foundations practice questions
Turning a patient can be harmful in
unstabilized spinal injuries
30. You are working with a student nurse to set up traction on a patient with Buck's traction. How often do you need to assess circulation to the affected leg? A) Within 30 minutes, then every 1 to 2 hours B) Within 30 minutes, then every 4 hours C) Within 30 minutes, then every 8 hours D) Within 30 minutes, then every shift
WITHIN 30 MINUTES THEN EVERY 1-2 HOURS **After skin traction is applied, the nurse assesses circulation of the foot or hand within 15 to 30 minutes and then every 1 to 2 hours. Therefore options B, C, and D are incorrect
12. To provide for the psychosocial needs of an immobilized client, an appropriate statement by the nurse is which of the following? 1. "The staff will limit your visitors so that you will not be bothered." 2. "A roommate can be a real bother. You'd probably rather have a private room." 3. "Let's discuss the routine to see if there are any changes we can make." 4. "I think you should have your hair done and put on some makeup."
"Let's discuss the routine to see if there are any changes we can make."
coefficient of friction
.5 for lumbar, .62 for c-spine
open C1-C2
0 to five degrees of flexion
1. The nurse recognizes that facilitating correct body alignment for a dependent client may well result in which of the following positive client outcomes? (Select all that apply.) 1. A comfortable night's sleep 2. Minimized activity intolerance 3. Muscle tone that promotes ambulation 4. Reduction of falls caused by general weakness 5. Minimal strain placed on the spinal column 6. Increased socialization, resulting in peace of mind
1. A comfortable night's sleep 2. Minimized activity intolerance 3. Muscle tone that promotes ambulation 4. Reduction of falls caused by general weakness 5. Minimal strain placed on the spinal column
What can the Logroll turn be used for?
1. Bed linen changes 2. change of body position 3. give back care
3 Major factors of principles underlying proper body mechanics are:
1. Center of gravity 2. Base of support 3. Line of gravity
2. The nurse chooses to use a mechanical lift to move an obese immobile client. The nurse recognizes that the positive outcomes for both the client and the staff resulting from this intervention will be: (Select all that apply.) 1. Less of the client's body will be dragged along the sheets during the transfer 2. There will be less chance of injuring the skin on the client's elbows and buttocks 3. The staff involved in the transfer will have less likelihood of self-injury 4. The staff will have a greater degree of control over the move 5. The client will feel physically safer during the transfer 6. The move will be accomplished more quickly
1. Less of the client's body will be dragged along the sheets during the transfer 2. There will be less chance of injuring the skin on the client's elbows and buttocks 3. The staff involved in the transfer will have less likelihood of self-injury 4. The staff will have a greater degree of control over the move
5. A client who experienced a myocardial infarction has been placed on bed rest. The nurse caring for the client recognizes that the inactivity will result in certain assessment findings that include: (Select all that apply.) 1. Lethargy 2. Confusion 3. Depression 4. Poor appetite 5. Hypoactive bowel sounds 6. Decrease in baseline respiratory rate
1. Lethargy 4. Poor appetite 5. Hypoactive bowel sounds 6. Decrease in baseline respiratory rate
3. A 16-year-old has had a full leg cast in place for 2 months, and it is being removed today. Which of the following assessment findings would be expected following the removal of the cast? (Select all that apply.) 1. Popliteal pulse equal in both legs 2. Slight footdrop noted on affected leg 3. Swelling noted at ankle on affected leg 4. Weight bearing less stable on affected leg 5. Calf circumference greater in unaffected leg 6. Greater range of motion of knee of unaffected leg
1. Popliteal pulse equal in both legs 4. Weight bearing less stable on affected leg 5. Calf circumference greater in unaffected leg 6. Greater range of motion of knee of unaffected leg
Reasons for changing a clients position:
1. Promotes comfort 2. Restores body function 3. Prevents Deformities 4. Relieves Pressure 5. Prevents muscle strain' 6. Stimulates proper respirations and circulations 7. To give Nursing treatmeants
4. Which of the following factors has an impact on the severity of physical impairment a client will experience from a period of immobility? (Select all that apply.) 1. The client's age 2. Prior overall health 3. Length of immobility 4. The degree of immobility 5. Situation requiring the inactivity 6. Client's mental attitude about the limitations
1. The client's age 2. Prior overall health 3. Length of immobility 4. The degree of immobility
Isometric exercises are helpful with strength in what:
1. abdominal 2. gluteal 3. quadriceps (all of which are necessary to be able to walk)
Isometric exercises prepare the client for what?
1. crutch walking 2. maintain muscle tone in a casted limb 3. wheelchair use 4. teach bowel training
Correct posture:
1. heads up 2. chest is out 3. back is straight 4. abdomen is in
Exercise can also help prevent the conditions such as:
1. hypostatic pneumonia 2. thrombophlebitis 3. footdrop 4. circualtory difficulties 5. skin breakdown 6. fecal impactions
Disorders and problems caused by staying in bed are:
1. pressure ulcers 2. blood clots 3. constipation 4. muscle weakness 5. pneumonia 6. joint deformities
Some daily activities can be turned into useful exercises such as:
1. reaching for objects on bedside table 2. pulling and pushing of bedside table to and from 3. brushing hair
three basic types of canes are
1. standard straight legged cane 2. the tripod cane (which has three feet) 3. the quad cane (which has four feet)
What can cause differences in ROM on an individual basis?
1.body developement 2. genetic inheritance 3. presence or absence of disease 4. amount of exercise a preson usually gets
lbs required for lumbar traction
1/4 body weight to overcome friction progressing up to 1/2 body weight
lumbar traction requires
1/4 of body wt to overcome friction
open C2-C5
10 to 20 degrees flexion
10. Before discharge, the nurse tells Karen that she should pace her activities. An example of pacing activities would be: a) doing all her household chores in the morning and resting in the afternoon b) taking a nap before going shopping c) hiring a helper to do the housework
10) B - pacing activities means alternating and balancing rest periods and activity in order to prevent excessive fatigue and over exertion. Rheumatoid arthritis is a chronic autoimmune disease characterized by inflammation and destruction of connective tissue within the joints that leads to eventual depletion of joint cartilage that weakens and cause dislocation of joint. This disease is characterized by periods of remissions and exacerbations. This disorder occurs three times more frequent in women until age 65 when both sexes have the same incidence. The most common joints affected are those of the hands, wrist, feet, ankles, elbows and knees. May also affect the heart, lungs and spleen late in the disease process.
11. Which type of medication is most commonly used to treat rheumatoid arthritis? a) glucocorticoids b) non-steroidal ant-inflammatory drugs (NSAIDs) c) antimalarial drugs d) gold salts
11) B - NSAID's are the first drugs of choice of RA. Its main action is to inhibit the inflammatory action of the mediators of inflammation; arachidonic acid and prostaglandins, etc to stop the disease process. It also provide pain relief. However it does not correct existing damage or bone deformity. below are the drugs used to treat RA. SALICYLATES: - ASA-Aspirin Anti-inflammatory and analgesic SIDE-EFFECTS take every 4-6 hours to maintain anti-inflammatory effect gastric irritation - take with food or milk toxicity - tinnitus, increase bleeding tendencies - instruct to report dark tarry stool hypersensitivity - rash NSAIAs (nonsteroidal) indomethacin (indocin) ibuprofen (motrin) tolmetin Na (tolectin) naproxen (naprosyn) fenoprofen (nalfon) sulindac (clinoril) diflunisal (dolobid) piroxicam (feldene) diclofenac Na (voltaren) SIDE-EFFECTS GIT irritation - take with food and milk, take with antacids headache and dizziness - discontinue and notify physician drowsiness - avoid driving do not use with salicylates or other anti-inflammatory agents do not crush enteric coated tablets Adrenocorticosteroids Prednisone Suppresses inflammatory reaction by the body SIDE-EFFECTS fluid retention - monitor weight increased susceptibility to infection - avoid exposure to persons with infection GIT irritation - take with food or antacid. Take in the morning if to be taken once a day decreased healing potential osteoporosis hirsutism adrenal crisis if abruptly withdrawn DM - do not stop, increase, decrease without doctor's order Antimalarials Hydroxychloroquine (plaquenil) Chloroquine (aralen) anti-inflammatory effect Quinacrine (atabrine) SIDE-EFFECTS effect expected after 6-12 months retinal edema that can lead to blindness - have an eye exam every 6 months yellow discoloration of the skin - may be stopped periodically to prevent deepening of skin discoloration Gold Salts: (IM) Gold Sodium Thimalate (myochrysine) Gold thioglucose (solganol) Gold (oral) Aurafin (ridaural) SIDE-EFFECTS effect after 3-6 months renal damage and hepatic damage - urinalysis and CBC before each injection dermatitis, ulcerations in mouth - report dermatitis and metallic taste and lesions in mouth to physician
open C5 -C7
20 to 30 degrees flexion
20. Which of the following will contribute to the development of primary gout? a) beer and wine b) eggs and milk c) vegetables and meat d) butter and fruits
20) A - beer and wine are purine-rich beverages. Gout is a metabolic disorder of purine. Other foods rich in purine are: organ meats, legumes, salted anchovies, shellfish, mushroom, sweetbreads, consomme, hearing fish.
lbs cervical spine
25 to 30 lbs
Situation: Maco, a newly registered nurse, works as a private duty nurse of a 55 year old female Canadian national who has gout. 3. Which of the following nursing diagnoses is a priority for a patient with gout? a) pain b) fatigue c) risk for infection d) risk for peripheral neurovascular dysfunction
3) A - Gouty arthritis is a metabolic disorder characterized by accumulation and deposition of uric acid crystals, called tophi, in tissues especially in joints that results in inflammatory response. It is caused by prolonged hyperuricemia due to problems in synthesizing purines or by poor excretion of uric acid by the kidney. This disorder is more common in men, with onset around age 50. The immediate problem of patient suffering from gout is the acute pain experienced on affected joints such as the great toe, feet, ankles, or knees. Other signs and symptoms include: malaise pruritus headache elevated serum uric acid presence of tophi positive monsodium urate crystals in synovial fluid inflammation of affected joint Nursing care during the acute phase when severe joint pain afflicts the patient includes: provide bed rest use bed cradle to support bed sheets and keep pressures of sheets off joint perform range of motion exercise gently carefully align joints so they are slightly flexed administer medications
semi fowlers
30 to 46 degree angle
30. Which of the following factors should concern the nurse most in a client who had undergone total hip replacement? a) the client has a small dog and a cat at home b) the client goes for a walk in the park each morning c) the client showers instead of having tub bath d) the client uses raised toilet seat
30) A - bending and stooping like taking care of a small dog and a cat, may cause dislodgement of the hip prosthesis.
31. The client is diagnosed to have fibromyalgia. Which of the following signs and symptoms is commonly experienced by the client? a) irritability b) headache c) fever d) lethargy
31) B - fibromyalgia is a chronic syndrome of musculoskeletal tissues characterized by chronic widespread pain. Assessment: painful muscles, fatigue, sleep disturbances, headache, restlessness leg syndrome, depression.
32. The client is being prepared for crutch-walking. Which of the following health teachings should be included? a) flex the arms at 90 degree angle with the crutches b) the axillae should rest on both crutches c) bear weight on the palms of the hands d) going up and down the stairs is not allowed when using crutches
32) C - when using crutches, the client should bear weight on the palms of the hands not on the axillae. This is to prevent crutch palsy
34. The client will go electromyography (EMG). Which of the following information should be given when preparing the client for this procedure? a) a contrast medium will be injected into your vein b) you will be placed in a tunnel-like device c) electrode needles will be inserted into your muscles d) scalp electrodes will be applied and graphical recording of electrical activities of your brain will be done
34) C - in EMG, electrode needles will be inserted into the muscles. There will be mild discomfort.
35. X-rays confirm that a patient has a fractured femur. While the patient is in balanced skeletal traction, which of these measures is important? a) adjusting the weights when moving him up in bed b) supporting his affected leg in plantar flexion c) raising him up in bed whenever he slips down d) maintaining him in semi-fowler's position
35) C - raising the patient with traction, up in bed whenever he slips down maintains efficiency of the traction.
40. A client with Paget's disease develops osteoporosis due to a) vitamin D deficiency b) inadequate calcium in diet c) bone resorption is rapid d) lack of pressure on the bones
40) C - paget's disease is characterized by very rapid bone resorption, followed by very rapid bone regeneration. However, the new bone tissues formed are weak. The client is prone to fracture.
41. A nurse is working with a nursing assistant on an orthopedic unit. The nurse observes the nursing assistant caring for a client after a left total hip replacement. The nurse will intervene if which of the following is observed? a) the nursing assistant stoops by bending at the hips and knees to pick up an object that the client dropped on the floor b) the nursing assistant keeps the client's bed in the low position when administering the bath c) the client is positioned with leg abducted slightly d) the head of the bed is elevated 30 degrees
41) B - during administration of bath, the nursing assistant should raise the bed to waist level to prevent bending and stooping. This prevents muscle strain and back injury.
open L5-S1
45 to 60 degrees
55. A nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which of the following findings? a) inflammation b) serous drainage c) pain at a pin site d) purulent drainage
55) B - A small amount of serous oozing is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported to the physician.
open L4-L5
60 to 75 degrees of flexion
the E-Z lift has a compacity of
600lbs
open L3-L4
75 to 90 degrees flexion
tx time disc herniation lumbar spine
8 to 10 minutes - longer hold times
27. Patients who do not have mechanical prophylaxis and pharmacologic prophylaxis have a higher incidence of DVT than patients who do. What is mechanical prophylaxis for a DVT? A) Pneumatic tourniquet B) Anti-embolism stockings C) CPM machine D) Thigh-high TEDs
ANTI-EMBOLISM STOCKINGS **The incidence of deep vein thrombosis (DVT) is 48% for patients who have not had any type of VTE preventive measures instituted, which includes mechanical prophylaxis (eg, anti-embolism stockings) and pharmacologic prophylaxis (eg, antithrombotic medications). Therefore options A, C, and D are incorrect.
_________Moving a body part away from the midline of the body
Abduction
AROM
Active Range of Motion
________is when the client is able to move and preform ROM on their own
Active Range of Motion
If the client is doing individual self directed exercises then they are doing what?
Active range of motion
___________Moving a body part toward the midline of the body
Adduction
36. The nurse understands that using metabolic functioning, measures of height, weight, and skinfold thickness, to evaluate muscle atrophy in an immobilized client is known as: 1. Anthropometric measurements 2. Anhydrous measurements 3. Balke test 4. Calorimetry
Anthropometric measurements
11. Antiembolic stockings (thromboembolic device [TED] hose) are ordered for the client on bed rest following surgery. The nurse explains to the client that the primary purpose for the TEDs is to: 1. Keep the skin warm and dry 2. Prevent abnormal joint flexion 3. Apply external pressure 4. Prevent bleeding
Apply external pressure
2. A 61-year-old client recently suffered left-sided paralysis from a cerebrovascular accident (stroke). In planning care for this client, the nurse implements which one of the following as an appropriate intervention? 1. Encourage an even gait when walking in place. 2. Assess the extremities for unilateral swelling and muscle atrophy. 3. Encourage holding the breath frequently to hyperinflate the client's lungs. 4. Teach the use of a two-point crutch technique for ambulation.
Assess the extremities for unilateral swelling and muscle atrophy.
Which of the following clients is at greatest risk for developing adverse effects of immobility? A) 3-year-old child with a fractured femur B) 78-year-old man in traction for a broken hip C) 48-year-old woman following a thyroidectomy D) 38-year-old woman undergoing a hysterectomy
B) 78-year-old man in traction for a broken hip
Fibrous tissues that bind joints together, connecting bone and cartilage, are known as: A) Tendons B) Ligaments C) Skeletal muscles D) Cartilaginous tissues
B) Ligaments
3. A patient is admitted to the unit in traction for a fractured proximal femur. What is the most appropriate type of traction to apply to a fractured proximal femur? A) Russell's traction B) Dunlop's traction C) Buck's extension traction D) Cervical head halter
BUCK'S EXTENSION TRACTION **Buck's extension is used for fractures of the proximal femur. Dunlop's traction is applied to the upper extremity for supracondylar fractures of the elbow and humerus. Russell's is used for lower leg fractures. Cervical head halters are used to treat back pain.
when lifting walking or performing any body activity __________is essential to maintain balance.
Body Alignment
From the Laws of physics we derive the general priciples of
Body mechanics (meaning some ways of moving and carrying objects are more effective than others)
12. A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. What may this be a sign of? A) Edema B) A pressure ulcer C) Compartment syndrome D) Disuse syndrome
COMPARTMENT SYNDROME **Compartment syndrome may manifest as unrelenting, uncontrollable pain. Discomfort from edema may be relieved with elevation of the limb; pain from ulcers is usually relieved when ulceration occurs. Disuse syndrome may result in disuse atrophy.
25. The nurse recognizes that a client who is inactive is at a risk for decreased muscle mass as a result of increased muscle atrophy and: 1. Decrease metabolic rate 2. Catabolic tissue breakdown 3. Inactivity-induced depression 4. Anorexia caused by decreased peristalsis
Catabolic tissue breakdown
CPM
Continous Passive Motion
__________ are used after surgery for joint replacement or arthoscopic repair of a joint
Continous Passive Motion CPM
________are mechanical devices with which the nurse provides continuous motion to a specific joint usually knee or hip joints
Continuous Passive Motion CPM
__________is the continuous contraction (shortening of the length) of the muscles that move the bones of the joints
Contracture
"Which of the following is a principle of good body mechanics when lifting or carrying objects? A) Keeping the knees in a locked position B) Bending at the waist to maintain a center of gravity C) Holding objects away from the body for improved leverage D) Maintaining a wide base of support and bending at the knees"
D - Maintaining a wide base of support and bending at the knees allows for good body mechanics. Locking the knees may cause strain on the lower back, as can bending at the waist. Holding objects close to the body helps use the center of gravity for leverage.
"In which age groups do maturational processes produce the greatest observable change? A) Adults and elders B) Infants and elders C) Adults and infants D) Childhood and old age"
D - Maturational processes cause the greatest change and have the most impact during childhood and old age. The other options are incorrect.
"After consulting with the physician, the nurse prepares a client for crutch walking by implementing which of the following interventions to help the client increase the strength of the thigh muscles? A) Providing a gait belt for the client to be used whenever the client ambulate to the bathroom or down the hallway B) Placing a lift sheet under the client and instructing the client to call for the nurse whenever the client needs to be lifted to the head of the bed C) Attaching a trapeze to the overbed frame and teaching the client to plant the foot in the bed and lift the buttocks off the bed 10 times every hour D) Inserting a footboard at the end of the bed and encouraging the client to press the ball of the foot of the unaffected leg against the board for 10 repetitions, 4 times a day"
D - Resistive isometric exercises of the foot against a footboard provide quadriceps-setting exercise, which promotes muscle strength and tone, and stress to the bone to promote bone healing. A trapeze and lift sheet help reduce friction forces when moving a client up in bed. They do not prepare muscles for crutch walking. Gait belts are an important part of safety when ambulating a client with crutches, but the belts themselves do not improve muscle strength.
"A client begins to fall during ambulation. What should the nurse do to prevent injury to the client? A) Call for assistance. B) Instruct the client to sit in the nearest chair. C) Prop the client up, and then complete the ambulation. D) Slide the client down the nurse's body and leg to the floor."
D - The nurse should allow the client to slide to the floor while protecting the client's head from injury. This prevents injury to both the client and the nurse. After the client is seated on the floor, the nurse should call for assistance and transfer the client appropriately. Instructing the client to sit in the nearest chair may not be practical. Propping the client is an incorrect answer.
The nurse is caring for a client who has osteoporosis. The nurse is teaching her about ways to prevent fractures. Which of the following statements by the client reflects a need for further education? A) "I usually go swimming with my family at the YMCA three times a week." B) "I need to ask my doctor if I should have a bone mineral density check this year." C) "If I don't drink milk at dinner, I will eat broccoli or cabbage to get the calcium that I need in my diet." D) "The more frequently I walk, the more likely I will be to fall and break my leg. I think I will get a wheelchair so I don't have to walk anymore."
D) "The more frequently I walk, the more likely I will be to fall and break my leg. I think I will get a wheelchair so I don't have to walk anymore."
The nurse is caring for a client who has right-sided weakness. The nurse needs to help the client walk. What should the nurse do while walking with the client? A) Hold the client's left hand while walking. B) Hold the client's right hand while walking. C) Put a gait belt on the client and provide support on the left side. D) Put a gait belt on the client and provide support on the right side.
D) Put a gait belt on the client and provide support on the right side.
A client who was in a car accident and broke his femur has been immobilized for 5 days. When the nurse gets this client out of bed for the first time, a nursing diagnosis related to the safety of this client would be: A) Pain B) Impaired skin integrity C) Altered tissue perfusion D) Risk for activity intolerance
D) Risk for activity intolerance
1. A client has been on prolonged bed rest, and the nurse is observing for signs associated with immobility. In assessment of the client, the nurse is alert to a(n): 1. Increased blood pressure 2. Decreased heart rate 3. Increased urinary output 4. Decreased peristalsis
Decreased peristalsis
Befor a rectal exam the client is encouraged to _____
Defecate
34. The nurse caring for a 78-year-old male client recovering from hip replacement surgery is assessing for signs of improvement of the client's activity tolerance. The nurse determined a baseline for ongoing assessments by: 1. Determining how much time it takes the client to recover from an activity 2. Assessing how much the client can do at one time 3. Determining the level of pain experienced by the client during the activity 4. Asking the client how much the client feels like doing
Determining how much time it takes the client to recover from an activity
The supine or dorsal recumbent position allows for _______and ______ to function with out being restricted.
Digestive system Respiratory system
___________Bending a body part toward the dorsum (backwards) as in moving the footso the toes are pulled toward the knee and thus facing backward
Dorsiflexion
_______has a special kind of sling that doesnt not have to be placed under the client, it is placed behind back and each leg is lifted seperately
E-Z lift
______device used to transfer a partially weight bearing client, contains a harness that helps support the client when he or she is standing
E-Z stand
Before a procedure the client is asked to____unless contraindicated
Empty the bladder (this helps person to relax and examiner to better palpate the aree being examed)
10. To promote respiratory function in the immobilized client, the nurse should: 1. Change the client's position every 4 to 8 hours 2. Encourage deep breathing and coughing every hour 3. Use oxygen and nebulizer treatments regularly 4. Suction the client's secretions every hour
Encourage deep breathing and coughing every hour
3. Two nurses are standing on opposite sides of the bed to move the client up in bed with a drawsheet. Where should the nurses be standing in relation to the client's body as they prepare for the move? 1. Even with the thorax 2. Even with the shoulders 3. Even with the hips 4. Even with the knees
Even with the shoulders
________turning the foot so that the sole faces away from the other foot
Eversion
__________increasing the angle between two bones as in straightening of the arm
Extension
31. What does plantar flexion demonstrate? A) Function of the plantar nerve B) Function of the tibial nerve C) Function of the radial nerve D) Function of the peroneal nerve
FUNCTION OF THE TIBIAL NERVE **Plantar flexion demonstrates function of the tibial nerve. It does not demonstrate function of the plantar nerve, radial nerve, or peroneal nerve.
Preventing ________is a primary nursing function
Falls
___________decreasing the angle betwwen two bones or bending a part on itself as in bending the elbow
Flexion
During range of motion excercises you should never______
Force a joint to move
What is the name of the scale used to evaluate the risks of falls?
Hendrich Fall Risk Tool
14. To reduce the chance of plantar flexion (footdrop) in a client on prolonged bed rest, the nurse should implement the use of: 1. Trapeze bars 2. High-top sneakers 3. Trochanter rolls 4. Thirty-degree lateral positioning
High-top sneakers
_____provides safe and easy movement from one horizontal surface to another
HoverMatt
__________increasing the angle of an extremity beyond normal as in bedning the head back to look at the ceiling
Hyperextension
40. When caring for a patient who underwent orthopedic surgery, the goals would include what? A) Improving function B) Restoring immobility C) Giving anti-inflammatory medications D) Doing passive range-of motion exercises
IMPROVING FUNCTION **The goals include improving function by restoring motion and stability and relieving pain and disability. The goals do not include restoring immobility, giving anti-inflammatory medications, or giving passive range-of-motion exercises.
effects of traction (3 increase 3 decrease)
Increase vertebral separation, IV foramen openings, separation of facets. Decrease disc pressure, disc protrusion, lumbar paraspinal activity
The _________govern all movement
Laws of physics
A client is admitted with a suspected right-hemisphere stroke. The nurse anticipates that the client will most likely be paralyzed or weak on the _______ side of the body.
Left
It takes ___effort to lift an object if the nurse works as closely to it as possible. Use arm and leg muscles as much as possible instead of the back.
Less
It is easier to pull push or roll and object than it is to_____it
Lift
A ______ sheet is often used to help move clients
Lifting (Lifting, Turning, Draw and Transfer sheets are all basically the same thing)
Some facilities have a _____that does all the lifts for that facility
Lifting team
If a client is faint you should?
Lower or assists client to a sitting position place clients head as close to lap as possible
Knee Chest
Lying on the knees with the chest resting on the bed, rectal or vaginal exam or after childbirth to move uterus back into place
When positioning the client for comfort you should:
Maintain functional alignment Maintain Safety Reassure the client to promote cooperation Properly handle the clients body Obtain assistance if needed Rember a specific order is needed for a client to be out ot bed Do not use special devices such as a splint if not ordered Make sure client is comfortable and call light with in reach
Sometimes a client will come back from surgery with the CPM already in place and____
Moving
Who provides exercise for smaller muscle groupd?
Occupational Therapy
PROM
Passive Range of Movement
if the client is unable to move the nurse helps by preforming what exercises?
Passive range of motion
Supine
Person laying on back, (dorsal recumbent) general exam
Lateral
Person laying on side, client is positioned for extended rest periods
Prone
Person lying on stomach, examination of spine and back
___________Bending the foot so that the toes are pointed down
Plantar Flexion
_______turning the hand so that the palm faces downward or backwards
Pronation
______moving foward or anteriorly as in jutting out the jaw
Protraction
The nurse rocks backward and foward on feet and with his or her body as a force of
Pulling and Pushing
Does the RN or LPN do the initial fall assessment?
RN
ROM
Range of Motion
What can prevent a contracture?
Regular exercise
_______moving backward or back into ananatomic position
Retraction
How do you make a hand roll?
Roll a small towel or washcloth. (or you can use a commercially prepared hand roll)
______moving a bone on a longitudinal axis (horizontally) as in shaking the head no
Rotation
During ROM if client is complaining of pain what should you do?
Stop and ask supervisor
______inversion turning the pallm anteriorly (foward)
Supination
15. Which of the following is the most important to consider when assisting the client in passive range-of-motion exercises? 1. Flex the joint to the point of discomfort. 2. Work from the proximal joints to the distal joints. 3. Quickly work through the range of motion. 4. Support the distal joints while performing range-of-motion exercises.
Support the distal joints while performing range-of-motion exercises.
If a client is having cardiac or respiratory conditions _______ position is used to make breathing easier
The Orthopneic Postion
The nurse can set the machine for?
The number of movements per minute (speed) it is to move and the degree of flexion of the joint as orderd by the healthcare provider.
_______is a variation of the prone posistion or of the side-lying position. it is more comfortable that lying flat on stomach and makes breathing easier than it is in just Prone
The semi-prone position
_________often called (______) is equipped with a cloth slimg taht is placed under the client and supports the clients body in more of a sitting posistion when lifted
The sling Lift or Hoyer Lift E-Z lift
Why is a bath blanket given during a procedure?
To provide warmth and privacy
________allows the person to provide secure support to the weak or unsteady person, it is a sturdy webbed belt with a buckle that easily secures around the clients waist
Transfer belt (gait belt)
A providers order may be needed for ROM exercises. (t/f)
True
An order is required for a client reminder device (T/F)
True
Generally all people have the same range of motion for their major joints. (t/f)
True
Befor a procedure a ______is collected if ordered
Urine sample
31. The nurse is caring for a 48-year-old male client who was involved in a motor vehicle accident and had a fractured pelvis, a ruptured spleen, and multiple contusions. The client has been in the hospital for 5 days on bed rest. The nurse knows that this client is at risk for venous thrombus formation because of prolonged bed rest, potential damage to vessel walls during surgery, and the platelets he received in the trauma unit. These three factors are also known as: 1. Trigeminy 2. Virchow's triad 3. Trigone 4. Hutchinson's triad
Virchow's triad
25. As skeletal traction overcomes the shortening spasms of affected muscles what happens to the skeletal traction? A) Nothing changes B) More weight is added to keep the limb in proper alignment C) Weight is removed to promote healing D) Weight is balanced between heavier and lighter
WEIGHT IS REMOVED TO PROMOTE HEALING **Skeletal traction frequently uses 7 to 12 kg (15 to 25 lb) to achieve the therapeutic effect. The weights applied initially must overcome the shortening spasms of the affected muscles. As the muscles relax, the traction weight is reduced to prevent fracture dislocation and to promote healing.
In some situations the client is turned only to
Wash or rub back, assess skin condition, wounds or dressings or to change the bed linens
should you offer PRN pain medicine 30 min befor a client is to get up?
Yes
Which of the following clients would benefit from the application of cold? a.) a client who has a sprained ankle b.) a client who has a raynauds phenomenon c.) a client who just had knee arthoplasty d.) a client who has a toothache e.) a client who has a nosebleed
a.) a client who has a sprained ankle c.) a client who just had knee arthoplasty d.) a client who has a toothache e.) a client who has a nosebleed
Identify the order in which the following steps of elastic stockings application should be completed a.) perform hand hygiene b.) smooth any creases or wrinkles c.) pull the remainder of the stocking over the clients heel and up on his leg d.) turn the stockings inside to the heel e.) assess the condition of the clients skin and the circulation of his leg f.) put the stockings on the clients foot g.) measure the clients calf/ and or thigh circumference and length of the leg, and selects the correct size stocking
a.) perform hand hygiene e.) assess the condition of the clients skin and the circulation of his leg g.) measure the clients calf/ and or thigh circumference and length of the leg, and selects the correct size stocking d.) turn the stockings inside to the heel f.) put the stockings on the clients foot c.) pull the remainder of the stocking over the clients heel and up on his leg b.) smooth any creases or wrinkles
Contracture (def)
abnormal shortening of muscles with results of deformities
fall assessment in accute care facilities is done usally _______ and fall assessment in long term is normall done______
accute care is at least twice a day long term is at least once a day
standard walkers are made of
alumininum
increase lumbar lordosis
anterior (from pubis) pull - DISC
A home care nurse is preparing the home for a client who is going home following a left hip replacement. The client is cooperative and can partially bear weight. What should the nurse order from the home medical supply company to help the client move from the bed to the chair? a.) a trapeze bar b.) a small transfer board c.) a powered standard assist device d.) an ankle foot orthotic (AFO) for the affected foot
b.) a small transfer board
Which of the following nursing interventions reduce the risk of thrombus development?(select all that apply) a.) teach the client not to use the valsalva maneuver b.) apply elastic stockings c.) review laboratory values for total protein level d.) place pillows under the clients knees and lower extremities f.) assist the client to change position often
b.) apply elastic stockings f.) assist the client to change position often
effects of immobility on cardiovascualr system
blood clots reduced blood flow
Always insert hand into the belt from ______of with your fingers pointing upward and the bottom of the belt in the palm of the hand
bottom
Leaning on crutches in the axilla can cause a serious disorder known as
brachial paralysis or crutch palsy
effects of immobility on skeletal system
brittle bones contractures muscle weakness
A nurse is caring for a client who has been sitting in a chair for 3 hr. Which of the following is the client at risk for developing? a.) stasis of secretions b.) muscle atrophy c.) pressure ulcer d.) fecal impaction
c.) pressure ulcer
The client can use the tampeze how for exercise while comfined to the bed
can pull up on it which works the arms
______is a slender hand held curved stick or device used to provide support whil walking
cane
70 degrees hip flexion
causes maximal vertebral seperation in all levels
tx time cervical facet stretch/mobilizations, stenosis, muscle realxation
cervical 25 minutes for muscle relaxation with equal on/off
mechanical cervical traction
cervical halter supine is better
Circumduction (def)
circular movement of a limb or the eye
________Moving an extremity in circles, the extremity draws a cone with the joint as the apex of the cone as in swinging
circumduction
____and ____excercises prepare the clients body for action
conditioning and strengthing
Transfer Belt can make the client have more
confidence
For certain procedures the client must sign a
consent form or release form
footdrop (def)
contracturedeformity that prevents the client from putting the heel on the floor; results in improper positioning or anterior leg muscle paralysis; abnormal plantar flexion of the foot
_______are walking aids made of wood or metal in the form of a shaft
crutches
Which of the following nursing interventions should be implemented to maintain a patent airway in a client on bed rest? a.) perform isometric exercises b.) suction every 8 hr c.) give low dose heparin as prescribed d.) teach to use an incentive spirometer while awake
d.) teach to use an incentive spirometer while awake
________refers to allowing the client to sit on the edge of the bed with the legs down and the feet supported on a footstool or on the floor
dangling
effects of immobility on digestive system
decreased appetite constipation incontinence
effects of immobility on integumentary system
decreased blood flow pressure ulcers
DJD (indication for traction)
degenrative joint disease - traction increases IV space
Orthopnea (def)
difficult or painful breathing except in an erect sitting or standing position.
Line of Gravity (def)
direction of gravitational pull an imaginary vertical line through the top of the head through the center of gravity and base of support
when using a lift all slings and matts must be
disinfected between each use
a wheeled walker is more difficult to use because it______
doesnt stay in place
traction
drawing apart
Effective use of the body will determine how ____and___the nurse is able to move clients
effective and safe
When entering or leaving an elevator with a wheelchair you should
enter and exit backwards with big wheel going first
Sims position (def)
examination position in which the client is lying on his or her left side with right knee flexed
Lithotomy (def)
examination postition in which the client is lying on his or her back with feet in stirrups
Fowlers position (def)
exmination postion in which the client is lying on his or her back withthe head elevated
Client reminder device may be used to keep a client from _____ of a chair
falling out
If the client can assist in repostioning the advise the client of what to do this helps the client
feel more in control increases self esteem and also takes strain off the nurse
A slanting footboard at about the same angle as if the person was standing is comfortable for the feet and prevents?
footdrop
friction
forces that oppose motion
When you use the hand roll what is the postion ccalled?
grasping posistion
when lifting to give side to side stability you should?
have one foot placed slightly in front of the other for back to front stability
Some times a full bladder can____with examination
help
If you are walking with a client and they begin to feel faint what should you do?
help the client to lean against the wall and bend over if this doesnt help and no one else is there ease the client to the floor
Get-up-and-go on the Hendrich fall risk tool means
how easily the person can get up and with what kind of assistance
The nurses physical strength is not as important as
how efficiently he or she uses the body
It is important to explain why the client is being repositioned and
how the repositioning will be done
precautions
hypermobility, acute inflammation, traction anxiety, pregnancy, symptoms increase, TMJ
Preventing clients from falling is very_______
important
When a person isto remain in the side-lying position for a while he or she is turned
in the same manner as if the postion was temporary (for example to recieve a back rub)
______Turning a partso that it faces medially or inside such as turning the ankle so that the foot faces the opposite foot
inversion
Footdrop (def)
is a contracture deformity in which the foot hangs in a plantar flexed position. This deformity prevents the heal from being placed on the ground and preventing walking
Logroll Turn (def)
is a method of turning the client that keeps the body in straight alignment (like a tree log)
Center of Gravity (def)
is located in the pelvic region and means approximately half the body weight is distributed above this area, half below it, when thinking of the body horizontally divided
force
is opposite of desired motion
effects of immobility on nervous system
lack of stimualtion feelings of anxiety feelings of isolation
Even if the client is falling the nurse must avoid________
letting the client grab the nurse by the neck
The hospital bed should be in ______ except for when giving bed side care
low position
Lumbar puncture
lying on right side knees and head flexed as sharply as possible with back exsposed and is held in postion by a healthcare worker, spinal tap lumbar puncture and specific drug admin
supine (def)
lying on the back
dorsal lithotomy
lying on the back with feet in the stirrups, pelvic or perineal examination
Fowlers
lying on the back with the head elevateed,promotes drainage assists with breathing preparation for dangling or walking (watch for diziness and fainting)
safety precautions when using a stretcher
make sure strapped and side rails are in place be sure covering is clean provide enough blankets to keep warm protect clients injury by lifting them correctly never leave the client alone on a stretcher
Body mechanics is applying mechanical principles of
movement to the human body
What does the Nurse or therapist do during PROM?
moves the joints and assists in assuming various positions
high fowlers
nearly verticle
angle to stretch soft tissue in cervical spine
neutral angle of neck
when is the evaluation for risk of falling done?
on admission to the facility and throughout the clients stay
It is important to give meticulous skin care to a person who has to remain
on his or her back
Who should attempt to move clients with cervical spinal injuries?
only specially trained clinical nurses
________is a drop in blood pressure when going from a laying down position to a sitting position
orthostatic or postural hypotension
Store gait belt where if the client is depressed, suicidal, or may assualt someone
outside the room
trochanter roll (def)
padding placed on sides of legs and feet of a client in bed to prevent abnormal outward rotation and related sequelae
Trochanter Rolls (def)
padding placed on the sides of the legs and feet of a cliient in bed to prevent abnormal outward rotation and related sequelae
Hemiplegia (def)
paralysis on one side of the body
What is a contracture?
permantently shortened muscles
Who will introduce the exercise and who makes sure the exercises are carried out?
physical therapist will introduce exercise nurs will supervise while client does them
How can you keep matress from slipping to footboard when bed is raised?
place a pillow or a rolled blanket in the space between the edge of the matress and the foot of the bed
What do you do to prevent pressure on the heels?
place a pillow or pad under ankles
Semi prone the bottom arm is
placed behind the client rather than in front of and client will be more on stomach than on the side
effects of immobility on respiratory system
pneumonia decreased respiratory effort decreased oxygenation of blood
Dangling (def)
positioning of a client so that they are sitting on side of bed with legs down and feet supported by a footstool or the floor
Prone (def)
posotioning a client so that he or she is lying on the stomach
increase lumbar kyphosis
posterior (from butt) pull - IV FORAMEN
the nurse must understand and_____ Proper body mechanics
practice
washing the back and massaging the back helps
prevent skin breakdown
Saftey in turning moving and transferring clients in and out of bed is a ______
priority
Stretching the body as tall as possible produces
proper body alignment
Generally the nurse can transfer even the weakest of clients when using _______
proper body mechanics
A piece of equipment used to ensure saftey of the client and the healthcare enviorment is called a _______
protective device or a client reminder device
JCAHO and OBRA have established firm standards for the use of any _____
protective device or restraint
Regulations are different for ________situations that just normal hospital settings
psychiatric
If the client can not be turned at all and is physically able the nurse will ask the client to do what to provide back care and interventions
pull up on the trampeze bar slightly
effects of immobility on urinary system
reduced kidney function incontinence urinary tract infections (UTI)
By pressing feet down on foot stool it can help with
regaining the feeling of standing
A client reminder device is considerd a _______
restraint and the orders must be updated every 24hrs
All clients in a healthcare facility must be evaluated for what risk?
risk of falling
To place a person in semi-prone posistion from prone you must
roll the person
nurses often need to teach clients the use of proper body mechanics for
safe walking and movement
any protective device safety device pr restrant can only be used to provide _____
safety to the client or to others
Good arch support is important it helps prevent a condition called___________
sciatica
______is pain along the sciatic nerve in the thigh and leg
sciatica
distraction
separtion of joint surfaces
To avoid joint abnormalities the nurse must be sure that clients exercise all joints _____
several times daily by means of ROM exercises
The method of using the draw sheet prevents what?
sheet burns or shearing of the tissue
orthopneic posistion (def)
sitting and leaning foward to facilitate breathing
Dangling can help the client prepare for?
sitting in a chair and eventually to walk
contraidnications
spinal infection, RA, osteporosis, malignancy, cord pressure, recent spinal fractures
A client is turned from the side-lying position to the_______ if the client is not supported on the side.
supine position
Transfer belt should be tight enough to
support the clients weight but not be uncomfortable
A client that does not move hands or is not able to needs to have his or her hands?
supported in an open position to prevent contractures
static
sustained tx - disc lesion, stretching, muscle relaxation
Many different posistions are used for physical examinations, nursing treatments and________
test
herniated disc w radiculopathy (indication for traction)
text book diagnosis for traction causes disc to suck back in
When lifting an object you should bend at knees and hips and keep
the back straight (this keeps the center of gravity over the feet giving extra stability)
if the score on the hendrich fall risk tool is 5 or greater
the client has a high risk of falling and requires special observations and normally will wear a special name band to warn of the falls
when dangling you should be mindful of
the client may become lightheaded or weakness due to a fall in blood pressure
What side is the cane held on?
the clients strong side
High Fowlers
the head of the bed is raised nearly verticle
When a person is in proper alignment then an imaginary line can be drawn connecting
the persons nose breastbone and pubic bone
_______weight bearing is permitted only on one foot
three point gait or swing through gait
Clients are encouraged to be up walking ASAP after surgery or serious illness. This helps prevent complications from immobility (T/F)
true
Some clients are allowed out of bed for the entire day other clients are up for certain lengths of time each day as their condition permits (t/f)
true
Usually older or immobile clients will be on a turn schedule (t/f)
true
do not attempt to go up and down a curb with a gurney (t/f)
true
Eversion (def)
turning inside out
______is partial weight bearing is permitted on both feet
two point gait
static cervical traction
tx for cervical disc herniations
intermittent cervical traction
tx for cervical facet stretch/mobilizations
a client using any safety device or restraint that he or she can not release is considered_____ and must be carefully monitored. this helps protect the client from assault
vulnerable
______is a four legged tubular device with hand grips, provides sturdy support for clients who are unable or too unstable to walk with a cane
walker
some clients have difficulty transferring from bed to chair because of :
weakness or paralysis
Footdrop can also occur in a person who_____
wears very high heels all the time
Semi Fowlers Position is
where the head of the bed is raised about 30 to 12 degrees
The CPM machine moves the clients leg_____effort on the part of the nurse or the client
without
When a persons body is in correct alignment all the muscles?
work together for the safest and most efficient movement without muscle strain.
29. The nurse is discussing joint mobility exercises with a client who experienced a stroke and now has left-sided weakness. Which of the following statements made by the client reflects the greatest insight regarding the best method for him to maintain mobility of the joints on his left side? 1. "My wife knows how to do those exercises for the joints on my left side." 2."Physical therapy really exercises my left side when I go there every afternoon." 3. "I'll remind the staff to exercise my left side when they come to help me with my bath and getting dressed." 4. "I will do those passive range of motion exercises you taught me to my left side at least 3 times a day."
"I will do those passive range of motion exercises you taught me to my left side at least 3 times a day."
22. A 16-year-old had a full leg cast for 4 months, and it is being removed today. Which of the following statements made by the client shows the most informed understanding of the effects of immobilization of a muscle on its strength and stamina? 1. "I'm hoping to be back at soccer practice in 3 weeks." 2. "Walking and riding my bike will help regain the muscle." 3. "I'll practice the strengthening routine the physical therapist taught me, so I can play baseball in the spring." 4. "There was a good bit of muscle and strength loss, but I'll work at getting it back like it was before the break."
"I'll practice the strengthening routine the physical therapist taught me, so I can play baseball in the spring."
15. A client is brought to the emergency room with compound femur fracture. What is the first action the emergency room nurse should do? a) cover the open wound b) check the clients blood pressure c) assess the client's neurologic status d) prepare the client for X-ray
15) B - compound fracture of the femur may cause severe internal bleeding. Internal bleeding is characterized by hypotension.
16. A 3-year old in Bryant's traction is with foot foam. You found the child pulling out the foot foam. What is your most appropriate nursing action? a) remove the foot foam and assess the area b) reapply the foot foam at once c) call another nurse to maintain traction as you reapply the foot foam d) tell the child to stop removing the foot foam
16) C - maintain the traction as the foot foam is reapplied.
2. Which of the following guidelines should a nurse include in the teaching plan for a patient who has osteoarthritis? a) achieve ideal body weight b) increase daily calcium intake to 1500 mg c) maintain a high fiber diet d) sleep at least 10 hours each day
2) A - the primary cause of arthritis is not yet known but it is often-associated with obesity, aging, trauma, fractures, and infections. Osteoarthritis is a wear and tear disease of the joints. The more pressure it takes the more severe and the faster is the progression of the disease. Thus, one of the important aspects of management if the patient is obese is to lose weight to lessen the pressure on the joints
top of crutch should be _____from the axilla
2-3 inches
How many nurses does a Logroll turn usually need?
2-3 nurses (if client is starting to vomit while in cspine or on a back board one nurse can do this in an emergency)
23. Which of the following should be included when giving client teaching to an obese woman, whose height is 5 feet and 2 inches, on prevention of progression of osteoporosis? a) bed rest b) avoid sunlight c) weight-bearing exercises and weight reduction d) limit intake of milk and dairy products
23) C - weight-bearing exercises promote calcium absorption in he bones. Weight reduction reduces strain at the cartilage of joints. These measures prevent progression of osteoporosis.
4. The nurse would instruct the patient which of the following to minimize complications? a) drinking a minimum of 3000 ml of fluid per day b) eating a minimum of 2500 calories per day c) walking at least three miles per day d) resting at least three hours per day
4) A - renal urate lithiasis (kidney stones) may result from precipitation of uric acid in the presence of low urinary pH. This can be avoided by allowing the patient liberal fluid intake to promote urinary excretion of uric acid.
How many repetitions should you do with a isometric exersize and for how long? whats the rest period?
5 repetitions each lasting 5 seconds with a 2 minute rest
tx time cervical herniated disc
5 to ten minutes with long holds
64. A nurse is caring for a client who has been placed in Buck's extension traction. The nurse provides for countertraction to reduce shear and friction by: a) using a footboard b) providing an overhead trapeze c) slightly elevating the foot of the bed d) slightly elevating the head of the bed
64) C - The part of the bed under an area in traction is usually elevated to aid in countertraction. For the client in Buck's extension traction (which is applied to a leg), the foot of the bed is elevated. An overhead trapeze or footboard is not used to provide countertraction. Option C provides a force that opposes the traction force effectively without harming the client.
7. A patient with rheumatoid arthritis asks the nurse why she is taking Prednisone (Deltasone) the nurse best response would be that it: a) enhance the immune system b) increase bone density c) decrease inflammation d) reduce peripheral edema
7) C - the main effect of corticosteroids is to supress inflammation. However, this same effect is also one of the main setback of corticosteroid therapy suppression of the inflammatory response also decreases the immune response making the patient susceptible to infection.
32. The nurse caring for a 73-year-old female client who has been hospitalized with a stroke instructs the client's daughter to continue to do passive range-of-motion exercises with her mother on her affected side to prevent contractures. The nurse explains to the daughter that this is very important in an immobile older adult client because contractures can form in as little as: 1. 8 hours 2. 24 hours 3. 1 week 4. 1 month
8 hours
16. Which of the following clients is most at risk for losing his or her balance? 1. A woman who is 9 months pregnant walking down a flight of stairs 2. A 16-year-old skate boarding down a 15-degree slope 3. A 45-year-old taking hypertensive medication 4. A 4-year-old riding a tricycle
A woman who is 9 months pregnant walking down a flight of stairs
"The nurse and an unlicensed assistant (UAP) are about to move a 200-lb client up in bed. Before lifting this client, the nurse instructs the UAP to do which of the following? (Select all that apply.) A) Bend at the knees. B) Stand as close to the bed as possible. C) Face in the direction of the head of the bed. D) Place feet close together, about 6 inches apart. E) Bend slightly (30 degrees) at the waist toward the client."
A, B, C - Standing close to the bed allows the weight lifted to be as close to the body as possible. This places the weight in the same plane as the lifter and close to the lifter's center of gravity for balance. By facing in the direction one is pulling the client, one avoids twisting. Bending at the knees helps the lifter maintain the center of gravity and lets the leg muscles do the work instead of the back muscles. The back should be maintained in an upright position, not bent over. This allows the stronger (leg) muscles to do the work. Body balance is achieved when a relatively low center of gravity is balanced over a wide base of support. The base of support can be widened by separating the feet to a comfortable distance, and balance is increased by bringing the center of gravity closer to the base of support.
21. A patient has suffered a muscle strain and is complaining of severe pain. The nurse knows that most pain can be relieved by what? A) Dangling the involved part B) Applying cold packs C) Immobilizing the involved part D) Administering anti-inflammatories as prescribed
APPLYING COLD PACKS **Most pain can be relieved by elevating the involved part, applying cold packs, and administering analgesics as prescribed. Immobilizing the involved part is a distractor for this question.
4. A client is leaving for surgery and because of preoperative sedation needs complete assistance to transfer from the bed to the stretcher. Which of the following should the nurse do first? 1. Elevate the head of the bed. 2. Explain the procedure to the client. 3. Place the client in the prone position. 4. Assess the situation for any potentially unsafe complications.
Assess the situation for any potentially unsafe complications.
"A client is more open to developing an exercise program if the client: A) Is requested to exercise by a family member B) Is at the stage of readiness to change his or her behavior C) Has been diagnosed with a chronic disease such as diabetes D) Has been ordered by the health care provider to begin an exercise program"
B - A person is not open to developing an exercise program until the person is at the stage of readiness to change his or her behavior. Being ordered to begin a program by a health care provider or requested to do so by a family member may help motivate the client, but the client will not actually do it until the client is ready. The diagnosis of a chronic disease may be a motivator, but, again, until the client is ready, the client will not be able to begin a program.
"Mr. Stone has been on bed rest for several days. When he attempts to walk with assistance he becomes dizzy and nauseated. These are most likely symptoms of which of the following? A) Rebound hypertension B) Orthostatic hypotension C) Dysfunctional proprioception D) Central nervous system rebound hypotension"
B - Some clients experience orthostatic hypotension when changing from a horizontal to a vertical position. A client on bed rest is at greater risk for this. Rebound hypertension is a result of withdrawing medications. Dysfunctional proprioception is the inability to distinguish the location of the body in space.
Client should have a good sense of _______before helping out of bed
Balance
"Buck's skin traction is being applied to the client's left leg because of a recent hip fracture. The client is scheduled for surgery in the morning. He is reporting pain in the left hip. The nurse should first: A) Assess the extremity for pulses. B) Remove the skin traction to examine the skin. C) Assess alignment of the left leg with the pulley. D) Determine the last time the client was given analgesics."
C - Pain may be due to incorrect alignment of the Buck's traction with the pulley. Determining when analgesics were last given should be done after alignment is evaluated, because the nonpharmacological intervention of alignment may be all that is needed to relieve the pain. A reassessment would be necessary after repositioning. Assessing for pulses is part of the neurovascular assessment and is appropriate to perform; however, it will not relieve pain. Removing the skin traction at this time might aggravate the pain.
"Which structures control balance? A) Eye and ear B) Cerebrum and pons C) Cerebellum and inner ear D) Cerebral cortex and gyrus"
C - The cerebellum is responsible for coordinating all voluntary movement and, along with the semicircular canals of the inner ear, controls balance. The cerebral cortex and the gyrus control major muscle movements, and the cerebrum and pons relay nervous impulses. The eye and ear are sensory organs that are involved in balance, but the eye does not control any balance functions.
The most significant hazard of restricted mobility is: A) Foot drop B) Tachycardia C) Deep vein thrombosis D) Orthostatic hypotension
C) Deep vein thrombosis
A client has been on bed rest for several days. The client stands, and the nurse notes that the client's systolic pressure drops 20 mm Hg. Which of the following should the nurse document in the medical record? A) Rebound hypotension B) Positional hypotension C) Orthostatic hypotension D) Central venous hypotension
C) Orthostatic hypotension
6. The nurse assesses that the client has torticollis and that this may adversely influence the client's mobility. This individual has a(n): 1. Exaggeration of the lumbar spine curvature 2. Increased convexity of the thoracic spine 3. Abnormal anteroposterior and lateral curvature of the spine 4. Contracture of the sternocleidomastoid muscle with a head incline
Contracture of the sternocleidomastoid muscle with a head incline
Isometric exercises preserve muscle mass and do not prevent ________
Contractures
Which of the following nursing interventions is most important for preventing deep vein thrombosis in an immobilized client? A) Measuring calf circumference daily B) Dorsiflexing the foot of the extremity in which thrombosis is suspected C) Providing passive range-of-motion exercise on every shift D) Ensuring that compression devices are fitted correctly and pumping
D) Ensuring that compression devices are fitted correctly and pumping
The nurse puts elastic stockings on a client after major abdominal surgery. The nurse teaches the client that the stockings are used after a surgical procedure to: A) Prevent varicose veins. B) Prevent muscular atrophy. C) Ensure joint mobility and prevent contractures. D) Facilitate the return of venous blood to the heart.
D) Facilitate the return of venous blood to the heart.
39. You are caring for a patient admitted to the orthopedic unit in skeletal traction. You know that this patient is at increased risk for a DVT. What would you do to decrease the risk of DVT in this patient? A) Pretend to ride a bicycle while you lay in bed. B) Allow the patient to assist with passive range-of-motion exercises. C) Encourage the patient to perform active ROM exercises on the affected leg. D) Do foot and ankle exercises every 1 to 2 hours while awake.
DO FOOT AND ANKLE EXERCISES EVERY 1-2 HOURS WHILE AWAKE **Venous stasis that predisposes the patient to venous thromboembolism occurs with immobility. The nurse teaches the patient to perform ankle and foot exercises within the limits of the traction therapy every 1 to 2 hours when awake to prevent DVT. You would not encourage active range-of-motion exercise nor would you assist in passive range-of-motion exercises.
goals of traction (4 decrease, 1 increase)
Decrease radicular signs, muscle gaurding, spasm and joint pain. Increase ROM
7. An immobilized client is suspected of having atelectasis. This is assessed by the nurse upon auscultation as: 1. Harsh crackles 2. Wheezing on inspiration 3. Diminished breath sounds 4. Bronchovesicular whooshing
Diminished breath sounds
10. The nursing instructor is talking with her class about cast care when one of the students asks what the nurse should do if a patient sticks something inside a cast to scratch whatever itched. What action would the instructor tell the students it would be appropriate for the nurse to take? A) Allow the patient to continue to scratch inside the cast with a pencil. B) Give the patient a sterile metal object to use for scratching instead of the pencil. C) Encourage the patient to avoid scratching, and obtain an order for diphenhydramine (Benadryl) if severe itching persists. D) Obtain an order for a sedative, such as diazepam (Valium), to prevent the patient from scratching.
ENCOURAGE THE PATIENT TO AVOID SCRATCHING, AND OBTAIN AN ORDER FOR DIPHENHYDRAMINE (BENADRYL) IF SEVERE ITCHING PERSISTS **Most patients can be discouraged from scratching if given a mild antihistamine, such as diphenhydramine, to relieve itching. Patients shouldn't scratch inside casts because of the risk of skin breakdown and potential damage to the cast. Sedatives aren't usually indicated for itching.
23. You are caring for a patient who is in skeletal traction. What is most important to do frequently when caring for a patient in skeletal traction to maintain effective traction? A) Check the traction apparatus to see that the ropes are in the wheel grooves of the pulleys. B) Make sure that the weights hang freely. C) Make sure that the knots in the rope are tied securely. D) Evaluate patient's position, because slipping down in bed results in ineffective traction.
EVALUATE PATIENT'S POSITION, BECAUSE SLIPPING DOWN IN BED RESULTS N INEFFECTIVE TRACTION **The nurse evaluates the patient's position, because slipping down in bed results in ineffective traction. Though all options are correct nursing interventions when caring for a patient in skeletal traction, options A, B, and C are incorrect because they do not maintain effective traction.
The commonly used position to eat meals, work at the overbed table or change position is known as the_________
Fowlers Position
A_______supports the wrist and keeps fingers bent slightly and the thumb out
Hand Roll
23. A staff member experienced a shoulder injury while assisting with a client transfer. The nurse manager's most therapeutic response to this situation is to: 1. Thoroughly review the accident report filed by the injured personnel to determine the factors that contributed to the injury 2. Have a nonpunitive meeting with all the involved staff to discuss correcting the factors that resulted in the injury 3. Require that mechanical lifts be used in the transfer of all clients incapable of assisting with the transfer 4. Implement new policies and procedures to correct the factors that resulted in the injury
Have a nonpunitive meeting with all the involved staff to discuss correcting the factors that resulted in the injury
The Fowlers position is simply a variation of the supine position except that the________
Head is raised
_____is paralyzed on one side of the body, normally caused by a CVA (stroke)
Hemiplegia
15. The nurse assesses the patient in traction frequently. What signs or symptoms would the nurse assess for when assessing for a DVT in a traction patient? A) Increased warmth of the calf B) Decreased circumference of the calf C) Loss of sensation to the calf D) Pale-appearing calf
INCREASED WARMTH OF THE CALF **Signs of DVT include increased warmth, redness, swelling, and calf tenderness. These findings are promptly reported to the physician for definitive evaluation and therapy. Signs and symptoms of a DVT do not include a decreased circumference of the calf, a loss of sensation in the calf, or a pale-appearing calf.
30. The nurse caring for a 38-year-old female client with multiple fractures in the trauma intensive care unit knows that this client is at high risk for pulmonary complications such as atelectasis from her immobility. One of the interventions that the nurse can do to help prevent this from occurring is to: 1. Keep the PaO2 level at or above 94% 2. Instruct the client to deep breathe and cough every hour while awake 3. Turn the client every 2 hours 4. Keep the client on the ventilator as long as possible
Instruct the client to deep breathe and cough every hour while awake
5. A client has sequential compression stockings in place. The nurse evaluates that they are implemented appropriately by the new staff nurse when the: 1. Initial measurement is made around the client's calves 2. Intermittent pressure is set at 40 mm Hg 3. Stockings are wrapped directly over the leg from ankle to knee 4. Stockings are removed every hour during application
Intermittent pressure is set at 40 mm Hg
______(muscle setting) exercises are those the client performs by tightening and releasing certain muscle groups
Isometric
By using preventative measures with the hand roll what might the client be able to do in the future?
It will help prevent contractures and maintain normal body function as normal
How often is the pain medicine give when a client has a CPM? (normally)
Its give PRN approximately 15 min. before the treatment begins to relieve pain and also allow for more movement
Every majot body joint must move regularly several times a day to prevent?
Joint stiffness or deformities
5. You are caring for a patient who has had a right hip replacement. What should the nurse follow when caring for a patient who has just had hip replacement surgery? A) Keep the hips in abduction. B) Keep hips flexed at 95 degrees. C) Elevate the head of the bed to a high Fowler's position. D) Seat the patient in a low chair.
KEEP THE HIPS IN ABDUCTION **The hips should be kept in abduction by an abductor pillow. Hips should not be flexed more than 90 degrees, and the head of bed should not be elevated more than 60 degrees. The patient's hips should be higher than the knees; as such, high seat chairs should be used.
13. The nursing instructor in the skills lab at the nursing school is showing a group of nursing students how to apply traction. What is an appropriate example of proper traction use? A) Knots in the rope should not be resting against pulleys. B) Weights should rest against the bed rails. C) The end of the limb in traction should be resting against the bed's footboard. D) Skeletal traction may be removed.
KNOTS IN THE ROPE SHOULD NOT BE RESTING AGAINST PULLEYS **Knots in the rope should not rest against pulleys, because this interferes with traction. Weights are used to apply the vector of force necessary to achieve effective traction and should hang freely at all times. To avoid interrupting traction, the limb in traction should not rest against anything. Skeletal traction is never interrupted.
______treats the clients body as one intact unit to prevent further injuries to the back or spine.
Logroll Turn
What method of turning is used for clients with a spinal injury or have had back surgery?
Logroll turn
7. A patient was brought to the emergency department after a fall. The patient is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what should the nurse do? A) Maintain the leg in an abducted position. B) Maintain the leg in an adducted position. C) Maintain the leg in a neutral position. D) Maintain the leg with the hip flexed greater than 90 degrees.
MAINTAIN THE LEG IN AN ABDUCTED POSITION **After receiving a hip prosthesis, the affected leg should be kept abducted. Adduction (option B) may dislocate the hip. Option C would be correct if an internal fixation device was used. Option D is incorrect because the hip must not be flexed more than 90 degrees for the first 2 months and even less than that for the first 10 days.
In clients with an unstabilized ccervical spinal injury on nures is required to do what?
Maintain the stability of the neck and keep it in correct alignment.
21. An infant born via cesarean section because of a breech presentation is diagnosed with bilateral congenital hip dysplasia. The primary nursing intervention directed toward this diagnosis is: 1. Assessing the infant frequently to determine abduction of the thighs 2. Maintaining the infant in the position of continuous abduction of both hips 3. Educating the parents about the importance of positioning the infant so that the head of the femurs are in alignment with the hip sockets 4. Providing pain management so that the infant is comfortable in the therapeutic position required
Maintaining the infant in the position of continuous abduction of both hips
8. The best approach for the nurse to use to assess the presence of thrombosis in an immobilized client is to: 1. Measure the calf and thigh circumferences 2. Attempt to elicit Homans' sign 3. Palpate the temperature of the feet 4. Observe for a loss of hair and skin turgor in the lower legs
Measure the calf and thigh circumferences
9. A client is getting up for the first time after a period of bed rest. The nurse should first: 1. Assess respiratory function 2. Obtain a baseline blood pressure 3. Assist the client with sitting at the edge of the bed 4. Ask the client if he or she feels light-headed
Obtain a baseline blood pressure
OOB
Out of bed
28. When using cementless components in a joint replacement surgery what must the patient have for the surgery to be successful? A) Inaccurate fitting B) Faulty cement C) Presence of healthy bone D) Inadequate blood supply
PRESENCE OF HEALTHY BONE **Accurate fitting and the presence of healthy bone with adequate blood supply are important in the use of cementless components. Cement, faulty or otherwise, is not used in a cementless procedure.
_________is the inability to move
Paralysis
_____is paralyzed from waist down, usually takes two nurses to safely transfer
Paraplegia
26. A 78-year-old inactive client diagnosed with acute renal failure is at risk for which of the following skeletal maladies? 1. Rickets 2. Osteomyelitis 3. Pathological fractures of long bones 4. Compression fractures of the spinal column
Pathological fractures of long bones
Prone (def)
Person may be positioned on the stomach for short periods to provide a variety of positions
Who determines the parameters for the continuous movements machine?
Physical therapist or Healthcare Provider
37. A patient has been in skeletal traction for 3 weeks. The nurse caring for the patient knows to assess what every 4 to 8 hours? A) Bladder B) Respiratory status C) Neurovascular status D) Skin
RESPIRATORY STATUS **The nurse auscultates the patient's lungs every 4 to 8 hours to assess respiratory status and teaches the patient deep-breathing and coughing exercises to aid in fully expanding the lungs and clearing pulmonary secretions. The nurse would not assess the bladder, the skin, and the neurovascular status of the patient every 4 to 8 hours.
Sims
Semi-prone lying on the side usually the left with the upper knee flexed, rectal examination, procedures such as a colonoscopy
1. The nurse is caring for a patient who has had a plaster leg cast applied. Immediately post-application, the nurse should inform the patient that: A) The cast will cool in 5 minutes. B) The cast should be covered with a towel. C) The cast should be supported on a board while drying. D) The cast will only have full strength when dry.
THE CAST WILL ONLY HAVE FULL STRENGTH WHEN DRY **A cast requires approximately 24 to 72 hours to dry, and until dry, it does not have full strength. While drying, the cast should not be placed on a hard surface. The initial cooling occurs in about 15 minutes after application of the cast.
32. You are caring for a patient in skeletal traction. What do you caution the patient about to prevent bony fragments from moving against one another? A) Removing the traction for bathing B) Repositioning with assistance C) Turning side to side D) Coughing
TURNING SIDE TO SIDE **To prevent bony fragments from moving against one another, the patient should not turn from side to side; however, the patient may shift position slightly with assistance.
35. The nurse and a nursing assistive personnel (NAP) are going to move an older adult client up in bed. Before moving the client, the nurse explains to the NAP that they will need to lift the client off the bed with an assistive device instead of using the drawsheet. The most important reason for using the assistive device is: 1. To avoid frightening the client 2. To avoid shearing the client's skin 3. To avoid getting "written up" for not following lift procedures 4. Because the nurse is tired
To avoid shearing the client's skin
13. To reduce the chance of external hip rotation in a client on prolonged bed rest, the nurse should implement the use of a: 1. Footboard 2. Trochanter roll 3. Trapeze bar 4. Bed board
Trochanter roll
What would you use on a client who is to lie on the back for sometime?
Trochanter rolls on each side of the legs
Some providers believe that the CPM does not promote healing and may actually increas inflamation (T/F)
True
The CPM can cause some discomfort and anxiety if not explained by the nurse. (T/F)
True
The client is instructed to call if there is pain with the CPM. (T/F)
True
33. The nurse understands that a pressure ulcer is an impairment of the skin as a result of prolonged ischemia. One of the easiest ways to prevent a pressure ulcer from occurring in an immobile client is to: 1. Keep the skin dry 2. Provide range of motion every shift 3. Use lift equipment when transferring a client 4. Turn the client a minimum of every 2 hours
Turn the client a minimum of every 2 hours
38. You are assuming care of a 16-year-old patient who is in skeletal traction following a motor vehicle accident. You take shift report and find out that the patient avoids using the urinal and bedpan because they "embarrass him." When you assess the patient you find that the patient's temperature is 101.5°F and his blood pressure and pulse are elevated. What would the nurse suspect? A) Sacral skin breakdown B) Infected pin sites C) Urinary infection D) Urinary incontinence
URINARY INFECTION **Incomplete emptying of the bladder related to positioning in bed can result in urinary stasis and infection.
36. As an orthopedic nurse you know that there are several immobility-related complications that a patient can acquire when they are placed in traction. What complications might a patient in traction acquire? A) Anorexia B) Thromboemboli C) Urinary stasis D) Diarrhea E) Lactose intolerance
URINARY STASIS **Immobility-related complications may include pressure ulcers, atelectasis, pneumonia, constipation, loss of appetite, urinary stasis, urinary tract infections, and venous thromboemboli formation.
29. A patient is scheduled for a total knee replacement. The surgeon explains the technique of creating a "bloodless" field for the surgery to the patient. What does this entail? A) Intermittent autotransfusion B) Postoperative blood salvage C) Intraoperative blood salvage with reinfusion D) Use of a pneumatic tourniquet
USE OF A PNEUMATIC TOURNIQUET **Blood is conserved during surgery to minimize loss. During orthopedic surgery on a limb (eg, total knee replacement [TKR]), a pneumatic tourniquet may be applied to produce a "bloodless field." This technique has the advantages of keeping the surgical field dry, minimizing blood loss, and providing some additional limb anesthesia. Intraoperative blood salvage with reinfusion is used when a large volume of blood loss is anticipated. Postoperative blood salvage with intermittent autotransfusion also reduces the need for blood transfusion.
20. A client recovering from hip surgery tells the nurse that she wants to get better so she can walk down the aisle to her seat at her granddaughter's wedding. Which of the following nursing interventions will have the greatest impact on achieving that goal? 1. Informing physical therapists that the client has expressed that goal 2. Reminding the ancillary staff to offer to walk with the client after her bath 3. Regularly praising the client for the efforts she is making to reach her goal 4. Walking with the client to and from the dining room where she eats her meals
Walking with the client to and from the dining room where she eats her meals
The cane supports ______and helps the client to walk
balance
The nurse needs to know why the examination is being done in order to
be able to answer clients questions and to anticipate any problems that might arise
Preform Limited range of motion during certain treatments such as_______
bed baths
______weight bearing is permitted on both feer
four point gait
When in side lying position what can you do for the clients comfort?
give pillows as needed
facet impingement (indication for traction)
traction distracts facets and allows capusle to escape
hypomobility (indication for traction)
traction mobilizes joints, increases synovial circulation activating gate control mechanism
muscle spasm/gaurding (indication for traction)
traction produces prolonged stretch and resets muscle spindle
______can be used in an emergency for cpr board
transfer board
to go down a curb with a wheelchair
you should turn the chair around and ease the large back wheel off the curb first
what do you check and why when getting a client out of bed?
you would check the doctors order to determine the level of activity the client is allowed
Always apply body mechanics principles to protect______and______from unnecessary body fatigue, strain, or injury
yourself and clients
tx time facet joint lumbar spine
25 to 30 minutes equal on/off times
The hip joint is classified as what type of joint? A) Fibrous B) Synovial C) Synostotic D) Cartilaginous
B) Synovial
"A nurse working in a nursing home decides to collaborate with the physical therapists in developing an exercise program for some of the residents. In developing this program, the nurse knows that which of the following are correct? (Select all that apply.) A) Tai chi is an excellent form of exercise for older adults. B) Purchasing isometric exercise machines will be necessary. C) Determining the clients' interests will be important. D) The old-old residents (over 90 years of age) will not be able to participate in any exercise activity."
A, C - Practice of tai chi has resulted in reduced fear of falling and increased sense of well-being. It is never too late to start exercising. Although not all residents will be able to perform the same types of exercise, even simple stretching can enhance circulation. Purchasing expensive equipment is not necessary. Less expensive alternatives such as using a stretch band, lifting cans of soup, or rolling a large ball can be effective in improving circulation, muscle tone, and strength.
22. A nurse is caring for a patient who just had skeletal traction removed and a brace applied to their leg. What is a brace used for? (Mark all that apply.) A) Prevent additional injury B) Align body part C) Provide support D) Control movement E) Prevent deformity
A, C, D PREVENT ADDITIONAL INJURY, PROVIDE SUPPORT, CONTROL MOVEMENT **Braces (ie, orthoses) are used to provide support, control movement, and prevent additional injury. They are custom fitted to various parts of the body.
4. The nurse is caring for a patient who is in skeletal traction. To prevent the complication of skin breakdown in a patient with skeletal traction, what preventive measures would the nurse implement? A) Do not remove the crusting around the pin insertion site. B) Encourage the patient to push up with the elbows when repositioning. C) Encourage the patient to perform ankle and calf muscle exercises once a shift. D) Assess the pin insertion site every 8 hours.
ASSESS THE PIN INSERTION SITE EVERY 8 HRS **The pin insertion site should be assessed every 8 hours for inflammation and infection. The patient should be encouraged to use the overhead trapeze to shift weight for repositioning. Ankle and calf exercises should be done 10 times an hour while awake.
9. A male patient with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of severe pain in the surgical wound. Which action should the nurse take? A) Assume he's anxious about discharge, and administer pain medication. B) Assess the surgical site and affected extremity. C) Reassure the patient that pain is a direct result of increased activity. D) Suspect a wound infection, and monitor the patient's temperature and vital signs.
ASSESS THE SURGICAL SITE AND AFFECTED EXTREMITY ** Worsening pain after a total hip replacement may indicate dislocation of the prosthesis. Assessment of pain should include evaluation of the wound and the affected extremity. Assuming he's anxious about discharge and administering pain medication don't address the cause of the pain. Sudden severe pain isn't normal after hip replacement. Wound infections are usually distinguished by purulent drainage.
"The physician's orders for a client immediately after total hip replacement call for the client to engage in two-touch weight bearing only. The nurse reinforces which of the following crutch-walking techniques taught by the physical therapist? A) Two point B) Three point C) Four point"
B - The three-point crutch-walking technique requires the client to bear all of the weight on one foot. The weight of the affected leg is borne on both crutches and then on the uninvolved leg. The two-point technique is a "swing-through" gait, and although no weight would be placed on the affected leg, it also minimizes the amount of weight placed on the unaffected leg, which is unnecessary. This gait is usually used by clients with paralysis of both lower extremities. A four-point gait gives stability to the client but requires weight bearing on both legs.
The nurse suspects the client is at risk for falling. Which of the following statements made by the client would most alert the nurse to this risk? A) "My cancer has been in remission for 5 years." B) "I have lost 20 pounds during the past 6 months." C) "I recently began taking medication for high blood pressure." D) "I no longer have pain in my knee after physical therapy."
C) "I recently began taking medication for high blood pressure."
Which of the following is the highest priority nursing diagnosis for an immobilized client? A) Risk for disuse syndrome B) Risk for deficient fluid volume C) Ineffective airway clearance D) Ineffective peripheral tissue perfusion
C) Ineffective airway clearance
What type of diet is most important for an immobilized client? A) Low protein B) Low residue C) Restricted carbohydrate D) High protein, high calorie
D) High protein, high calorie
An immobilized client is at risk for: A) Hyponatremia B) Hypocalcemia C) Hypernatremia D) Hypercalcemia
D) Hypercalcemia
The clients body alignment when lying down should be approximately the same as if the person where__________
standing
modified standing
standing with chest on table, prostate exam
Often Less energy force is required to keep and object moving than it is to
start and stop it
when client is gettign up to walk they must wear
sturdy shoes with non-slippery soles they should fit well have a low wide heels (slipper are not acceptable)
when approaching a curb or single stair with a wheelchair you should
tip the chair back and put the small wheels up on the curb or step move ahead by lifting or pushing the back wheels over the curb
_______may be used for the client who is unable to stand and will help with a transfer
transfer board sliding board bridge
28. The nurse is providing ancillary personnel with instructions regarding the performance of passive range-of-motion (ROM) exercises for a client experiencing paralysis from the waist down (paraplegia) as a result of an automobile accident. Which of the following statements made by the ancillary personnel reflects the greatest insight regarding the frequency with which the intervention should be provided for this client? 1. "I will do a whole body range of motion as I complete her daily bath." 2. "Bath time, bedtime, after lunch, and at least once more; she can pick when." 3. "It works well with her bath and when she is being prepared for bed at night." 4. "I'll ask her when she wants me to exercise her joints in addition to bath time."
"Bath time, bedtime, after lunch, and at least once more; she can pick when."
18. Which of the following statements made by ancillary staff reflects the most informed knowledge regarding the benefit of having a client assist with his or her own activities of daily living (ADLs) to that client's activity tolerance? 1. "The more he does for himself, the more he will be able to do for himself." 2. "He doesn't like washing and dressing himself, but it makes him stronger." 3. "Doing for himself makes him tired, but in the long run he has more energy and strength when he does." 4. "By washing and dressing himself he is building muscle strength that lets him actually walk a little better."
"By washing and dressing himself he is building muscle strength that lets him actually walk a little better."
19. Which of the following statements regarding physical activity and its effect on activity tolerance made by a client shows the most informed knowledge regarding the connection between the two? 1. "I know I need to walk more if I want to get stronger." 2. "I don't like walking, but I do it because I know it will make me stronger." 3. "I try to walk a little farther each afternoon so I can dance at my grandson's wedding." 4. "I walk with my son three evenings a week because it's good for his weight and for my bones."
"I try to walk a little farther each afternoon so I can dance at my grandson's wedding."
24. Which of the following statements made by a nurse caring for a client who experienced a myocardial infarction 8 hours ago shows the greatest insight as to the purpose for keeping the client on bed rest? 1. "This has been exhausting; she needs a period of uninterrupted rest." 2. "The pain she experienced is exhausting; it's imperative that she rest." 3. "Keeping her on bed rest decreases the need her body has for oxygen" 4. "She needs complete rest; she is really very ill, especially her heart."
"Keeping her on bed rest decreases the need her body has for oxygen"
24. The best position for a child with myelomeningocele is a) prone b) supine c) semi-fowler's d) modified trendelenburg
24) A - prone position will prevent trauma to the sac at the lumbosacral area in a child with myelomeningocele.
1. Mr. Alcasid asks the nurse, "What is osteoarthritis?" Which response from the nurse is correct? a) your bones are inflamed b) your weight bearing joints are inflamed c) you have inflammation in your joints d) there is shortening of your long bones
1) B - Osteoarthritis, also known as hypertrophic arthritis, osteoarthritis, senescent arthritis and degenerative joint disease is characterized by destruction of the articular cartilage, which becomes opaque, yellow, soft, weak and deteriorated. It is followed by thickening of bone under the cartilage and formation of osteophytes or bone spurs. Unlike RH, osteoarthritis is not a systemic disease and affects only the joint and its surrounding tissue. This disorder commonly occurs in the 50-70 year age group but women are more severely affected. The Signs and Symptoms of Osteoarthritis include: pain - worse with weight bearing, improves with rest may occur with paresthesia joint swelling and enlargement - may be from inflammatory exudates entering joint capsule causing an increase in synovial fluid or from fragments of osteophytes entering synovial cavity decreased ROM - depends on the amount of destroyed cartilage muscular atrophy - from disuse, joint instability and deformity crepitus - must be present on movement of the joint joint stiffness - worse in the morning and after a period of rest and disuse heberden's nodes - bony protuberances occurring on the dorsal surface of the distal interphalangeal joints of the fingers bouchard's nodes - bony protruberances occurring on the proximal interphalangeal joints of fingers coxaarthrosis - pain in the hip on weight bearing with pain progressing to include the groin and medial knee pain and limited range of motion varus (bowlegs) or valgus (knock kneed)
12. Which assessment findings should the nurse expect for Karen? a) an asymmetrical pattern of affected joints b) a positive rheumatoid factor titer c) the presence of Herberden's nodes d) a positive antinuclear antibody titer
12) B - Signs and Symptoms: Begins as fatigue, musculoskeletal pain, low grade fever, lack of appetite and weight loss. Criteria for diagnosis of RA: The first four signs must be present for at least six weeks. Four of these signs and symptoms must be present at the same time to establish a diagnosis. stiffness after prolonged period of inactivity. Morning stiffness lasting at least one hour swelling of three or more joints swelling of the wrist, proximal interphalangeal (PIP) or metacarpophalangeal (MCP) joints symmetric joint swelling, same joint on each side of the body excluding the phalangeal joints positive rheumatoid factor rheumatoid nodules - painless and firm nodules found in subcutaneous tissue that develop during periods of exacerbation and most often in the wrist, carpal, knee, elbow and finger joints X-ray - decalcified areas of bone near joint margins Other Signs: - formation of pannus - fibrous scar tissue at the cartilage that eventually invades and erodes bones - hand deformities ulnar drift boutonniere deformity swan neck deformity - poor mucin precipitate in synovial fluid histological changes of synovium - presence of chronic inflammatory infiltrate
13. The nurse discussed to Karen the nature of RA. Which of the following statements by indicate a correct understanding of disease process? a) the nodules under my skin behind my forehead is part of RA b) I have to be careful because my bones have become brittle c) I have been working very hard lifting heavy things while selling in the market d) my disease is a normal aspect of my aging
13) A - the bones in rheumatoid arthritis do not become brittle as it is the joints that are affected not the bone. Brittle bone is characterized of osteoporosis. Overuse of joint is associated with osteoarthritis which is a wear and tear disease. Rheumatoid arthritis is not a part of normal aging as it is a disease process and occurs often in young women. Nodules which are firm and nontender may develop in the subcutaneous tissues of patients with RA.
14. The nurse should include which of the following client teachings for prevention of rapid progression of osteoporosis? a) avoid taking skim milk b) avoid taking protein-rich foods c) avoid calcium supplement d) avoid alcohol
14) D - avoiding alcohol and cigarette smoking will prevent rapid progression of osteoporosis. Skim milk is indicated among elderly because it is low in fats. Protein foods are necessary for calcium absorption. Calcium supplements help maintain integrity of the bones.
39. Which non-pharmacologic intervention should the nurse include in the care plan for a patient who has moderate rheumatoid arthritis? a) massaging inflamed joints b) avoiding range of motion c) selecting clothing that have Velcro fasteners d) using assistive devices at meal times
39) C - selecting clothing that have Velcro fasteners facilitates task of the client with rheumatoid arthritis. Joints of fingers of the client are the most commonly affected joint. This makes it difficult for the client to perform activities of daily living like dressing and grooming.
17. How do you position a client with left hip fracture in Buck's traction? a) head of bed raised at 45 degree angle b) left calf on pillow from knee to ankle c) position the left on affected side with pillows between legs d) position the left in the center of the bed with the leg extended
17) B - elevate the leg with pillow to relieve pressure from the heel of the foot and to improve the effectiveness of the countertraction.
18. A patient had hip surgery. On the second post-op day, the patient is agitated, is tremulous and confused. What should the nurse primarily assess? a) the surgical wound b) alcohol use before surgery c) peripheral circulation d) breathing pattern
18) B - the client's sign and symptoms indicate alcohol withdrawal.
19. A nurse is conducting a health screening among females at the mall to assess those who are at risk for developing osteoporosis. Which of the following questions is most appropriate to be asked by the nurse in relation to development of osteoporosis? a) at what age did you have your menstruation? b) did you have any fracture? c) are you taking corticosteroids? d) are you on the diet high in vitamin D?
19) C - corticosteroids promote calcium loss. This increases the risk for osteoporosis.
If client is very unsteady or heavy then _____
2 nurses can assist
21. Which of the following nursing interventions will best help alleviate the discomfort of the patient with rheumatoid arthritis? a) walking a mile each morning b) active range-of-motion exercises of joints c) application of hot or cold packs on the joints d) splinting the joint during waking hours
21) C - during acute phase of pain, cold application is recommended. Cold numbs nerve endings and therefore, relieves pain. After the acute phase of pain, heat application is done. This thins the synovial fluid and relieves joint stiffness. Heat also improves circulation to the area, improves oxygen supply and will relieve pain.
22. Which of the following instructions should the nurse include when giving health teachings on prevention of crutch palsy? a) assuming a tripod position when using crutches b) bearing the weight on the palms of the hands and elbows c) bearing the weight on the axillae d) placing the crossbar of the crutches so that the elbows are extended
22) B - during crutch-walking, the weight of the body should be borne by the hands and elbows, not by the axillae to prevent crutch palsy.
25. Which of the following complications does the nurse suspect when a client had fracture of the femur and is now experiencing respiratory distress? a) sepsis b) fat embolism c) bleeding d) shock
25) B - fat embolism is a common complication of fracture of the long bones, like fracture of the femur. Yellow marrow is released into the circulation and reaches the pulmonary circulation. Acute respiratory distress syndrome may occur.
26. Which among these clients is at highest risk for developing low back pain? a) the man working with a drill hammer b) the man delivering mails in the building c) the salesman selling truck tires d) the man washing windows of a building
26) A - dealing with drill hammer puts strain at the back more than the other jobs mentioned.
27. The client had been diagnosed to have fracture of the tibia after a motorcycle accident. Few hours after, he complains of pain distal to the injury, with numbness and tingling sensation. The nurse notes pallor and coolness of the extremity with absent distal pulse. What complication of fracture does the nurse identify in this client?
27) Compartment Syndrome - compression and edema of the content of the compartment (blood vessels, nerves, and muscles) leads to five p's - pain, pallor, pulselessness, paresthesia, paralysis.
28. A man with cast will start to walk with crutches. What should the nurse check first? a) lying and sitting blood pressure b) pulse rate c) temperature d) respiratory rat
28) A - BP should be checked first before starting to ambulate to assess for potential postural hypotension
29. Which of the following is the primary reason for splinting the hands and wrists of client with rheumatoid arthritis? a) to improve the strength of the hands and wrists b) to prevent contractures c) to relieve muscle spasm d) to relieve pain
29) B - splinting of hands and wrists of the client with rheumatoid arthritis is done primarily to prevent contractures.
38. The client had undergone total hip replacement. Which of the following crutch-walking gaits is most appropriate for the client? a) four-point gait b) two-point gait c) swing-to gait d) three-point gait
38) D - three point gait is the most appropriate crutch gait for the client who had undergone total hip replacement. It is a non-weight bearing crutch gait.
33. The nurse notes that the client on cast has diminished distal pulse. Which of the following is the most appropriate nursing action? a) check the client's vital signs b) get doppler and check for distal pulse c) elevate the affected feet d) notify the physician
33) D - diminished distal pulse in an extremity on cast indicates that the cast is too tight. This leads to circulatory impairment. Therefore, the physician should be notified. Bivalving/splitting of the cast will be done by the physician to prevent necrosis and gangrene formation.
36. A patient was admitted and diagnosed with fibromyalgia. Which of the following is true of the disease? a) the disease is characterized by muscle weakness b) the signs and symptoms are relieved by steroids c) the disease is related to arthritis d) the disease is characterized by tender points in the different parts of the body and headache
36) D - fibromyalgia is characterized by muscle pain and tender points in the different parts of the body and headache. Treatment of choice is non-steroidal anti-inflammatory drugs.
37. The client with cervical spinal cord injury is on halo-vest traction. Which of the following emergency equipment is most important to keep readily available at the bedside? a) small wrench b) suction apparatus c) ambu bag d) tracheostomy tray
37) A - the small wrench taped over the vest will be used for untightening the screws of the traction if CPR needs to be done to the client with halo-vest traction.
42. A nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse determines that the client needs additional teaching if the client states: a) aspirin can cause bleeding after surgery b) aspirin can cause my ability to clot blood to abnormal c) I need to discontinue the aspirin 48 hours before the scheduled surgery d) I need to continue to take aspirin until the day of surgery
42) D - anticoagulants alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. Options A, B, and C are accurate client statements.
43. A 4-year old sustains a fall at home and is brought to the emergency room by the mother. After an x-ray examination, the child is determined to have a fractured arm and plaster cast is applied. The nurse provides instructions to the mother regarding care for the child's cast. Which statement by the mother indicates a need for further instructions? a) the cast may feel warm as the cast dries b) I can use lotion or powder around the cast edges to relieve itching c) a small amount of white shoe polish can touch up a soiled white cast d) if the cast becomes wet, a blow drier set on the cool setting may be used to dry the cast
43) B - The mother needs to be instructed not to use lotion or powders on the skin around the cast edges or inside the cast. Lotions or powders can become sticky or caked and cause skin irritation. Options A, C, and D are appropriate instructions.
44. A nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction? a) I will encourage my child to perform prescribed exercises b) I will have my child wear soft fabric clothing under the brace c) I should apply lotion under the brace to prevent skin breakdown d) I should avoid the use of powder because it will cake under the brace
44) C - The use of lotions or powders under a brace should be avoided because they can become sticky and cake under the brace, causing irritation. Options A, B, and D are appropriate interventions in the care of a child with a brace.
45. A 1-month old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip (DDH). The nurse assesses the infant, knowing that which of the following findings would be noted in this condition? a) limited range of motion in the affected hip b) an apparent lengthened femur on the affected side c) asymmetrical adduction of hte affected hip when the infant is placed supine with the knees and hips flexed d) symmetry of the gluteal skinfolds when the infant is placed prone and the legs are extended against the examining table
45) A - In DDH, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Asymmetrical abduction of the affected hip, when the child is placed supine with the knees and hips flexed, would be an assessment finding in DDH in infants beyond the newborn period. Other findings include an apparent short femur on the affected side, asymmetry of the gluteal skinfolds, and limited range of motion in the affected extremity.
46. A client is treated in physician's office for a sprained ankle after a fall. Radiographic examination has ruled out a fracture. Before sending the client home, the nurse plans to teach the client to avoid which of the following in the next 24 hours? a) resting the foot b) applying a heating pad c) applying an elastic compression bandage d) elevating the ankle on a pillow while sitting or lying down
46) B - Soft tissue injuries such as sprains are treated by RICE (rest, ice, compression, and elevation) for the first 24 hours after the injury. Ice is applied intermittently for 20 to 30 minutes at a time. Heat is not used in the first 24 hours because it could increase venous congestion, which would increase edema and pain.
47. A nurse is conducting health screening for osteoporosis. Which of the following client is at greatest risk of developing this disorder? a) a 25-year old woman who jogs b) a 36-year old man who has asthma c) a 70-year old man who consumes excess alcohol d) a sedentary 65-year old woman who smokes cigarettes
47) D - Risk factors for osteoporosis include female gender, postmenopausal, advanced age, low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids, anticonvulsants, and/or furosemide (Lasix) also increases risk.
48. A nurse has given instructions to a client returning home after knee arthroscopy. The nurse determines that the client understands the instructions if the client states that he or she will: a) resume regular exercise the following day b) stay off the leg entirely for the rest of the day c) report fever or site inflammation to the physician d) refrain from eating food for the remainder of the day
48) C - After arthroscopy, the client usually can walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for at least a few days. The client may resume the usual diet. Signs and symptoms of infection should be reported to the physician.
49. A client with possible rib fracture has never had a chest radiograph. The nurse would plan to tell the client which of the following items about the procedure? a) the x-rays stimulate a small amount of pain b) removal of jewelry and any other metal objects is necessary c) the client will be asked to breathe in and out as the x-ray is taken d) the x-ray technologist will stand next to the client during the procedure
49) B - A radiograph is a photographic image of part of the body on a special film, which is used to diagnose a wide variety of conditions. Radiography itself is painless; any discomfort would arise from repositioning a painful part for filming. The nurse may want to premedicate a client who is at risk for pain. Any radiopaque objects such as jewelry or other metal must be removed. The client is asked to breathe in deeply and then hold the breath while the chest radiograph is taken. To minimize risk of radiation exposure, the x-ray technologist stands in a separate area protected by a lead wall. The client also wears a lead shield over his or her gonads.
5. Foods allowed in the diet of gout patient include: a) cheese b) beef c) sardines d) liver
5) A - preventive measures for gout: uric acid is formed from metabolism of purine. To prevent further formation and accumulation of uric acid, the patient must be advised to stick on a low purine diet. This means that the patient must avoid: sweet breads, yeast, heart, herring, sardines, anchovies, shellfish, heavy alcohol intake avoidance of excessive weight gain alkaline ash diet to increase the pH of urine to discourage precipitation of uric acid and enhance the action of drugs such as probenicid (Benemid)
50. A nurse is one of several persons who witness a vehicle hit a pedestrian at fairly low speed on a small street. The person is dazed and tries to get up. The leg appears fractured. The nurse would plna to: a) try to reduce the fracture manually b) assist the person to get up and walk to the sidewalk c) leave the person for a few moments to call an ambulance d) stay with the person and encourage the person to remain still
50) D - With a suspected fracture, the client is not moved unless it is dangerous to remain in that spot. The nurse should remain with the client and have someone else call for emergency help. A fracture is not reduced at the scene. Before the client is moved, the site of fracture is immobilized to prevent further injury.
51. A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when the client will be able to walk using the casted leg. The nurse replies that the client will be able to bear weight on the casted leg: a) in 48 hours b) in 24 hours c) in about hours d) within 20 to 30 minutes of application
51) D - A fiberglass cast is made of water-activated polyurethane materials that are dry to the touch within minutes and reach full rigid strength in about 20 minutes. Because of this, the client can bear weight on the cast within 20 to 30 minutes.
52. A nurse has given a client with a leg cast instructions on cast care at home. The nurse would evaluate that the client needs further instruction if the client makes which of the following statements? a) I should avoid walking on wet, slippery floors b) I'm not supposed to scratch the skin underneath the cast c) it's okay to wipe dirt off the top of the cast with a damp cloth d) if the cast gets wet, I can dry it with a hair dryer turned to the warmest setting
52) D - Client instructions should include avoiding walking on wet slippery floors to prevent falls. Surface soil on a cast can be removed with a damp cloth. If the cast gets wet, it can be dried with a hair dryer set to a cool setting to prevent skin breakdown. If the skin under the cast itches, cool air from a hair dryer may be used to relieve it. The client should never scratch under a cast because of the risk of skin breakdown and ulcer formation.
53. A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction primarily: a) allows bony healing to begin before surgery b) provides rigid immobilization of the fracture site c) lengthens the fractured leg to prevent severing of blood vessels d) provides comfort by reducing muscle spasms and provides fracture immobilization
53) D - Buck's extension traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps immobilize the fracture. Traction does not lengthen the leg for the purpose of preventing blood vessel severance. Traction also does not allow for bony healing to begin.
54. A client returns to the nursing unit following the application of skeletal leg traction. Upon assessment, the nurse notes a small amount of bleeding around the pin insertion sites. The nurse should take which action? a) notify the surgeon b) recheck the site in 1 hour c) check the client's vital signs d) place a small pressure dressing at the bleeding site
54) D - Following pin insertion for skeletal traction, a small amount of bleeding is expected. This can be controlled with small pressure dressings; however, bleeding that continues for more than 24 hours should be brought to the surgeon's attention. It is not necessary to notify the surgeon immediately. Rechecking the site in 1 hour delays necessary intervention. Although vital signs may be checked in the immediate post-operative period, this action is unrelated to the small amount of bleeding.
56. A client with a fractured right ankle has a short leg cast applied in the emergency department. During discharge teaching, the nurse provides which information to the client to prevent complications? a) trim the rough edges of the cast after it is dry b) weigh-bearing on the right leg is allowed once the cast feels dry c) expect burning and tingling sensations under the cast for 3 to 4 days d) keep the right ankle elevated above the heart level with pillows for 24 hours
56) D - Leg elevation is important to increase venous return and decrease edema, which can cause compartment syndrome, a major complication of fractures and casting. Weight-bearing on a fractured extremity is prescribed by the physician during follow-up examination, after radiographs are obtained. Additionally, a walking heel or cast shoe may be added to the cast if the client is allowed to bear weight and walk on the affected leg. Although the client may feel heat after the cast is applied, burning and/or tingling sensations indicate nerve damage or ischemia and are not expected. These complaints should be reported immediately. Option 1 is incorrect. The client and/or family may be taught how to "petal" the cast to prevent skin irritation and breakdown, but rough edges, if trimmed, can fall into the cast and cause a break in skin integrity.
66. A client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse prepares to provide which type of wound care to the fasciotomy site? a) dry sterile dressings b) hydrocolloid dressings c) wet sterile saline dressings d) one-half strength betadine dressings
66) C - The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with wet sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. A hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so there should be no reason to require Betadine. Additionally, Betadine can be irritating to normal tissues.
57. An older adult female client with a fractured left tibia has a long leg cast and is using crutches to ambulate. In caring for the client, the nurse assesses for which sign or symptom that indicates a complication associated with crutch walking? a) left leg discomfort b) weak biceps brachii c) triceps muscle spasms d) forearm muscle weakness
57) D - Forearm muscle weakness is a sign of radial nerve injury caused by crutch pressure on the axillae. When a client lacks upper body strength, especially in the flexor and extensor muscles of the arms, he or she frequently allows weight to rest on the axillae and on the crutch pads instead of using the arms for support while ambulating with crutches. Leg discomfort is expected as a result of the injury. Triceps muscle spasms may occur as a result of increased muscle use but is not a complication of crutch walking. Weak biceps brachii is a common physical assessment finding in older adults and is not a complication of crutch walking.
58. A nurse is caring for a client with Buck's traction and is monitoring the client for complications of the traction. Which assessment finding indicates a complication? a) weak pedal pulses b) drainage at the pin sites c) complaints of discomfort d) warm toes with brisk capillary refill
58) A - Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage or prefabricated boot used to secure this type of traction.
59. A client has fallen and sustained a leg injury. Which question would the nurse ask the cleint to help determine if the injury caused a fracture? a) is the pain a dull ache? b) is the pain sharp and continuous? c) does the discomfort feel like a cramp? d) does the pain feel like the muscle was stretched?
59) B - Fracture pain is generally described as sharp, continuous, and increasing in frequency. Bone pain is often described as a dull, deep ache. Strains result from trauma to a muscle body or to the attachment of a tendon from overstretching or overextension. Muscle injury is often described as an aching or cramping pain, or soreness.
6. The patient is placed on allopurinol (Zyloprim) therapy. To monitor effectiveness of the therapy, the nurse will monitor which the following serum laboratory values? a) uric acid b) fasting blood glucose c) serum calcium d) alkaline phosphatase
6) A - preventive therapy - prevention of future gout attacks is by placing the patient on daily medication that either promote uric acid excretion or prevent uric acid formation. To evaluate the effectiveness of the therapy, serum uric acid level of the patient must be monitored. The medication is effective when uric acid goes down to normal level below 6.9 mg/dl
60. The nurse is assessing the casted extremity of a client for signs of infection. Which of the following findings is indicative of infection? a) dependent edema b) diminished distal pulse c) coolness and pallor of the skin d) presence of a "hot spot" on the cast
60) D - Signs and symptoms of infection under a casted area include a musty odor or purulent drainage from the cast or the presence of "hot spots," which are areas on the cast that are warmer than others. The physician should be notified if any of these occur.
61. A nurse is performing pin site care on a client in skeletal traction. Which finding would the nurse expect to note when assessing the pin sites? a) loose pin sites b) clear drainage from the pin sites c) purulent drainage from the pin sites d) redness and swelling around the pin sites
61) B - A small amount of clear drainage ("weeping") may be expected after cleaning and removing crusting around the pin sites. Redness and swelling around the pin sites and purulent drainage may be indicative of an infection. Pins should not be loose, and, if this is noted, the physician should be notified.
62. A nurse is caring for a client who has been placed in Buck's extension traction while awaiting surgical repair of a fractured femur. The nurse prepares to perform a complete neurovascular assessment of the affected extremity and plans to assess: a) vital signs and bilateral lung sounds b) warmth of the skin and the temperature in the affected extremity c) pain level and for the presence of edema in the affected extremity d) color, sensation, movement, capillary refill, and pulse of the affected extremity
62) D - A complete neurovascular assessment of an extremity includes color, sensation, movement, capillary refill, and pulse of the affected extremity.
63. A client in the emergency department has a cast applied. The client arrives at the nursing unit, and the nurse prepares to transfer the client into the bed by: a) placing ice on top of the cast b) supporting the cast with the fingertips only c) asking the client to support the cast during transfer d) using the palms of the hands and soft pillows to support the cast
63) D - The palms or the flat surface of the extended fingers should be used when moving a wet cast to prevent indentations. Pillows are used to support the curves of the cast to prevent cracking or flattening of the cast from the weight of the body. Half-full bags of ice may be placed next to the cast to prevent swelling, but this action would be performed after the client is placed in bed. Asking the client to support the cast during transfer is inappropriate.
65. The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. The nurse's response is based on the understanding that: a) A bone fragment has injured the nerve supply in the area b) an injured artery causes impaired arterial perfusion through the compartment c) bleeding and swelling cause increased pressure in an area that cannot expand d) the fascia expands with injury, causing pressure on underlying nerves and muscles
65) C - Compartment syndrome is caused by bleeding and swelling within a compartment, which is lined by fascia that does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms.
67. An older client admitted to the hospital with a hip fracture is placed in Buck's extension traction. The nurse plans to frequently monitor which specimen item? a) temperature b) mental state c) neurovascular status d) range of motion ability
67) C - The neurovascular status of the extremity of the client in Buck's extension traction must be assessed frequently. Older clients are especially at risk for neurovascular compromise because many older clients already have disorders that affect the peripheral vascular system. Although the client's temperature is monitored, it is not specific to the use of Buck's extension traction. Although clients in some types of traction do become depressed after a few days or weeks, Buck's extension traction is usually used preoperatively, which typically involves a few hours or 1 to 2 days, at the most. Range of motion of the involved leg is contraindicated in hip fractures.
68. Buck's extension traction is applied to an older client following a hip fracture. The nurse explains to the client that this type of traction is: a) traction involving the use of a cast b) skeletal traction involving the use of surgically inserted pins c) circumferential traction involving the use of a belt around the body d) skin traction involving the use of traction attached to the skin and soft tissues
68) D - Buck's extension traction is a form of skin traction and involves the use of a belt or boot that is attached to the skin and soft tissues. The purpose of this type of traction is to decrease painful muscle spasms that accompany fractures. The weight that is used as a pulling force is limited (usually 5 to 10 pounds) to prevent injury to the skin. Options A, B, and C are incorrect descriptions.
69. A client has Buck's extension traction applied to the right leg. The nurse plans which of the following interventions to prevent complications from the device? a) provide pin care once a shift b) massage the skin of the right leg with lotion every 8 hours c) inspect the skin on the right leg at least once every 8 hours d) release the weights on the right leg for range of motion exercises daily
69) C 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. Massaging the skin with lotion is not indicated. The nurse never releases the weights of traction unless specifically ordered by the physician. There are no pins to care for with skin traction.
bottom of crutch should be about ____from feet
6inches
70. The nurse is caring for a client with a newly applied leg cast. The nurse prevents the development of compartment syndrome by: a) elevating the limb and applying ice to the affected leg b) elevating the limb and covering the limb with bath blankets c) keeping the leg horizontal and applying ice to the affected leg d) placing the leg in a slight dependent position and applying ice
70) A - Compartment syndrome is prevented by controlling edema. This is achieved most optimally with the use of elevation and the application of ice. The use of bath blankets or a dependent or horizontal leg position will not prevent this syndrome.
71. A client has sustained a closed fracture and has just has a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which has provided very little pain relief. The nurse interprets that this pain may be caused by: a) infection under the cast b) the anxiety of the client c) impaired tissue perfusion d) the newness of the fracture
71) C - Most pain associated with fractures can be minimized with rest, elevation, application of cold, and administration of analgesics. Pain that is not relieved from these measures should be reported to the physician, because it may be caused by impaired tissue perfusion, tissue breakdown, or necrosis. Because this is a new closed fracture and cast, infection would not have had time to set in.
72. The client with a fractured femur experiences sudden dyspnea. A set of arterial blood gases reveal the following: pH is 7.32, PaCO2 is 43, PaO2 is 58, and HCO3 is 20. Which of the following components of the ABG results supports the nurse's suspicion of fat embolus? a) pH b) PaO2 c) HCO3 d) PaCO2
72) B - A key feature of fat embolism is a significant degree of hypoxemia with a Pao2 often less than 60 mm Hg. Other features that distinguish fat embolism from pulmonary embolism are an elevated temperature and the presence of fat in the blood with fat embolus.
73. The rehabilitation nurse is providing home care instruction for a client being discharged after above-the-knee amputation of the right lower limb with a fitted prosthesis. The nurse determines the client requires further teaching if the client makes which of the following statements? a) I will elevate the residual limb on a pillow b) I will change the residual limb sock everyday c) I will check the residual limb for skin irritation daily d) I will notify my prosthesis if my residual limb sock becomes stretched or ill-fitting
73) A - Clients must avoid elevation of the residual limb to prevent flexion contractures of the right hip. Additionally, sitting in a chair should be limited to 1-hour intervals to avoid the same. If there is no contraindication, clients should lie in the prone position three to four times a day to promote hip extension. Limb socks should be removed daily, laundered in mild soap, and replaced with a clean sock. When the sock is removed, the residual limb should be inspected for erythema and excoriation. As the edema resolves, the residual limb shrinks and the sock may not fit properly, leading to skin irritation. The prosthetist should be notified of the ill-fitting sock.
74. A client arrives at the clinic complaining of knee pain. On assessment the nurse notes that the knee area is swollen. The nurse interprets that the client's signs and symptoms likely indicate: a) osteoporosis b) a recent injury c) rheumatoid arthritis d) degenerative joint disease
74) B - Pain and swelling are associated with musculoskeletal inflammation, infection, or a recent injury. Degenerative joint disease, osteoporosis, and rheumatoid arthritis may be accompanied by pain, but swelling may or may not be present.
75. A client seeks treatment in the emergency department for a lower leg injury. There is visible deformity to the lower aspect of the leg, and the injured leg appears shorter than the other leg. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this client has experienced a: a) strain b) sprain c) fracture d) contusion
75) C - Typical signs and symptoms of fracture include pain, loss of function in the area, deformity, shortening of the extremity, crepitus, swelling, and ecchymosis. Not all fractures lead to the development of every sign. A strain results from a pulling force on the muscle. Symptoms include soreness and pain with muscle use. A sprain is an injury to a ligament caused by a wrenching or twisting motion. Symptoms include pain, swelling, and inability to use the joint or bear weight normally. A contusion results from a blow to soft tissue and causes pain, swelling, and ecchymosis.
76. The nurse is assessing the client who has just been measured and fitted for crutches. The nurse determines that the client's crutches are fitted correctly if: a) the top of the crutch is even with the axilla b) the elbow is straight when the hands is on the handgrip c) the client's axilla is resting on the crutch pad during ambulation d) the elbow is at a 30-degree angle when the hand is on the handgrip
76) D - For optimal upper extremity leverage, the elbow should be at approximately 30 degrees of flexion when the hand is resting on the handgrip. The top of the crutch needs to be two to three finger widths lower than the axilla. When crutch walking, all weight needs to be on the hands to prevent nerve palsy from pressure on the axilla.
77. The nurse is assigned to care for a client who is in traction. The nurse ensures a safe environment for the client by: a) making sure that the knots are at the pulleys b) checking the weights to be sure that they are off the floor c) making sure that the head of the bed is kept at a 90-degree angle d) monitor the weights to be sure that they are resting on a firm surface
77) B - To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. Weights are not to be kept resting on a firm surface. The head of the bed is usually kept low to provide countertraction
78. A client with a possible rib fracture has never had a chest x-ray. The nurse plans to tell the client which of the following about the procedure? a) the x-ray stimulates a small amount of pain b) the client will be asked to breathe in and out continuously during the x-ray c) the x-ray technologist will stand next to the client during the x-ray d) it is necessary to remove jewelry and any other metal objects from the chest area
78) D - An x-ray is a photographic image of a part of the body on a special film, which is used to diagnose a wide variety of conditions. Any radiopaque objects such as jewelry or other metal must be removed from the chest area because they will interfere with the interpretation of the results. The x-ray is painless, and any discomfort would arise from repositioning a painful part for filming. The nurse may premedicate a client, if prescribed, who is at risk for pain. The client is asked to breathe in deeply and then hold the breath while the chest x-ray is taken. To minimize the risk of radiation exposure, the x-ray technologist stands in a separate area protected by a lead wall. The client also wears a lead shield over the reproductive organs.
79. The nurse has an order to get the client out of bed to a chair on the first postoperative day following total knee replacement. The nurse plans to do which of the following to protect the knee joint? a) apply a compression dressing and put ice on the knee while sitting b) obtain a walker to minimize weigh-bearing by the client on the affected leg c) lift the client to the bedside chair, leaving the continuous passive motion (CPM) machine d) apply a knee immobilizer before getting the client up and elevate the client's surgical leg while sitting
79) D - The nurse assists the client to get out of bed on the first postoperative day after putting a knee immobilizer on the affected joint to provide stability. The surgeon orders the weight-bearing limits on the affected leg. The leg is elevated while the client is sitting in the chair to minimize edema. Ice is not used unless prescribed. A compression dressing should already be in place on the wound. A CPM machine is used only while the client is in bed
8. A patient under steroid therapy should be advised by the nurse to: a) limit carbohydrates in the diet b) take the medication on an empty stomach c) avoid individuals who have infections d) stop the medication when symptoms have subsided
8) C - Long Term Side Effects of Prednisone Therapy causes GI irritation so it must be taken with food. Patient may need antacid (must not contain sodium) to prevent ulcer. Give once-daily dose in the morning to lessen toxicity. Maybe diluted in juice or semi-solid food such as apple sauce causes sodium and water retention that results in cushinghoid appearance: moon face, buffalo hump, thinning of hair, hypertension and edema. Advise patient on low sodium diet that's high in potassium and protein avoid discontinuing abruptly as it can cause adrenal insufficiency and rebound inflammation. Reduce dosage gradually can cause glaucoma and cataract so monitor patient for visual disturbances and advise to have annual eye exam if on long term therapy increases cholesterol and glucose levels so diabetics must increase insulin dosage skin tests will be false-negative because it suppresses immune response avoid active immunization while under therapy because patient is immunosuppressed causes hypocalcemia and hypokalemia and increased urine calcium levels, causes osteoporosis so patient needs Vitamin D and calcium supplement will decrease iodine uptake and protein-bound iodine levels in thyroid function test tell patient to report: slow healing, exposure to infection, depression, insomnia, psychotic symptoms, weakness and fatigue, dizziness, joint pain, fever, anorexia and fainting always give by deep IM in gluteal muscle to prevent sterile abscess if given by subcutaneous and rotate injection sites route to prevent tissue atrophy always give the lowest dose to minimize toxicity
80. The nurse is conducting a health screening clinic for osteoporosis. The nurse determines that which client seen in the clinic is at the greatest risk of developing this disorder? a) a 25-year old female who jogs b) a 36-year old male who has asthma c) a 70-year old male who consumes excess alcohol d) a sedentary 65-year old female who smokes cigarettes
80) D - Risk factors for osteoporosis include being female, postmenopausal status, advanced age, low-calcium diet, excessive alcohol intake, sedentary lifestyle, and cigarette smoking. The long-term use of corticosteroids, anticonvulsants, and furosemide (Lasix) also increase the risk.
9. Which type of exercise should the nurse recommend to Cindy? a) jogging b) swimming c) bicycling d) skating
9) B - swimming is an ideal exercise for patient with arthritis because it allows ROM exercise for most of the joints of the body with less danger of injury.
"Which of the following is something the nurse would plan to provide for a client after total hip replacement to reduce friction? A) Trapeze B) Fracture bedpan C) Egg crate mattress overlay D) Continuous passive motion machine"
A - A trapeze will allow the client to lift the buttocks during linen changes, bedpan application, movement up in bed, and delivery of posterior skin care. Lifting decreases the pressure between the client and the bed. Use of a fracture bedpan would be more comfortable for the client but does not reduce friction. Placing an egg crate on the mattress will improve comfort, but it does not alleviate pressure nor does it reduce friction forces. A continuous passive motion machine is used after total knee replacements, not total hip replacements.
"What is the appropriate action for Mr. Stone when he experiences these symptoms? (Select the priority intervention.) A) Call for assistance. B) Allow Mr. Stone to sit down. C) Take Mr. Stone's blood pressure and pulse. D) Continue to ambulate Mr. Stone so he begins to build up endurance."
A - Call for assistance and allow Mr. Stone to sit down and rest for a few minutes. While he is resting, checking his blood pressure and pulse rate is a prudent thing to do. After he begins to feel better, he may again attempt to ambulate. Having the client sit on the side of the bed before walking for at least 1 to 2 minutes can help prevent orthostatic hypotension.
"Which of the following is a result of children's being less physically active outside of school? A) An increase in obesity B) An increase in heart disease C) Greater computer literacy among children D) Improved school attendance and grades"
A - Children who are less physically active outside of school stand a greater likelihood of being obese. Later in life, this group may have a greater incidence of heart disease, but heart disease is not common during childhood. Obesity and the diseases that come with it can help increase school absences. Physical activity does not correlate with computer literacy.
"Before the client participates in physical therapy after total knee replacement, the nurse does which of the following? A) Administers an analgesic 30 to 60 minutes before therapy B) Places a heating pad over the affected knee 1 hour before therapy C) Instructs the client to bend over and touch the toes as a warm-up exercise D) Discontinues use of the continuous passive motion (CPM) machine 4 hours before therapy"
A - Clients often experience pain during physical therapy, and thus their progress may be impeded. Administering analgesics before the therapy will help the client participate more fully. The CPM machine assists the client in maintaining mobility in the affected joint. Discontinuing it may cause the joint to become stiff and more painful during therapy. Application of heat would increase circulation to the knee and increase swelling. Application of cold would be more therapeutic. Having the client perform the described warm-up exercises may be inappropriate for this client and in fact may cause injury.
17. It has been determined that all of the following clients are at risk for falling. Which one requires the nurse's priority for ambulation? 1. A 16-year-old with a sprained ankle being discharged from the emergency department 2. A 54-year-old who has taken the initial dose of an antihypertensive medication 3. A 45-year-old postoperative client up for the first time since knee surgery 4. An 81-year-old who is asthmatic and had a hip replaced 18 months ago
A 45-year-old postoperative client up for the first time since knee surgery
24. The physician writes an order to discontinue skeletal traction on your patient. Once the traction is discontinued what occurs to immobilze and support the healing bone? A) A walking boot is applied. B) A cast is applied. C) Patient is shown how to use crutches. D) Patient is instructed in the use of a cane.
A CAST IS APPLIED **When skeletal traction is discontinued, the extremity is gently supported while the weights are removed. The pin is cut close to the skin and removed by the physician. Internal fixation, casts, or splints are then used to immobilize and support the healing bone. A walking boot would not be used after skeletal traction, nor would crutches or a cane until the bone has healed completely.
Base of Support (def)
A persons feet provide the base of support the wider the base of support the more stable the object is within limits (feet cant be too wide)
Which of the following laboratory values would the nurse expect to see for a client experiencing prolonged immobility? A) Calcium 11.5 mg/dl B) Sodium 142 mmol/L C) Potassium 4.2 mmol/L D) Hemoglobin 14.6 g/dl
A) Calcium 11.5 mg/dl
A client had a left-sided cerebrovascular accident 3 days ago and is being given 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The client is receiving enteral feedings through a small-bore nasogastric tube because of dysphagia. Which of the following symptoms requires the nurse to call the health care provider immediately? A) Hematuria B) Unilateral neglect C) Limited range of motion in the right hip D) Coughing up of a moderate amount of clear, thin sputum
A) Hematuria
Before transferring a client from the bed to a stretcher, the nurse must assess to determine which of the following? (Select all that apply.) A) How much the client's weighs B) Whether intravenous (IV) lines are present C) What the client's nutritional status is D) How cooperative the client is
A) How much the client's weighs B) Whether intravenous (IV) lines are present D) How cooperative the client is
When a client is immobilized, which of the following positions is preferred to prevent skin breakdown? A) Semi-Fowler's B) Side-lying with knees flexed C) Prone with upper extremities flexed D) Supine with lower extremities extended
A) Semi-Fowler's
34. Orthopedic surgery can be used to correct a variety of orthopedic conditions. What conditions can be corrected by orthopedic surgery? (Mark all that apply.) A) Joint disease B) Stable fractures C) Tumors D) Inflammed tissue E) Nectotic tissue
A, C JOINT DISEASE, TUMORS **Conditions that may be corrected by surgery include unstabilized fractures, deformity, joint disease, necrotic or infected tissue, and tumors.
knees being flexed does what?
absorbs jolts
"When a client has a right-sided cerebral hemorrhage, what may also be present? A) Bilateral hemiplegia B) Left-sided hemiplegia C) Right-sided hemiplegia D) Degenerative hemiplegia"
B - The motor fibers from the right motor strip of the precentral gyrus regulate voluntary motion on the left side of the body, and the fibers on the left motor strip regulate voluntary motion on the right side of the body, so a right-sided hemorrhage is likely to create left-sided hemiplegia.
The immobilized client should be instructed to: A) Eat a restricted-calorie diet. B) Take in a minimum of 2000 ml of water per day. C) Deep breathe and cough every 4 hours. D) Quickly resume walking exercises when able.
B) Take in a minimum of 2000 ml of water per day.
33. A student nurse is helping with the initial assessment of an 85-year-old patient. What can the student do to ensure that shearing forces are avoided? (Mark all that apply.) A) Puts on foam boots three or more times a day. B) Inspect and provide skin care q shift. C) Palpate the area of the traction tapes daily. D) Provides back care at least q 2 hours. E) Give massage q shift.
B, C, D INSPECT AND PROVIDE SKIN CARE Q SHIFT, PALPATE THE AREA OF THE TRACTION TAPES DAILY, PROVEDES BACK CARE AT LEAST Q 2 HRS. ** During the initial assessment, the nurse identifies sensitive, fragile skin (common in older adults). The nurse also closely monitors the status of the skin in contact with tape or foam to ensure that shearing forces are avoided. The nurse performs the following procedures to monitor and prevent skin breakdown: removes the foam boots to inspect the skin, the ankle, and the Achilles tendon three times a day. A second nurse is needed to support the extremity during the inspection and skin care. The nurse palpates the area of the traction tapes daily to detect underlying tenderness, and provides back care at least every 2 hours to prevent pressure ulcers. The patient who must remain in a supine position is at increased risk for development of a pressure ulcer. Special mattress overlays (eg, air-filled, high-density foam) are used to prevent pressure ulcers.
19. A patient you are caring for undergoes a total hip replacement. You are getting ready to review the patient teaching that you presented over the past few days. What statement made by the patient would indicate to the nurse that the patient requires further teaching? A) "I'll need to keep several pillows between my legs at night." B) "I need to remember not to cross my legs. It's such a habit." C) "The occupational therapist is showing me how to use a 'sock puller' to help me get dressed." D) "I will need my husband to assist me in getting off the low toilet seat at home."
I WILL NEED MY HUSBAND TO ASSIS ME IN GETTING OFF THE LOW TOILET SEAT AT HOME **To prevent hip dislocation after a total hip replacement, the patient must avoid bending the hips beyond 90 degrees. Assistive devices, such as a raised toilet seat, should be used to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Likewise, teaching the patient to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a patient get dressed without flexing the hips beyond 90 degrees.
35. A patient is undergoing preoperative respiratory testing to provide baselines of respiratory function for the postoperative period. A patient you are caring for has preoperative testing that indicates he is at increased risk for respiratory complications. What therapy would you initiate to aid in the prevention of respiratory complications for your patient? A) Respiratory exercises B) Incentive spirometer C) Chest percussion D) Broad-spectrum antibiotics
INCENTIVE SPIROMETER **If the patient history and baseline assessment indicate that the patient is at risk for development of respiratory complications, specific therapies (eg, use of incentive spirometer) may be indicated. Chest percussion, respiratory exercises, and broad-spectrum antibiotics would not be started preoperatively
26. A patient comes to the clinic complaining of pain at the site of their hip replacement. The patient tells the nurse they had their hip replacement surgery 3 years ago. On assessment the nurse notes the area around the surgical scar is erythematous and edematous. What would the nurse suspect? A) Infection at the surgical site that has spread from another site in the body B) A delayed surgical infection C) An acute infection D) A host infection
INFECTION AT THE SURGICAL SITE THAT HAS SPREAD FROM ANOTHER SITE IN THE BODY **Infections occurring more than 2 years after surgery are attributed to the spread of infection through the bloodstream from another site in the body. Delayed surgical infections may appear 4 to 24 months after surgery and may cause return of discomfort in the hip. Acute infections may occur within 3 months after surgery and are associated with progressive superficial infections or hematomas. A host infection is a distracter for this question
17. A patient with a right tibial fracture is being discharged home after having a cast applied. The nurse gives instructions to the patient and his family. What instruction should the nurse provide in relationship to the patient's cast care? A) Cover the cast with a blanket until the cast dries. B) Keep your right leg elevated above heart level. C) Use a knitting needle to scratch itches inside the cast. D) A foul smell from the cast is normal.
KEEP YOUR RIGHT LEG ELEVATED ABOVE HEART LEVEL **The leg should be elevated to promote venous return and prevent edema. The cast shouldn't be covered while drying because this will cause heat buildup and prevent air circulation. No foreign object should be inserted inside the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection.
8. A patient with a fractured femur is in balanced suspension traction. The patient needs to be repositioned toward the head of the bed. During repositioning, what should the nurse do? A) Place slight additional tension on the traction cords. B) Release the weights and replace them immediately after positioning. C) Lift the traction and the patient during repositioning. D) Maintain the same degree of traction tension.
MAINTAIN THE SAME DEGREE OF TRACTION TENSION **Traction is used to reduce the fracture and must be maintained at all times, including during repositioning. Options A, B, and C are incorrect because it isn't appropriate to increase traction tension or release or lift the traction during repositioning.
18. A nurse is admitting an 83-year-old female patient who arrives at the emergency department by ambulance after falling on the ice outside her senior citizens' housing facility. The admitting diagnosis is right hip fracture. What would be most important for the nurse to assess? A) Leg shortening B) Complaints of pain C) Neurovascular compromise D) Internal or external rotation
NEUROVASCULAR COMPROMISE **Because impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment. Leg shortening and internal or external rotation are common findings with a fractured hip. Pain, especially on movement, is also common after a hip fracture.
20. The nurse is admitting a patient to the unit who presented with a lower extremity fracture. What signs and symptoms best represent peroneal nerve injury? A) Numbness and burning of the foot B) Numbness and burning of the hand C) Cyanotic toes D) Inadequate capillary refill
NUMBNESS AND BURNING OF THE FOOT **Peroneal nerve injury may result in numbness, tingling, and burning in the feet. Cyanosis and decreased capillary refill are signs of inadequate circulation.
________and _________ share the responsibility of managing ROM exercise programs for the clients
Nurses and Physical Therapy
2. An 18-year-old male patient broke his arm in a skateboarding accident. The arm was put in an arm cast. The patient states that he is unable to straighten his fingers. The nurse notes that the patient is experiencing Volkmann's contracture, which is due to what? A) Obstructed arterial blood flow to the forearm and hand B) Obstructed venous blood flow from the forearm and hand C) The cast being applied too loosely D) Muscle spasm of the forearm
OBSTRUCTED ARTERIAL BLOOD FLOW TO THE FOREARM AND HAND **Volkmann's contracture occurs when arterial blood flow is restricted to the forearm and hand and results in contractures of the fingers and wrist. Therefore options B, C, and D are incorrect.
14. What statement about skeletal traction is most accurate? A) Traction weight is increased as muscles relax. B) Often balanced traction is used. C) Skeletal traction is used until the fracture is healed. D) Pins are attached to the muscle of the affected limb.
OFTEN BALANCED TRACTION IS USED **Balanced traction is often used with skeletal traction. As the muscles relax, the amount of weight is decreased, pins are inserted through the bone, and skeletal traction is discontinued when callus formation is evident by radiograph.
11. A patient who underwent a total hip replacement is being routinely turned. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis? A) Keep the affected leg in a position of adduction. B) Use measures other than turning to prevent pressure ulcers. C) Prevent internal rotation of the affected leg. D) Keep the hip flexed by placing pillows under the patient's knee.
PREVENT INTERNAL ROTAITON OF THE AFFECTED LEG **External rotation and abduction of the hip helps to prevent dislocation of a new hip joint. Internal rotation and adduction should be avoided. Postoperative total hip replacement patients may be turned onto the unaffected side. While the hip may be flexed slightly, it shouldn't exceed 90 degrees and maintenance of flexion isn't necessary.
16. The nurse is preparing instructions for a patient who is going home with a cast on his leg. What teaching point is most critical to emphasize in the teaching session? A) Using crutches properly B) Exercising joints above and below the cast, as ordered C) Avoiding walking on a leg cast without the physician's permission D) Reporting signs of impaired circulation
REPORTING SIGNS OF IMPAIRED CIRCULATION **Although all of these interventions are important, reporting signs of impaired circulation is the most critical. Signs of impaired circulation must be reported to the physician immediately to prevent permanent damage. The other options reflect more long-term concerns. The patient should learn to use his crutches properly to avoid nerve damage. The patient may exercise above and below the cast, as the physician orders. The patient should be told not to walk on the cast without the physician's permission.
6. While assessing a patient who has had knee replacement surgery, the nurse notes that the patient has developed a hematoma at the knee replacement surgical site. The affected leg has a decreased pedal pulse. What would be the most appropriate nursing diagnosis for this patient? A) Risk for infection B) Risk of peripheral neurovascular dysfunction C) Ineffective health maintenance D) Self-esteem disturbance
RISK OF PERIPHERAL NEUROVASCULAR DYSFUNCTION **The hematoma may cause an interruption of tissue perfusion, so the most appropriate nursing diagnosis is Risk of peripheral neurovascular dysfunction. Therefore options A, C, and D are incorrect.
_____is the type of lift used when a client can not support heads or for some clients with burns or other traumas
Supine lift
Sequential compression devices are used to a.) prevent pressure ulcers b.) promote venous return c.) prevent muscular atrophy d.) increase joint motility
b.) promote venous return
Range of Motion (def)
is the ability to move various joints and structures of the body to their limits between the two points of resistance at which the joint would neither open nor close any further
CPM promotes what?
joint mobility and speed Rehabilitation
if a transfer board or client lift is not avaiable it is possible to transfer a client using only a
lifting sheet (draw sheet)
what controls joint movements?
ligaments muscles and tendons that connect to the bones
If you explained why you repositioned the client then they are
likely to maintain that position
clients who have injured their tendons muscles or ligaments will have what?
limited joint movement
If using a transfer board make sure there are _______between the board and client
linens
another name for stretcher is
litter or gurney ( is a four wheeled cart that is used to move people who can not walk
if the client is extremely violent or out of control _____ may be necessary
locked leather restraints
Logroll (def)
method of turning a client that keeps the body in straight alignment, used for clients with injuries to the back or spinal cord
intermittent
mobilization of joints, distraction, stretching soft tissue,
To achieve the orthopneic position you would place the overbed table across the bed with one or two pillows and asked the client?
to lean foward across the table with hes arms on or beside pillows and rest head on pillow
The complete prone position is
uncomfortable for extended amounts of time because having the head turned to the side can strain the neck and cause a headache
Body mechanics (def)
use of safe and efficient methods of moving and lifting
Body Mechanics (def)
use of the safest and most efficient methods of moving and lifting
crutches that fit properly are ______and do not create pressure under the arms
used correctly and are comfortable
