderate activity such as walking, bike riding, or swimming at least 3 days a week. A contributing factor may be use of steroids. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1355 OBJ: 11 TOP: Osteoporosis KEY: Nursing Process Step: Implementation

16. Which foods should the home health nurse suggest for the patient with osteoporosis to help slow the disease? a. Leafy green vegetables b. Foods high in sodium c. Tea and coffee d. Vitamin A

ANS: A To slow the bone loss, a patient with osteoporosis should eat green leafy vegetables, foods low in sodium, and also avoid caffeine. Vitamin A does not help with the absorption of calcium. PTS: 1 DIF: Cognitive Level: Application REF: Page 1357, Patient Teaching OBJ: 11 TOP: Osteoporosis diet KEY: Nursing Process Step: Implementation

4. The nurse instructs the patient who is to have a unicompartmental knee replacement that a major advantage of this partial knee replacement is that: a. the patient will be up and walking 2 to 3 hours after the operation. b. the kneecap is completely removed. c. the procedure is especially helpful in the treatment of rheumatoid arthritis. d. a small titanium disk replaces the worn cartilage.

ANS: A Unicompartmental knee arthroplasty is also referred to as partial knee replacement in which the worn cartilage is replaced with a plastic disk. It is not as invasive as a full knee replacement and does not disturb the kneecap so that the patient can be up and walking in 2 to 3 hours after surgery. It is not recommended for RA patients. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1361 OBJ: 13 TOP: Unicompartmental knee replacement KEY: Nursing Process Step: Implementation

39. Which of the following are the main purposes of traction? (Select all that apply.) a. Align and stabilize a fracture b. Prevent deformities c. Relieve muscle spasms d. Promote bed rest e. Increase circulation to the rest of the body

ANS: A, B, C Skin and skeletal traction provide alignment and stabilize a fracture. This prevents deformities and relieves muscle spasms by putting muscles under tension until they are fatigued. PTS: 1 DIF: Cognitive Level: Application REF: Page 1383 OBJ: N/A TOP: Traction KEY: Nursing Process Step: Assessment

42. Which instructions should the nurse include in a teaching plan for a person with gouty arthritis? (Select all that apply.) a. Avoid excessive alcohol. b. Maintain rest and immobility while disease is symptomatic. c. Check urine and urine output for possible kidney stones. d. Include food high in purine in the diet. e. Use bed cradle to support linens.

ANS: A, B, C, E The person with gout should avoid alcohol and food with high purine content, maintain rest and immobility while symptomatic, and check urine and urine output for possible kidney stones. PTS: 1 DIF: Cognitive Level: Application REF: Page 1354 OBJ: 8 TOP: Gout KEY: Nursing Process Step: Implementation

30. The office nurse has noted the presence of an increase in lumbar curvature in a 20-year-old female patient. What is this condition known as? a. Scoliosis b. Lordosis c. Kyphosis d. Spondylitis

ANS: B Common deformities include an increase in the curve at the lumbar space region that throws the shoulder back, making the "lordly or kingly" appearance that is known as lordosis. Scoliosis involves the S curvature of the spine. Kyphosis is the rounding of the thoracic spine. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1396 OBJ: 22 TOP: Lordosis KEY: Nursing Process Step: Assessment

17. What should the nurse include in the teaching plan for a patient who is taking alendronate (Fosamax)? a. Take drug with any meal b. Take drug first thing in the morning c. Drink at least 5 oz of milk before taking drug d. Take drug with an antacid to avoid heartburn

ANS: B Alendronate (Fosamax) should be taken on an empty stomach first thing in the morning with 6 oz of water, accompanied by no other medication. PTS: 1 DIF: Cognitive Level: Application REF: Page 1356, Table 43-6 OBJ: 8 TOP: Osteoporosis drug KEY: Nursing Process Step: Planning

8. A patient had an open reduction with internal fixation (ORIF) for a compound fracture of the left tibia and has been placed in a long leg cast. The assessments by the nurse are: left foot warm/pink, pedal pulse weaker than right, capillary refill 3 seconds, and small 1 cm area of blood on cast. What should the nurse do? a. Notify charge nurse of impending compartment syndrome b. Document that all assessments are within normal limits c. Inform charge nurse about probable hemorrhage d. Place warm compresses on left foot

ANS: B All of the assessments are within normal limits. A small amount of blood on the cast is expected and should be monitored. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1397 OBJ: 19 TOP: Compound fracture KEY: Nursing Process Step: Assessment

10. Which patient statement indicates the need for additional teaching for a patient with rheumatoid arthritis who is taking meloxicam (Mobic)? a. "I am keeping a daily record of my blood pressure." b. "I take aspirin before I go to bed." c. "I know I can take meloxicam with or without regard to meals." d. "I weigh every day so I will be aware of any weight gain."

ANS: B Aspirin or products containing aspirin should be avoided while taking meloxicam. PTS: 1 DIF: Cognitive Level: Application REF: Page 1346, Table 43-5 OBJ: 9 TOP: Rheumatoid arthritis KEY: Nursing Process Step: Evaluation

9. When a patient recovering from a fractured tibia asks what callus formation is, the nurse tells her it is: a. when blood vessels of the bone are compressed. b. a part of the bone healing process after a fracture when new bone is being formed over the fracture site. c. the formation of a clot over the fracture site. d. when the hematoma becomes organized and a fibrin meshwork is formed.

ANS: B Callus formation occurs when the osteoblasts continue to lay the network for bone buildup and osteoclasts destroy dead bone. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1371 OBJ: 15 TOP: Bone healing KEY: Nursing Process Step: Implementation

18. The patient has been diagnosed as having gouty arthritis. The patient asks the nurse to explain the cause of the inflammation of the great toe. What is the most appropriate nursing response? a. "You have calcium oxalate deposits that are seen in gouty arthritis." b. "The inflammation is from small accumulations of uric acid crystals, which are called tophi." c. "The small nodules are not related to the arthritis condition." d. "You have fat deposits that are common with gouty arthritis."

ANS: B Gout is a metabolic disease resulting from an accumulation of uric acid in the blood. It is an acute inflammatory condition associated with ineffective metabolism of purines. PTS: 1 DIF: Cognitive Level: Application REF: Page 1353 OBJ: 8 TOP: Gouty arthritis KEY: Nursing Process Step: Implementation

38. What does prolonged bed rest put the older adult at risk for? a. Ankylosing spondylitis b. Pathologic fractures c. Osteomyelitis d. Gout

ANS: B Immobilization results in bone resorption, and the bone tissue becomes less dense. Prolonged bed rest puts the patient at risk for pathologic fracture. This is a serious concern for an older adult in terms of regaining mobility. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1344 OBJ: 11 TOP: Disorders of musculoskeletal system KEY: Nursing Process Step: Assessment

28. What should the home health nurse include assessment for in the plan of care for an 82-year-old female with severe kyphosis from ankylosis? a. Urinary output b. Respiratory effort c. Sleep cycle d. Nutritional status

ANS: B Severe kyphosis may hinder the patient's ability to expand the ribcage and interfere with easy respiration. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1350 OBJ: 22 TOP: Kyphosis KEY: Nursing Process Step: Implementation

22. What should the nurse do when a patient with osteomyelitis is admitted with an open wound that is draining? a. Enforce a low calorie diet b. Initiate drainage and secretion precautions c. Frequently do passive ROM on the elbow d. Ambulate several times daily

ANS: B The patient with osteomyelitis should be at least in drainage and secretion precaution. The limb should be positioned for maximum comfort and left at rest. These patients are usually on bed rest and require a high-calorie, high-protein diet. PTS: 1 DIF: Cognitive Level: Application REF: Page 1358 OBJ: 19 TOP: Osteomyelitis KEY: Nursing Process Step: Implementation

32. Which patient is most likely to develop osteoporosis? a. 43-year-old African American woman b. 57-year-old white woman c. 48-year-old African American man d. 62-year-old Latino woman

ANS: B White and Asian women have a higher incidence of osteoporosis than African American women or Hispanic women because of the greater bone density in the African American. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1356, Culture OBJ: 11 TOP: Osteoporosis KEY: Nursing Process Step: Assessment

41. What are the three vital functions muscles perform when they contract? (Select all that apply.) a. Absorb uric acid b. Maintenance of posture c. Motion d. Store minerals e. Production of heat f. To assist in return of venous blood to the left side of the heart

ANS: B, C, E The three vital functions muscles perform when they contract are maintenance of posture, motion, and production of 85% of body heat. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1336 OBJ: 6 TOP: Functions of muscular system KEY: Nursing Process Step: Assessment

5. A patient who has had a right below the knee amputation continues to complain of unpleasant sensation in the right foot. What can the nurse explain about this "phantom pain"? a. It only exists in the mind. b. It is a complication following an amputation and can be clarified by the surgeon. c. It is related to the severed nerves that are still sending messages to the brain. d. It occurs when the person becomes focused on the loss of the limb.

ANS: C Phantom pain (pain felt in the missing extremity as if it were still present) may occur and be frightening to the patient. Phantom pain occurs because the nerve tracts that register pain in the amputated area continue to send a message to the brain (this is normal). PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1394 OBJ: 21 TOP: Phantom pain KEY: Nursing Process Step: Implementation

20. The nurse clarifies to a patient who is being evaluated for possible rheumatoid arthritis that the elevated erythrocyte sedimentation rate indicates the presence of: a. immunoglobulin M. b. abnormal serum protein. c. increased inflammatory reaction in the body. d. C-reactive protein.

ANS: C The ESR indicates an increase in the inflammatory reactions in the body. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1345 OBJ: 8 TOP: Rheumatoid arthritis KEY: Nursing Process Step: Implementation

13. Forty-eight hours after a patient sustained a fractured femur in a car accident, the nurse assessed a pulse of 110, respirations at 25, and labored crackles in both lung fields. The nurse immediately reports to the charge nurse the probability of a(n): a. impending pneumonia. b. atelectasis. c. fat embolism. d. anxiety attack.

ANS: C A pulmonary fat embolism involves the embolization of fat tissue with platelets and circulation of free fatty acids within the pulmonary circulation. Dyspnea, tachypnea, and chest pain are symptomatic of a fat embolus. PTS: 1 DIF: Cognitive Level: Application REF: Page 1376 OBJ: 17 TOP: Fat embolism KEY: Nursing Process Step: Assessment

21. What should the nurse instruct the patient before the initiation of the antimalarial drug hydroxychloroquine (Plaquenil)? a. Get a complete blood count to assess anemia. b. Get a chest x-ray. c. Get an eye examination. d. Take prophylaxis for malaria.

ANS: C An eye examination should be completed before starting the drug and an eye examination should be done every 6 months while on the drug, because the drug can damage the retina and lead to blindness. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1336, Table 43-5 OBJ: 8 TOP: Gout KEY: Nursing Process Step: Implementation

37. A 56-year-old female patient is being seen for osteoarthritis of the knee in the clinic. What should the nurse recommend when discussing strengthening exercises? a. Jogging b. Walking rapidly on a treadmill c. Bicycling d. Aerobic exercises

ANS: C Bicycling or swimming is recommended for osteoarthritis of the hip or knee. Jogging would put undue stress on knee joints. Climbing stairs should be avoided. Walking should be done on level ground, not up or down elevations. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1351, Box 43-3 OBJ: 10 | 11 TOP: Osteoarthritis KEY: Nursing Process Step: Implementation

25. A patient has undergone a bipolar hip repair (hemiarthroplasty). Which is the most appropriate instruction? a. Sit in whatever position is most comfortable b. Sit in a firm, straight-backed chair at a 90-degree angle c. Avoid crossing the legs d. Begin full weight bearing as soon as tolerated

ANS: C Instructing the patient not to cross the legs is important because crossing the legs can adduct the affected extremity and dislocate the hip. PTS: 1 DIF: Cognitive Level: Application REF: Page 1367, Figure 43-18 OBJ: 14 TOP: Hip replacement KEY: Nursing Process Step: Implementation

3. What should the nurse instruct the patient before a magnetic resonance imaging (MRI) procedure? a. Void to completely empty the bladder b. Omit all citrus food for 12 hours before the procedure c. Remove all metal, such as jewelry, glasses, and hair clips d. Wear only cotton garments for the procedure

ANS: C MRI procedures require that the patient remove all metal because it will become magnetized. PTS: 1 DIF: Cognitive Level: Application REF: Page 1341 OBJ: 7 TOP: Diagnostic examinations KEY: Nursing Process Step: Assessment

6. The patient that has a bipolar hip replacement following an intracapsular fracture has an order to be turned every 2 hours. The nurse understands that the correct nursing intervention is to keep the legs: a. together so they do not separate while turning. b. flexed to stabilize the prosthesis. c. abducted so the prosthesis does not become dislocated. d. adducted to prevent additional pain for the patient with turning.

ANS: C Nursing interventions also involve postoperative maintenance of leg abduction by using an abduction splint for 7 to 10 days to prevent dislocation of the prosthesis. PTS: 1 DIF: Cognitive Level: Application REF: Page 1367, Figure 43-13 OBJ: 14 TOP: Maintaining abduction KEY: Nursing Process Step: Implementation

36. Calcium is a mineral found in many foods that can slow bone loss during the aging process. Which food is high in calcium? a. Oranges b. Bananas c. Spinach d. Eggs

ANS: C Spinach and green vegetables, as well as yogurt, are considered calcium-rich foods. Fresh oranges, bananas, and eggs are not good calcium choices. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1355, Patient Teaching OBJ: 11 TOP: Osteoporosis KEY: Nursing Process Step: Implementation

35. In order for a patient to flex the lower leg, which muscle must be contracted? a. Quadriceps b. Gastrocnemius c. Biceps femoris d. Rectus femoris

ANS: C The contraction of the biceps femoris allows for the contraction of the lower leg. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1335, Table 43-1 OBJ: 4 TOP: Muscle action KEY: Nursing Process Step: Implementation

7. A patient has been casted to stabilize a fracture of the right radius and ulna. The nurse assesses a capillary refill of 5 seconds and cold fingers of the right hand. Which initial intervention should the nurse deploy? a. Notify the charge nurse of a probable compartment syndrome b. Apply a warm compress to the fingers to relieve swelling c. Elevate the right hand to heart level to maintain arterial pressure d. Cut the cast off to release constriction

ANS: C The nurse should first elevate the right hand to heart level and notify the charge nurse. Permanent damage can occur in as little time as 6 hours. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1375 OBJ: 19 TOP: Compartment syndrome KEY: Nursing Process Step: Implementation

26. The nurse explains to a patient who has had a knee replacement that warfarin (Coumadin) is ordered to: a. increase the red blood cells. b. reduce the threat of hemorrhage. c. prevent formation of emboli. d. help stabilize the prosthesis.

ANS: C Warfarin (Coumadin) is a standard postsurgical drug to prevent the formation of emboli. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1367 OBJ: 13 TOP: Coumadin therapy KEY: Nursing Process Step: Implementation

15. A patient, age 68, has suffered an intertrochanteric fracture of the right hip. Before surgery, to provide support and comfort, an immobilizing device of a is applied. a. Thomas splint b. Bryant traction c. Russell traction d. Buck traction

ANS: D Buck traction is a form of traction used as a temporary measure to provide support and comfort to a fractured extremity until a more definite treatment is initiated. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1383 OBJ: 21 TOP: Fracture KEY: Nursing Process Step: Implementation

2. What is the large, fan-shaped muscle that covers the anterior chest from the sternum to the proximal end of the humerus and acts on the joint of the shoulder to flex, adduct, and rotate? a. Serratus anterior b. Intercostal c. Transversus abdominis d. Pectoralis major

ANS: D Pectoralis major is the large, fan-shaped muscle that covers the anterior chest and is an adductor muscle, which will cause the shoulder to flex. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1341, Figure 43-4 OBJ: 4 TOP: Muscle functions KEY: Nursing Process Step: Assessment

29. What should the nurse stress to a patient who has had a hip replacement and is beginning strengthening exercises for the unaffected leg? a. Flex the knee and flex the foot b. Lift the leg from the mattress and rotate the foot c. Pull knee to chest and extend the foot d. Push foot down against the footboard for a count of five

ANS: D The unaffected leg should be strengthened by pushing the foot down against the footboard for a count of five and repeating frequently during the day. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1367, Patient Teaching OBJ: 13 TOP: Exercise KEY: Nursing Process Step: Implementation