Mobility and Tissues ATI Quiz
A nurse in a medical clinic is providing teaching to an older adult client who has osteoarthritis that is affecting her knees. Which of the following client statements indicates an understanding of the teaching? -"I can use either heat or ice to help relieve the discomfort." -"Ibuprofen is the first step in medication therapy for osteoarthritis." -"I should limit physical activity to prevent further injury." -"I will elevate my legs by placing two pillows under my knees when I go to bed."
"I can use either heat or ice to help relieve the discomfort." The nurse should reinforce that different treatment modalities, such as heat or cold therapy, can be tried to determine which one is more effective for the client. Heat application can help with muscle relaxation in the area around the affected joint. The application of cold numbs nerve endings and decreases joint inflammation.
A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching? -"I will reduce my intake of sodium." -"I will decrease my intake of caffeine." -"I will limit my intake of soft drinks." -"I will reduce my intake of vitamin K-rich foods."
"I will reduce my intake of vitamin K-rich foods." Vitamin K is necessary for bone health. The nurse should instruct the client to increase her intake of vitamin K-rich foods—such as green, leafy vegetables—to promote bone health.
A nurse is teaching a client who is starting to take alendronate effervescent tablets to treat osteoporosis. Which of the following info should the nurse include? -"Sit upright or stand for at least 30 minutes after taking this medication." -"Take this medication with food." -"Take this medication with orange juice." -"Chew or suck on the tablet."
"Sit upright or stand for at least 30 minutes after taking this medication." The nurse should instruct the client to sit or stand for 30 minutes after administration of this medication to reduce prolonged contact of the medication with the esophageal mucosa that can cause esophagitis.
A nurse is teaching a client who has a new prescription for topical betamethasone to treat contact dermatitis. Which of the following instructions should the nurse include? -"Cover areas of excoriated skin with cream." -"Use hot water to soothe the lesions." -"Cover area with an occlusive dressing after application." -"Use the cream for a few days after the area has healed."
"Use the cream for a few days after the area has healed" The client should continue to apply steroid cream to affected area for a few days after the area has healed to reduce the risk for reoccurrence
A nurse is teaching a client who is scheduled for dual-energy x-ray absorptiometry(DXA) to screen for osteoporosis. Which of the following instructions should the nurse include in the teaching? -"You will need to remove all jewelry before the test." -"You will need to lie flat for 4 hours following the test." -"You will need to empty your bladder before the test." -"You will need to fast for 12 hours before the test."
"You will need to remove all jewelry before the test." The nurse should instruct the client to remove all jewelry or metal objects that can interfere with the test. A DXA scan is the mostly commonly used screening and diagnostic tool for measuring bone mineral density.
A nurse is preparing a presentation at a community center about osteoarthritis. The nurse should plan to include which of the following information?(Select all that apply) -Affects weight-bearing joints -Crepitus can occur in affected joints -Affects bilateral, symmetrical joints -Causes joint stiffness -Causes joint pain
-Affects weight-bearing joints -Crepitus can occur in affected joints -Causes joint stiffness -Causes joint pain
A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching?(Select all that apply) -Bacteria -Diuretics -Aging -Obesity -Smoking
-Aging -Obesity -Smoking
A nurse is providing teaching to a client who has osteoporosis and a new prescription for alendronate. Which of the following adverse effects should the nurse instruct the client to report to the provider?(Select all that apply) -Tinnitus -Jaw pain -Blurred vision -Drowsiness -Dysphagia
-Jaw pain -Blurred vision -Dysphagia
A nurse is preparing to preform wound irrigation on a client who has a puncture wound to the left leg. Identify the sequence of steps the nurse should take to perform the irrigation.
-Place a waterproof pad on the bed under the client's leg - Don clean gloves to remove and discard the old dressing. -Clean the puncture site using a circular motion -Open a sterile dressing set and supplies. -Irrigate the wound until the solution becomes clear
A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching?(Select all that apply) -Poor nutritional state -Altered mental status -Obesity -Pain medication administration -Wound infection
-Poor nutritional state -Obesity -Wound infection
A nurse is teaching a client about risk factors for osteoporosis. Which of the following factors should the nurse include in the teaching? (Select all that apply) -Sedentary lifestyle -Obesity -Aging -Caffeine intake -Secondhand smoke
-Sedentary lifestyle: Immobility depletes bone. -Aging: Women lose bone due to estrogen depletion after menopause. -Caffeine intake: Excessive caffeine intake causes calcium loss in the urine. -Secondhand smoke: Smoking is a risk factor for osteoporosis, both active and passive (secondhand) smoking.
A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the nurse include in the teaching? (Select all that apply) -Vitamin A -Vitamin B12 -Vitamin C -Vitamin D -Vitamin K
-Vitamin A: is important for tissue synthesis, wound healing, and immune function. -Vitamin B12: assists in the development of red blood cells, maintenance of nerve function, and is needed for cell maintenance and tissue synthesis. -Vitamin C: is important for capillary formation, tissue synthesis, and wound healing. -Vitamin K: functions as an enzyme in the synthesis of prothrombin and other proteins required for normal blood clotting
A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client? -Lordosis -Ankylosis -Kyphosis -Scoliosis
Kyphosis Kyphosis, a forward "stooping" posture with a loss of height, is an angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is most common in older adults and increases with aging and vertebral fractures.
A nurse i completing a physical assessment of a client who has early osteoarthritis. Which of the following manifestations should the nurse expect? -Symmetric joints affected -Pain worsens with activity -Weight loss -Ulnar deviation
Pain worsens with activity The typical cycle of pain and relief in a client who has early osteoarthritis consists of pain with activity and pain relief with rest. As the disorder progresses, clients typically experience pain even while the joint is at rest.
A nurse is providing nutritional teaching to a client who has osteoporosis. Which of the following foods should the nurse recommend as being the highest in calcium? -1 cup carrot strips -3 oz canned salmon -1 cup chopped chicken breast -1 plain baked potato
3oz canned salmon The nurse should recommend canned salmon as a food to increase calcium intake. A 3 oz serving of canned salmon contains 197 mg of calcium.
A nurse is planning care for an adolescent who has scoliosis and requires surgical intervention. Which of the following behaviors by the adolescent should the nurse anticipate because it is most common reaction? -Identity crisis -Body image changes -Feelings of displacement -Loss of privacy
Body image changes Body image changes are the most common behaviors observed in adolescents who have scoliosis and require surgery.
A nurse is teaching a client at high risk for osteoporosis about dietary measures she can take to increase her calcium level. Which of the following foods should the nurse advise the client to increase in her diet? -Carrots -Broccoli -Cabbage -Potatoes
Broccoli Broccoli is high in calcium. Most vegetables contain considerably less calcium, except for kale, collard greens with stems, and turnip greens, which are also good sources of calcium.
A nurse in a clinic is talking with a client who has a new diagnosis of osteoarthritis. The nurse should anticipate that the client will require teaching about which of the following medications? -Acetaminophen -Celecoxib -Cyclobenzaprine -Ibuprofen
Acetaminophen According to the American Pain Society, acetaminophen is the primary drug of choice for treating osteoarthritis. The provider would likely begin with this medication.
A nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. The nurse should include which of the following information in the teaching?
Buck's extension traction will relieve muscle spasms. Buck's extension traction immobilizes the fractured bone to relieve associated muscle spasms and thereby relieve pain. Any movement of the fractured extremity will aggravate severe muscle spasm and trigger pain.
A nurse is assessing a client who has a cast in place for a fractured tibia. Which of the following actions should the nurse take first? -Checking capillary refill -Discussing cast care -Managing pain -Performing range of motion
Checking capillary refill The priority action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to check the client's capillary refill. Musculoskeletal injuries can cause changes in the neurovascular system, usually distal to the injury. Capillary refill provides data about the client's circulation.
A nurse is caring for a client who has a cast in place for a fractured tibia. Which of the following nursing actions is the priority immediately after the provider has applied the cast? Checking capillary refill distal to the cast Teaching the client about cast care Managing pain Performing range of motion
Checking capillary refill distal to the cast The priority action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to check capillary refill. Musculoskeletal injuries can cause changes in the neurovascular system, usually distal to the injury from the pressure of the cast. Capillary refill provides data about the client's circulation.
A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? -Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. -Irrigate the wound with an antiseptic prior to obtaining the specimen. -Include intact skin at the wound edges in the culture. -Swab an area of skin away from the wound to identify the usual flora.
Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. The nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results.
A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, which of the following actions should the nurse take first? -Raise the head of the client's bed 15° to 20°. -Place the client supine with knees bent. -Assess the client for manifestations of shock. -Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation
Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation According to evidence-based practice, the nurse should first cover the area with a sterile dressing moistened with normal saline to protect the client's internal organs. The nurse should not attempt to reinsert the client's organs or viscera.
A nurse is assessing a client who has had staple removed from an abdominal wound postop. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? -Check the client's vital signs. -Assess the client's pain level. -Cover the wound with a moist, sterile gauze dressing. -Obtain a culture and sensitivity of the wound drainage.
Cover the wound with a moist, sterile gauze dressing. The client's wound has dehisced, or opened along the suture line, and is now draining. The primary clinical objective in managing a dehisced wound is to keep it clean and moist, and manage any exudate. The nurse's priority action therefore is to cover the wound with a moist, sterile, saline-soaked gauze dressing.
A nurse is talking with a young adult client who has a family history of osteoporosis. Which health promotion activity should the nurse recommend as a possible preventive measure? -Increase sodium intake. -Have a bone-density scan each year. -Engage in weight-bearing exercise regularly. -Drink a cup of coffee each morning.
Engage in weight-bearing exercise regularly Regular weight-bearing exercise, such as walking and stair-climbing, increases bone density and can reduce the risk for osteoporosis.
A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first? -Change in temperature of the toes. -Pallor of the toes. -Edema of the toes. -Inability to move toes.
Pallor of the toes If a cast is too tight it will increase pressure on the blood vessels, impairing circulation. When this occurs, pallor of the toes is the initial finding. The nurse should immediately report this finding to the provider.
A nurse is caring for a client who has a large lower-leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing? -Kidney beans -Grilled salmon -Peanut butter -Raw spinach
Grilled salmon Poultry, fish, eggs, and beef are complete proteins and are optimal sources of protein to support wound healing.
A nurse is assessing a client who has a left lower are fracture. Which of the following findings indicates impaired venous return in the client's affected arm? -Increasing edema -A bounding distal pulse -Acute pain -Ecchymosis of the surrounding skin
Increasing edema Increasing edema is a sign of impaired circulation. It is important for client who has a limb fracture to keep the limb elevated to reduce edema.
A nurse is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation. Which of the following interventions should the nurse include in the plan of care? -Keep the head of the bed at a 30° angle. -Reposition the client by log rolling every 4 hr. -Place the client in protective isolation. -Initiate the use of a PCA pump for pain control.
Initiate the use of a PCA pump for pain control The nurse should initiate the use of a PCA pump for an adolescent who is postoperative following scoliosis repair. The PCA pump allows the client to control the delivery of pain medications.
A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when preforming an assessment of the client's neurovascular status? -Measure the circumference of the thigh. -Palpate the femoral pulse. -Monitor the client's calf for edema. -Instruct the client to wiggle his toes.
Instruct the client to wiggle his toes. The nurse should observe the client's ability to move his toes when collecting data regarding neurovascular status distal to the fracture. Other means of evaluating neurovascular status include assessing skin color and temperature, sensation, pain, and capillary refill.
A nurse is teaching a group of clients about osteoarthritis. Which of the following recommendation should the nurse include in the teaching? -Use Echinacea to manage joint pain. -Apply ice to the joint before exercising. -Maintain a recommended body weight. -Reduce the amount of purine in the diet.
Maintain a recommended body weight Obesity is a risk factor for the development of osteoarthritis. Maintenance of an ideal weight is one way a client can prevent added wear and tear on joints and promote overall joint health.
A nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. To assist in meeting this goal, which of the following nursing interventions is the highest priority? -Maintain immobilization and alignment. -Provide optimal nutrition and hydration. -Promote independence in activities of daily living. -Provide relief from pain and discomfort.
Maintain immobilization and alignment Maintaining the prescribed immobilization and body alignment will keep the fracture fragments in close anatomical proximity, thereby promoting functional fracture healing. According to the safety and risk reduction priority setting framework, this goal should receive the highest priority.
A nurse is assessing a client who has a hip fracture. Which of the following findings should the nurse expect? -Leg lengthening -Hip pallor -Muscle spasms -Leg abduction
Muscle spasms The nurse should expect muscle spasms with a hip fracture
A nurse is caring for a client who is postop following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postop period? -Medicate the client for pain. -Instruct the client on use of crutches. -Perform neurovascular checks of the extremities. -Direct the client to perform exercises of the ankle and toes.
Perform neurovascular checks of the extremities. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is the performance of neurovascular checks. These are a vital aspect of care for the client who has a sustained a fracture and should be monitored every hour for the first 24 hr. Circulation can easily become impaired due to constriction, which develops as the extremity swells from edema. This may cause nerve damage and tissue anoxia.
A nurse working in a community health center is preparing a flow sheet detailing essential screenings according to age group. At which developmental stage on the chart should the nurse add scoliosis screening? -Infant -Toddler/Preschooler -Pre-adolescent/adolescent -Older Adult
Pre-adolescent/adolescent Scoliosis is a condition involving a lateral curvature to the spine. The nurse should include screening for scoliosis during the pre-adolescence/adolescence age group: for girls in grades 5 through 7 and for boys in grade 8 or 9.
A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching? -Protein -Calcium -Vitamin B1 -Vitamin D
Protein Protein is the major structural and functional component of every cell. It is required in increased amounts during times when the body needs to heal itself and protein will promote wound healing.
A nurse is teaching a client about medications that prevent osteoporosis. The nurse should instruct the client that which of the following medications is prescribed to prevent osteoporosis? -Levothyroxine -Calcitonin -Raloxifene -Allopurinol
Raloxifene Raloxifene is prescribed for the prevention and treatment of osteoporosis in postmenopausal women.
A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first? -Administer an opioid analgesics -Obtain a prescription to adjust the weight amount. -Offer a muscle relaxant to the client -Realign the client's position
Realign the client's position. The greatest risk to this client is injury form circulatory compromise and tissue damage; therefore, the first action the nurse should take is to realign the client's position.
A nurse is providing discharge teaching to a client who has a fracture of the right tibia and a fiberglass cast. Which of the following instructions should the nurse include in the teaching? -Use a blow dryer on a moderate heat setting to dry the cast after showering. -Use a cotton swab to relieve itching under the cast. -Report any worsening or unrelieved pain. -Avoid moving the affected leg.
Report any worsening or unrelieved pain Pain can be a sign of complications such as compartment syndrome or skin breakdown. The client should report it to the provider.
A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which of the following is an expected finding? -Report of exposure to a skin irritant -Denial of pruritus -Systemic symptoms including elevated temperature -Report of generalized joint discomfort
Report of exposure to a skin irritant The most common cause of contact dermatitis is exposure to a topical irritant therefore identifying this irritant is a component of treatment.
A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following actions is the nurse's priority? -Instruct the client about home disposal of contaminated dressings. -Schedule a follow-up visit by a home health nurse for dressing changes. -Provide a dietary list of foods which promote wound healing. -Establish a follow-up appointment with the client's provider.
Schedule a follow-up visit by a home health nurse for dressing changes. The greatest risk to this client is injury from a wound infection. Therefore, the priority action the nurse should take is to schedule a follow-up visit by a home health nurse for dressing changes. Wounds healing by secondary intention are open and have edges that are not approximated, which increases the risk for infection.
A nurse in a provider's office is collecting a health history from a client who is at risk for primary osteoporosis. Which of the following findings is a risk factor for the development of osteoporosis? -Obesity -Sedentary lifestyle -Long-term use of diuretics -Prolonged stress
Sedentary lifestyle A sedentary lifestyle places the client at risk for osteoporosis. Regular, weight-bearing exercises help to build bone tissue.
A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? -Serous -Purulent -Sanguineous -Serosanguineous
Serosanguineous Watery red drainage should be documented as serosanguineous.
A nurse in a clinic is assessing a client. Which of the following findings should the nurse identify as a risk factor for osteoporosis? -Drinks one alcoholic beverage per day -Smokes 1 pack of cigarettes per day -Large body stature -History of bone fracture during childhood
Smokes 1 pack of cigarettes per day The nurse should identify active or passive smoking as a risk factor for osteoporosis.
A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs? The client complains of pain. The client develops a life-threatening situation. The client needs to have an x-ray of the femur performed. The client has to be repositioned in the bed.
The client develops a life-threatening situation Traction weights, which are to hang freely at all times, are never to be removed without a specific provider prescription unless there is a life-threatening situation.
A nurse is reviewing risk factors for osteoporosis with a group of nursing students. The nurse should include that which of the following types of medication therapy is a risk factor for osteoporosis? -Thyroid hormones -Anticoagulants -NSAIDs -Cardiac glycosides
Thyroid hormones Long-term use of a synthetic thyroid hormone, such as levothyroxine, can accelerate bone loss.
A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take? -Apply a light layer of talcum powder with each diaper change. -Change to cloth diapers until the skin is healed. -Expose the excoriated area to hot air frequently. -Use a moisturizer to wipe urine from the skin.
Use a moisturizer to wipe urine from the skin. It is appropriate for the nurse to use a moisturizer to wipe urine from the skin. This will prevent further breakdown of the skin.
