Musculoskeletal
The nurse is teaching the client to administer enoxaparin (Lovenox) following a total hip arthroplasty? The nurse should instruct the client about which of the following? Select all that apply. 1. Report promptly any difficulty breathing, rash, or itching. 2. Notify the health care provider of unusual bruising. 3. Avoid all aspirin-containing medications. 4. Wear or carry medical identification. 5. Expel the air bubble from the syringe before the injection. 6. Remove needle immediately after medication is injected.
1, 2, 3, 4. Client/ family teaching should include advising the client to report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever, swelling, or difficulty breathing to healthcare provider immediately. Instruct the client not to take aspirin or nonsteroidal anti-inflammatory drugs without consulting health care provider while on therapy. A low-molecular weight heparin is considered to be a high-risk medication and the client should wear or carry medical identification. The air bubble should not be expelled from the syringe because the bubble insures the client receives the full dose of the medication. The client should allow 5 seconds to pass before withdrawing the needle to prevent seepage of the medication out of the site.
The nurse is assessing a client's left leg for neurovascular changes following a total left knee replacement. Which of the following are expected normal findings? Select all that apply. 1. Reduced edema of the left knee. 2. Skin warm to touch. 3. Capillary refill response. 4. Moves toes. 5. Pain absent. 6. Pulse on left leg weaker than right leg.
1, 2, 3, 4. Postoperatively, the knee in a total knee replacement is dressed with a compression bandage and ice may be applied to control edema and bleeding. Recurrent assessment by the nurse for neurovascular changes can prevent loss of limb. Normal neurovascular findings include: color normal, extremity warm, capillary refill less than 3 seconds, moderate edema, tissue not palpably tense, pain controllable, normal sensations, no paresthesia, normal motor abilities, no paresis or paralysis, and pulses strong and equal.
A client with osteoporosis needs education about diet and ways to increase bone density. Which of the following should be included in the teaching plan? Select all that apply. 1. Maintain a diet with adequate amounts of vitamin D, as found in fortified milk and cereals. 2. Choose good calcium sources, such as figs, broccoli, and almonds. 3. Use alcohol in moderation because a moderate intake has no known negative effects. 4. Try swimming as a good exercise to maintain bone mass. 5. Avoid the use of high-fat foods, such as avocados, salad dressings, and fried foods.
1, 2, 3. A diet with adequate amounts of vitamin D aids in the regulation, absorption, and subsequent utilization of calcium and phosphorus, which are necessary for the normal calcification of bone. Figs, broccoli, and almonds are very good sources of calcium. Moderate intake of alcohol has no known negative effects on bone density but excessive alcohol intake does reduce bone density. Swimming, biking, and other non- weight-bearing exercises do not maintain bone mass. Walking and running, which are weight-bearing exercises, do maintain bone mass. The client should eat a balanced diet but does not need to avoid the use of high-fat foods.
When developing a teaching plan for a client who is prescribed acetaminophen (Tylenol) for muscle pain, which information should the nurse expect to include? Select all that apply. 1. The drug can be used if the person is allergic to aspirin. 2. Acetaminophen does not affect platelet aggregation. 3. This drug causes little or no gastric distress. 4. Acetaminophen exerts a strong anti-inflammatory effect. 5. The client should have the International Normalized Ratio (INR) checked regularly.
1, 2, 3. Acetaminophen is an alternative for a client who is allergic to aspirin. It does not affect platelet aggregation and the client does not need to have coagulation studies (such as INR). Acetaminophen causes little or no gastric distress. Acetaminophen exerts no anti-inflammatory effects.
The nurse is assessing a client who had a left hip replacement 36 hours ago. Which of the following indicates the prosthesis is dislocated? Select all that apply. 1. The client reported a "popping" sensation in the hip. 2. The left leg is shorter than the right leg. 3. The client has sharp pain in the groin. 4. The client cannot move his right leg. 5. The client
1, 2, 3. Dislocation of a hip prosthesis may occur with positioning that exceeds the limits of the prosthesis. The nurse must recognize dislocation of the prosthesis. Signs of prosthesis dislocation include: acute groin pain in the affected hip, shortening of the affected leg, restricted ability or inability to move the affected leg, and reported "popping" sensation in the hip. Toe wiggling is not a test for potential hip dislocation.
The nurse is preparing the discharge of a client who has had a knee replacement with a metal joint. The nurse should instruct the client about which of the following? Select all that apply. 1. Notify health care providers about the joint prior to invasive procedures. 2. Avoid use of Magnetic Resonance Imaging (MRI) scans. 3. Notify airport security that the joint may set off alarms on metal detectors. 4. Refrain from carrying items weighing more than 5 lb. 5. Limit fluid intake to 1,000 mL/ day.
1, 2, 3. The nurse should instruct the client to notify the dentist and other health care providers of the need to take prophylactic antibiotics if undergoing any procedure (e.g., tooth extraction) due to the potential of bacteremia. The nurse should also advise the client that the metal components of the joint may set off the metal-detector alarms in airports. The client should also avoid MRI studies because the implanted metal components will be pulled toward the large magnet core of the MRI. Any weight bearing that is permitted is prescribed by the orthopedic surgeon and is usually not limited to 5 lb. Post surgery, the client can resume a normal diet with regular fluid intake.
Of the clients listed below, who is at risk for developing rheumatoid arthritis (RA)? Select all that apply. 1. Adults between the ages of 20 and 50 years. 2. Adults who have had an infectious disease with the Epstein-Barr virus. 3. Adults that are of the male gender. 4. Adults who possess the genetic link, specifically HLA-DR4. 5. Adults who also have osteoarthritis.
1, 2, 4. Rheumatoid arthritis (RA) affects women three times more often than men, between the ages of 20 and 55 years. Research has determined that RA occurs in clients who have had infectious disease, such as the Epstein-Barr virus. The genetic link, specifically HLA-DR4, has been found in 65% of clients with RA. People with osteoarthritis are not necessarily at risk for developing rheumatoid arthritis.
Which of the following statements should the nurse include in the teaching session when preparing a client for arthrocentesis? Select all that apply. 1. "A local anesthetic agent may be injected into the joint site for your comfort." 2. "A syringe and needle will be used to withdraw fluid from your joint." 3. "The procedure, although not painful, will provide immediate relief." 4. "We'll want you to keep your joint active after the procedure to increase blood flow." 5. "You will need to wear a compression bandage for several days after the procedure."
1, 2, 5. An arthrocentesis is performed to aspirate excess synovial fluid, pus, or blood from a joint cavity to relieve pain or to diagnosis inflammatory diseases such as rheumatoid arthritis. A local agent may be used to decrease the pain of the needle insertion through the skin and into the joint cavity. Aspiration of the fluid into the syringe can be very painful because of the size and inflammation of the joint. Usually a steroid medication is injected locally to alleviate the inflammation; a compression bandage is applied to help decrease swelling; and the client is asked to rest the joint for up to 24 hours afterwards to help relieve the pain and promote rest to the inflamed joint. The client may experience pain during this time until the inflammation begins to resolve and swelling decreases.
A client is to have a total hip replacement. The preoperative plan should include which of the following? Select all that apply. 1. Administer antibiotics as prescribed to ensure therapeutic blood levels. 2. Apply leg compression device. 3. Request a trapeze be added to the bed. 4. Teach isometric exercises of quadriceps and gluteal muscles. 5. Demonstrate crutch walking with a 3-point gait. 6. Place Buck's traction on the bed.
1, 3, 4. Administration of antibiotics as prescribed will aid in the acquisition of therapeutic blood levels during and immediately after surgery to prevent osteomyelitis. The nurse can request that a trapeze be added to the bed so the client can assist with lifting and turning. The nurse should also demonstrate and have the client practice isometric exercises (muscle setting) of quadriceps and gluteal muscles. The client will not use crutches after surgery; a physical therapy assistant will initially assist the client with walking by using a walker. The client will not use Buck's traction. The client will require anti-embolism stockings and use of a leg compression device to minimize the risk of thrombus formation and potential emboli; the leg compression device is applied during surgery and maintained per physician order.
A client with osteoarthritis will undergo an arthrocentesis on his painful edematous knee. What should be included in the nursing plan of care? Select all that apply. 1. Explain the procedure. 2. Administer preoperative medication 1 hour before surgery. 3. Instruct the client to immobilize the knee for 2 days after the surgery. 4. Assess the site for bleeding. 5. Offer pain medication.
1, 4, 5. To prepare a client for an arthrocentesis, the nurse should tell the client that a local anesthetic administered by the physician will decrease discomfort. There may be bleeding after the procedure, so the nurse should check the dressing. The client may experience pain. The nurse should offer pain medication and evaluate outcomes for pain relief. Because a local anesthetic is used, the client will not require preoperative medication. The client will rest the knee for 24 hours and then should begin range-of-motion and muscle strengthening exercises.
When preparing a client for discharge from the hospital after a total knee replacement, the nurse should include which of the following information in the discharge plan? Select all that apply. 1. Report signs of infection to health care provider. 2. Keep the affected leg and foot on the floor when sitting in a chair. 3. Remove anti-embolism stockings when sleeping. 4. The physical therapist will encourage progressive ambulation with use of assistive devices. 5. Change the dressing daily.
1, 4. After a total knee replacement, efforts are directed at preventing complications, such as thromboembolism, infection, limited range of motion, and peroneal nerve palsy. The nurse should instruct the client to report signs of infection, such as an increased temperature. To prevent edema, the affected leg must remain elevated when the client sits in a chair. After discharge, the client may undergo physical therapy on an outpatient basis per physician order. The client should leave the dressing in place until the follow-up visit with the surgeon.
A client who had a total hip replacement 2 days ago has developed an infection with a fever. The nursing diagnosis of fluid volume deficit related to diaphoresis is made. Which of the following is the most appropriate outcome? 1. The client drinks 2,000 mL of fluid per day. 2. The client understands how to manage the incision. 3. The client's bed linens are changed as needed. 4. The client's skin remains cool throughout hospitalization.
1. An average adult requires approximately 1,100- 1,400 mL of fluids per day. In some instances, such as when a person has an increase in body temperature or has increased perspiration, additional water may be necessary. With an increase in body temperature, there is also an increase in insensible fluid loss. The increased loss of fluid causes an increased need for fluid replacement. If the loss is significant and/ or goes untreated, an individual's intake will not be balanced with output. Managing the incision, changing the bed linens, or keeping the client's skin cool are not outcomes indicative of resolution of a fluid volume deficit.
2. A client with rheumatoid arthritis states, "I can't do my household chores without becoming tired. My knees hurt whenever I walk." Which nursing diagnosis would be most appropriate? 1. Activity intolerance related to fatigue and pain. 2. Self-care deficit related to increasing joint pain. 3. Ineffective coping related to chronic pain. 4. Disturbed body image related to fatigue and joint pain.
1. Based on the client's complaints, the most appropriate nursing diagnosis would be Activity intolerance related to fatigue and pain. Nursing interventions would focus on helping the client conserve energy and decrease episodes of fatigue. Although the client may develop a self-care deficit related to the activity intolerance and increasing joint pain, the client is voicing concerns about household chores and difficulty around the house and yard, not self-care issues. Over time, the client may develop ineffective coping or body image disturbance as the disorder becomes chronic with increasing pain and fatigue.
After teaching the client with severe rheumatoid arthritis about prescribed methotrexate (Rheumatrex), which of the following statements indicates the need for further teaching? 1. "I will take my vitamins while I'm on this drug." 2. "I must not drink any alcohol while I'm taking this drug." 3. "I should brush my teeth after every meal." 4. "I will continue taking my birth control pills."
1. Because some over-the-counter vitamin supplements contain folic acid, the client should avoid self-medication with vitamins while taking methotrexate, a folic acid antagonist. Because methotrexate is hepatotoxic, the client should avoid the intake of alcohol, which could increase the risk for hepatotoxicity. Methotrexate can cause bone marrow depression, placing the client at risk for infection. Therefore, meticulous mouth care is essential to minimize the risk of infection. Contraception should be used during methotrexate therapy and for 8 weeks after the therapy has been discontinued because of its effect on mitosis. Methotrexate is considered teratogenic.
Which of the following statements indicates that the client with osteoarthritis understands the effects of capsaicin (Zostrix) cream? 1. "I always wash my hands right after I apply the cream." 2. "After I apply the cream, I wrap my knee with an elastic bandage." 3. "I keep the cream in the cabinet above the stove in the kitchen." 4. "I also use the same cream when I get a cut or a burn."
1. Capsaicin cream, which produces analgesia by preventing the reaccumulation of substance P in the peripheral sensory neurons, is made from the active ingredients of hot peppers. Therefore, clients should wash their hands immediately after applying capsaicin cream if they do not wear gloves, to avoid possible contact between the cream and mucous membranes. Clients are instructed to avoid wearing tight bandages over areas where capsaicin cream has been applied because swelling may occur from inflammation of the arthritis in the joint and lead to constriction on the peripheral neurovascular system. Capsaicin cream should be stored in areas between 59 ° F and 86 ° F (15 ° C and 30 ° C). The cabinet over the stove in the kitchen would be too warm. Capsaicin cream should not come in contact with irritated and broken skin, mucous membranes, or eyes. Therefore it should not be used on cuts or burns.
The client diagnosed with osteoarthritis states, "My friend takes steroid pills for her rheumatoid arthritis. Why don't I take steroids for my osteoarthritis?" Which of the following is the best explanation? 1. Intra-articular corticosteroid injections are used to treat osteoarthritis. 2. Oral corticosteroids can be used in osteoarthritis. 3. A systemic effect is needed in osteoarthritis. 4. Rheumatoid arthritis and osteoarthritis are two similar diseases.
1. Corticosteroids are used for clients with osteoarthritis to obtain a local effect. Therefore, they are given only via intra-articular injection. Oral corticosteroids are avoided because they can cause an acceleration of osteoarthritis. Rheumatoid arthritis and osteoarthritis are two different diseases.
Which of the following should the nurse include in the teaching plan for a client with arterial insufficiency to the feet that is being managed conservatively? 1. Daily lubrication of the feet. 2. Soaking the feet in warm water. 3. Applying antiembolism stockings. 4. Wearing firm, supportive leather shoes.
1. Daily lubrication, inspection, cleaning, and patting dry of the feet should be performed to prevent cracking of the skin and possible infection. Soaking the feet in warm water should be avoided because soaking can lead to maceration and subsequent skin breakdown. Additionally, the client with arterial insufficiency typically experiences sensory changes, so the client may be unable to detect water that is too warm, thus placing the client at risk for burns. Antiembolism stockings, appropriate for clients with venous insufficiency, are inappropriate for clients with arterial insufficiency and could lead to a worsening of the condition. Footwear should be roomy, soft, and protective and allow air to circulate. Therefore, firm, supportive leather shoes would be inappropriate.
Following a total joint replacement, which of the following complications has the greatest likelihood of occurring? 1. Deep vein thrombosis (DVT). 2. Polyuria. 3. Intussception of the bowel. 4. Wound evisceration.
1. Deep vein thrombosis is a complication of total joint replacement and may occur during hospitalization or develop later when the client is home. Clients who are obese or have previous history of a DVT or PE are at high risk. Immobility produces venous stasis, increasing the client's chance to develop a venous thromboembolism. Signs of a DVT include: unilateral calf tenderness, warmth, redness, and edema (increased calf circumference). Findings should be reported promptly to the physician for definitive evaluation and therapy. Polyuria may be indicative of diabetes mellitus. Intussusception of the bowel and wound evisceration tend to occur after abdominal surgeries.
Which of the following should lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus? 1. Acute respiratory distress syndrome. 2. Migraine-like headaches. 3. Numbness in the right leg. 4. Muscle spasms in the right thigh.
1. Fat emboli usually result in symptoms of acute respiratory distress syndrome, such as apprehension, chest pain, cyanosis, dyspnea, tachypnea, tachycardia, and decreased partial pressure of arterial oxygen resulting from poor oxygen exchange. Migraine-like headaches are not a symptom of a fat embolism, but mental confusion, memory loss, and a headache from poor oxygen exchange may be seen with central nervous system involvement. Numbness in the right leg is a peripheral neurovascular response that most likely is related to the femoral fracture. Muscle spasms in the right thigh are a symptom of a neuromuscular response affecting the local muscle around the femoral fracture site.
A postmenopausal client is scheduled for a bone-density scan. To plan for the client's test, what should the nurse communicate to the client? 1. Request that the client remove all metal objects on the day of the scan. 2. Instruct the client to consume foods and beverages with a high content of calcium for 2 days before the test. 3. Inform the client that she will need to ingest 600 mg of calcium gluconate by mouth for 2 weeks before the test. 4. Tell the client that she should report any significant pain to her physician at least 2 days before the test.
1. Metal will interfere with the test. Metallic objects within the examination field, such as jewelry, earrings, and dental amalgams, may inhibit organ visualization and can produce unclear images. Ingesting foods and beverages days before the test will not affect bone mineral status. Short-term calcium gluconate intake will also not influence bone mineral status. The client may already have had chronic pain as a result of a bone fracture or from osteoporosis.
A physician orders a lengthy X-ray examination for a client with osteoarthritis. Which of the following actions by the nurse would demonstrate client advocacy? 1. Contact the X-ray department and ask the technician if the lengthy session can be divided into shorter sessions. 2. Contact the physician to determine if an alternative examination could be scheduled. 3. Provide a dose of acetaminophen (Tylenol). 4. Cancel the examination because of the hard X-ray table.
1. Shorter sessions will allow the client to rest between the sessions. Changing the physician's order to a different examination will not provide the information needed for this client's treatment. Acetaminophen is a nonopioid analgesic and an antipyretic, not an anti-inflammatory agent. Thus, it would not help this client avoid the adverse effects of a lengthy X-ray examination. Although the X-ray table is hard, there are other options for making the client comfortable, rather than canceling the examination.
A client has a Pearson attachment on the traction setup. Which of the following is the purpose of this attachment? 1. To support the lower portion of the leg. 2. To support the thigh and upper leg. 3. To allow attachment of the skeletal pin. 4. To prevent flexion deformities in the ankle and foot.
1. The Pearson attachment supports the lower leg and provides increased stability in the overall traction setup. It also makes it easier to maintain correct alignment. It does not support the thigh and upper leg or prevent flexion deformities in the ankle and foot. It is not attached to the skeletal pin.
The client asks the nurse what his activity limitations are while he is in Buck's traction. The nurse should tell the client: 1. "You can sit up whenever you want." 2. "You must lie flat on your back most of the time." 3. "You can turn your body." 4. "You must lie on your stomach."
1. The client can sit up in bed, remaining in the supine position so that an even, sustained amount of traction is maintained under the bandage used in the Buck's traction. Maintenance of even, sustained traction decreases the chance that the bandage or traction strap might slip and cause compression or stress on the nerves or vascular tracts, resulting in permanent damage. The client does not have to remain flat but may adjust the head of the bed to varying degrees of elevation while remaining in the supine position. The client should not turn his body to another position because the bandage may slip.
The client has a nursing diagnosis of Self-care deficit related to the confinement of traction. Which of the following would indicate a successful outcome for this diagnosis? 1. The client assists as much as possible in his care, demonstrating increased participation over time. 2. The client allows the nurse to complete his care in an efficient manner without interfering. 3. The client allows his wife to assume total responsibility for his care. 4. The client allows his wife to complete his care to promote feelings of usefulness.
1. The client's assisting as much as possible in his care and increasing participation over time indicate that the client has accomplished self-care by gaining a sense of control. If the client lets the nurse complete his care without interfering, his behavior would indicate passivity, possibly from denial or depression. If the client allows his wife to assume total responsibility for his care or to complete his care, he still has a self-care deficit and a successful outcome has not been reached.
Because a client has a Thomas splint, the nurse should assess the client regularly for which of the following? 1. Signs of skin pressure in the groin area. 2. Evidence of decreased breath sounds. 3. Skin breakdown behind the heel. 4. Urine retention.
1. The nurse should assess for signs of skin pressure in the groin area because the Thomas splint, which is a half-ring that slips over the thigh and suspends the lower extremity in direct skeletal traction, may cause discomfort, pressure, or skin irritation in the groin. The nurse always assesses respirations as part of routine vital signs, but assessing for evidence of decreased breath sounds is not a routine assessment related directly to the Thomas splint. The head of the bed can be elevated to facilitate breathing, but not more than 25 degrees, to avoid continually moving the client toward the foot of the bed from the weight of the traction. The nurse always assesses for pressure areas on dependent parts, but assessing for skin breakdown behind the heel is not a routine assessment related directly to the Thomas splint, in which the heel is free of any contact with padding or metal parts of the Pearson attachment for the balanced suspension traction. The client who is in a Thomas splint is able to use a bedpan to urinate, especially the fracture bedpan for a female client and the urinal for a male. Urine retention should not be a special assessment directly related to the Thomas splint, but it may be a client-specific assessment.
A client has a tibial fracture that required casting. Approximately 5 hours later, the client has increasing pain distal to the left tibial fracture despite the morphine injection administered 30 minutes previously. Which of the following should be the nurse's next assessment? 1. Presence of a distal pulse. 2. Pain with a pain rating scale. 3. Vital sign changes. 4. Potential for drug tolerance.
1. The nurse should assess the client's ability to move her toes and for the presence of distal pulses, including a neurovascular assessment of the area below the cast. Increasing pain unrelieved by usual analgesics and occurring 4 to 12 hours after the onset of casting or trauma may be the first sign of compartment syndrome, which can lead to permanent damage to nerves and muscles. Although the nurse can use a pain rating scale or assess for changes in vital signs to objectively assess the client's pain, the client's complaints suggest early and important signs of compartment syndrome requiring immediate intervention. The nurse should not confuse these signs with the potential for drug tolerance. This assessment might be appropriate once the suspicion of compartment syndrome has been ruled out.
The client has just had a total knee replacement for severe osteoarthritis. Which of the following assessment findings should lead the nurse to suspect possible nerve damage? 1. Numbness. 2. Bleeding. 3. Dislocation. 4. Pinkness.
1. The nurse should suspect nerve damage if numbness is present. However, whether the damage is short-term and related to edema or long-term and related to permanent nerve damage would not be clear at this point. The nurse needs to continue to assess the client's neurovascular status, including pain, pallor, pulselessness, paresthesia, and paralysis (the five P's). Bleeding would suggest vascular damage or hemorrhage. Dislocation would suggest malalignment. Pink color would suggest adequate circulation to the area. Numbness would suggest neurologic damage.
A client says, "I hate the idea of being an invalid after they cut off my leg." Which of the following would be the nurse's most therapeutic response? 1. "At least you will still have one good leg to use." 2. "Tell me more about how you're feeling." 3. "Let's finish the preoperative teaching." 4. "You're lucky to have a wife to care for you."
2. Encouraging the client who will be undergoing amputation to verbalize his feelings is the most therapeutic response. Asking the client to tell more about how he is feeling helps to elicit information, providing insight into his view of the situation and also providing the nurse with ideas to help him cope. The nurse should avoid value-laden responses, such as, "At least you will still have one good leg to use," that may make the client feel guilty or hostile, thereby blocking further communication. Furthermore, stating that the client still has one good leg ignores his expressed concerns. The client has verbalized feelings of helplessness by using the term "invalid." The nurse needs to focus on this concern and not try to complete the teaching first before discussing what is on the client's mind. The client's needs, not the nurse's needs, must be met first. It is inappropriate for the nurse to assume to know the relationship between the client and his wife or the roles they now must assume as dependent client and caregiver. Additionally, the response about the client's wife caring for him may reinforce the client's feelings of helplessness as an invalid.
The nurse prepares a teaching plan for a client about crutch walking using a two-point gait pattern. Which of the following should the nurse include? 1. Advance a crutch on one side and then advance the opposite foot; repeat on the opposite side. 2. Advance a crutch on one side and simultaneously advance and bear weight on the opposite foot; repeat on the opposite side. 3. Advance both crutches together and then follow by lifting both lower extremities to the level of the crutches. 4. Advance both crutches together and then follow by lifting both lower extremities past the level of the crutches.
2. A two-point gait involves partial weight bearing on each foot, with each crutch advancing simultaneously with the opposing leg. Advancing a crutch on one side and then advancing the opposite foot, and repeating on the opposite side, illustrates the four-point gait. When the client advances both crutches together and follows by lifting both lower extremities to the same level as the crutches, the gait is called a "swing to" gait. When the client advances both crutches together and follows by lifting both lower extremities past the level of the crutches, the gait is called a "swing through" gait. The "swing through" gait is often used by paraplegic clients because it allows them to place weight on their legs while the crutches are moved one stride ahead.
The client with a fractured femur is upset and agitated about her injury and its treatment. She says, "How can I stay like this for weeks? I can't even move!" Which of the following is the most appropriate nursing diagnosis? 1. Impaired physical mobility related to traction. 2. Ineffective coping related to prolonged immobility. 3. Deficient diversional activity related to prolonged hospitalization. 4. Activity intolerance related to impaired mobility.
2. Based on the client's statements, Ineffective coping is the most appropriate nursing diagnosis because the client is voicing frustration about the current situation and her inability to move. The nurse should seek ways to help the client adjust to and cope with her present state of immobility. Emphasis should be placed on what the client can do to care for herself, such as participating in her daily care and exercises to maintain muscle strength, to help her maintain some control over her situation. The data do not support a diagnosis of Impaired mobility, Deficient diversional activities, or Activity intolerance.
A 25-year-old client taking hydroxychloroquine (Plaquenil) for rheumatoid arthritis reports difficulty seeing out of her left eye. Correct interpretation of this assessment finding indicates which of the following? 1. Development of a cataract. 2. Possible retinal degeneration. 3. Part of the disease process. 4. A coincidental occurrence.
2. Difficulty seeing out of one eye, when evaluated in conjunction with the client's medication therapy regimen, leads to the suspicion of possible retinal degeneration. The possibility of an irreversible retinal degeneration caused by deposits of hydroxychloroquine (Plaquenil) in the layers of the retina requires an ophthalmologic examination before therapy is begun and at 6-month intervals. Although cataracts may develop in young adults, they are less likely, and damage from the hydroxychloroquine is the most obvious at-risk factor. Eyesight is not affected by the disease process of rheumatoid arthritis.
The client who had an open femoral fracture was discharged to her home where she developed fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg. Which of the following reflects the best interpretation of these findings? 1. Pulmonary emboli. 2. Osteomyelitis. 3. Fat emboli. 4. Urinary tract infection.
2. Fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg are clinical manifestations of osteomyelitis, which is a pyogenic bone infection caused by bacteria (usually staphylococci), a virus, or a fungus. The bone is inaccessible to macrophages and antibodies for protection against infections, so an infection in this site can become serious quickly. The client with a pulmonary or fat embolus would develop symptoms of pulmonary compromise, such as shortness of breath, chest pain, angina, and mental confusion. Signs and symptoms of urinary tract infection would include pain over the suprapubic, groin, or back region with fever and chills, with no restrictive movement of the leg.
The client with peripheral arterial disease says, "I've really tried to manage my condition well." Which of the following should the nurse determine as appropriate for this client? 1. Resting with the legs elevated above the level of the heart. 2. Walking slowly but steadily for 30 minutes twice a day. 3. Minimizing activity as much and as often as possible. 4. Wearing antiembolism stockings at all times when out of bed.
2. Slow, steady walking is a recommended activity for the client with peripheral arterial disease because it stimulates the development of collateral circulation needed to ensure adequate tissue oxygenation. The client with peripheral arterial disease should not minimize activity. Activity is necessary to foster the development of collateral circulation. Elevating the legs above the heart is an appropriate strategy for reducing venous congestion. Wearing antiembolism stockings promotes the return of venous circulation, which is important for clients with venous insufficiency. However, their use in clients with peripheral arterial disease may cause the disease to worsen.
A client has severe arterial occlusive disease and gangrene of the left great toe. Which of the following findings is expected? 1. Edema around the ankle. 2. Loss of hair on the lower leg. 3. Thin, soft toenails. 4. Warmth in the foot.
2. The client with severe arterial occlusive disease and gangrene of the left great toe would have lost the hair on the leg due to decreased circulation to the skin. Edema around the ankle and lower leg would indicate venous insufficiency of the lower extremity. Thin, soft toenails (i.e., not thickened and brittle) are a normal finding. Warmth in the foot indicates adequate circulation to the extremity. Typically, the foot would be cool to cold if a severe arterial occlusion were present.
The nurse is planning care for a client with osteomyelitis. The client is taking an antibiotic, but the infection has not resolved. The nurse should advise the client to do which of the following? 1. Use herbal supplements. 2. Eat a diet high in protein and vitamins C and D. 3. Ask the health care provider for a change of antibiotics. 4. Encourage frequent passive range-of-motion to the affected extremity.
2. The goal of care for this client is healing and tissue growth while the client continues on long-term antibiotic therapy to clear the infection. A diet high in protein and vitamins C and D promotes healing. Herbal supplements may potentiate bleeding (e.g., ginkgo, ginger, tumeric, chamomile, kelp, horse chestnut, garlic, and dong quai) and have not been proven through research to promote healing. Frequent passive motion will increase circulation but may also aggravate localized bone pain. It is not appropriate to advise the client to change antibiotics as treatment may take time.
The client asks the nurse, "Why can't the physician tell me exactly how much of my leg he's going to take off? Don't you think I should know that?" On which of the following should the nurse base the response? 1. The need to remove as much of the leg as possible. 2. The adequacy of the blood supply to the tissues. 3. The ease with which a prosthesis can be fitted. 4. The client's ability to walk with a prosthesis.
2. The level of amputation often cannot be accurately determined until during surgery, when the surgeon can directly assess the adequacy of the circulation of the residual limb. From a moral, ethical, and legal viewpoint, the surgeon attempts to remove as little of the leg as possible. Although a longer residual limb facilitates prosthesis fitting, unless the stump is receiving a good blood supply the prosthesis will not function properly because tissue necrosis will occur. Although the client's ability to walk with a prosthesis is important, it is not a determining factor in the decision about the level of amputation required. Blood supply to the tissue is the primary determinant.
After teaching a group of clients with osteoarthritis about using regular exercise, which of the following client statements indicates effective teaching? 1. "Performing range-of-motion exercises will increase my joint mobility." 2. "Exercise helps to drive synovial fluid through the cartilage." 3. "Joint swelling should determine when to stop exercising." 4. "Exercising in the outdoors year-round promotes joint relaxation."
2. Weight-bearing exercise plays a very important role in stimulating regeneration of cartilage, which lacks blood vessels, by driving synovial fluid through the joint cartilage. Joint mobility is increased by weight-bearing exercises, not range-of-motion exercises, because surrounding muscles, ligaments, and tendons are strengthened. Pain is an early sign of degenerative joint bone problems. Swelling may not occur for some time after pain, if at all. Osteoarthritic pain is worsened in cold, damp weather; therefore, exercising outdoors is not recommended year round in all settings.
A client who had a total hip replacement 4 days ago is worried about dislocation of the prosthesis. The nurse should respond by saying which of the following? 1. "Don't worry. Your new hip is very strong." 2. "Use of a cushioned toilet seat helps to prevent dislocation." 3. "Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid them." 4. "Decreasing use of the abductor pillow will strengthen the muscles to prevent dislocation."
3. Dislocation precautions include: avoid extremes of internal rotation, adduction, and 90-degree flexion of affected hip for at least 4 to 6 weeks after the procedure. Use of an abduction pillow prevents adduction. Decreasing use of the abductor pillow does not strengthen the muscles to prevent dislocation. Informing a client to "not worry" is not therapeutic. A cushioned toilet seat does not prevent hip dislocation.
The nurse has established a goal with a client to improve mobility following hip replacement. Which of the following is a realistic outcome at the time of discharge from the surgical unit? 1. The client can walk throughout the entire hospital with a walker. 2. The client can walk the length of a hospital hallway with minimal pain. 3. The client has increased independence in transfers from bed to chair. 4. The client can raise the affected leg 6 inches with assistance.
3. Expected outcomes at the time of discharge from the surgical unit after a hip replacement include the following: increased independence in transfers, participates in progressive ambulation without pain or assistance, and raises the affected leg without assistance. The client will not be able to walk throughout the hospital, walk for a distance without some postoperative pain, or raise the affected leg more than several inches. The client may be referred to a rehabilitation unit in order to achieve the additional independence, strength, and pain relief.
The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which of the following client statements indicates that the client still has a knowledge deficit? 1. "I can use heat and cold as often as I want." 2. "With heat, I should apply it for no longer than 20 minutes at a time." 3. "Heat-producing liniments can be used with other heat devices." 4. "Ten to 15 minutes per application is the maximum time for cold applications."
3. Heat-producing liniment can produce a burn if used with other heat devices that could intensify the heat reaction. Heat and cold can be used as often as the client desires. However, each application of heat should not exceed 20 minutes, and each application of cold should not exceed 10 to 15 minutes. Application for longer periods results in the opposite of the intended effect: vasoconstriction instead of vasodilation with heat, and vasodilation instead of vasoconstriction with cold.
A client who has been taking carisoprodol (Soma) at home for a fractured arm is admitted with a blood pressure of 80/ 50 mm Hg, a pulse rate of 115 bpm, and respirations of 8 breaths/ minute and shallow. The nurse interprets these findings as indicating which of the following? 1. Expected common adverse effects. 2. Hypersensitivity reaction. 3. Possible habituating effect. 4. Hemorrhage from gastrointestinal irritation.
3. Hypotension, tachycardia, and depressed respirations are signs of high levels of ingestion of muscle relaxants, and the client may be developing a habit of taking this drug for a prolonged period. The potential for abuse should be considered when large doses of a muscle relaxant such as carisoprodol are taken for prolonged periods. Expected common adverse effects would include drowsiness, fatigue, lassitude, blurred vision, headache, ataxia, weakness, and gastrointestinal upset. Hemorrhage from gastrointestinal irritation is not associated with this drug. Hypersensitivity reactions would be manifested by pruritus and rashes.
The nurse is planning care for a group of clients who have had total hip replacement. Of the clients listed below, which is at highest risk for infection and should be assessed first? 1. A 55-year-old client who is 6 feet tall and weighs 180 lb. 2. A 90-year-old who lives alone. 3. A 74-year-old who has periodontal disease with periodontitis. 4. A 75-year-old who has asthma and uses an inhaler.
3. Infection is a serious complication of total hip replacement and may necessitate removal of the implant. Clients who are obese, poorly nourished, elderly, have poorly controlled diabetes, rheumatoid arthritis, or concurrent infections (e.g., dental, urinary tract) are at high risk for infection. Clients who are of normal weight and have well-controlled chronic diseases are not at risk for infection. Living alone is not a risk factor for infection.
On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for: 1. Limited motion of joints. 2. Deformed joints of the hands. 3. Early morning stiffness. 4. Rheumatoid nodules.
3. Initially, most clients with early symptoms of rheumatoid arthritis complain of early morning stiffness or stiffness after sitting still for a while. Later symptoms of rheumatoid arthritis include limited joint range of motion; deformed joints, especially of the hand; and rheumatoid nodules.
A client has a leg immobilized in traction. Which of the following activities demonstrated by the client indicate that the client understands actions to take to prevent muscle atrophy? 1. The client adducts the affected leg every 2 hours. 2. The client rolls the affected leg away from the body's midline twice per day. 3. The client performs isometric exercises to the affected extremity three times per day. 4. The client asks the nurse to add a 5-lb weight to the traction for 30 minutes/ day.
3. Isometric contractions increase the tension within a muscle but do not produce movement. Repeated isometric contractions make muscles grow larger and stronger. Adduction of the leg puts work onto the hip joint as well as altering the pull of traction. Rolling the leg, or external rotation, alters the pull of traction. Additional weight should not be added to traction unless ordered by the physician; it will not prevent muscle atrophy.
A client is in the acute phase of rheumatoid arthritis. Which of the following should the nurse identify as lowest priority in the plan of care? 1. Relieving pain. 2. Preserving joint function. 3. Maintaining usual ways of accomplishing tasks. 4. Preventing joint deformity.
3. Maintaining usual ways of accomplishing tasks would be the lowest priority during the acute phase. Rather, the focus is on developing less stressful ways of accomplishing routine tasks. Pain relief is a high priority during the acute phase because pain is typically severe and interferes with the client's ability to function. Preserving joint function and preventing joint deformity are high priorities during the acute phase to promote an optimal level of functioning and reduce the risk of contractures.
The client with a fractured tibia has been taking methocarbamol (Robaxin). Which of the following indicate that the drug is having the intended effect? 1. Lack of infection. 2. Reduction in itching. 3. Relief of muscle spasms. 4. Decrease in nervousness.
3. Methocarbamol is a muscle relaxant and acts primarily to relieve muscle spasms. It has no effect on microorganisms, does not reduce itching, and has no effect on nervousness.
A client is in balanced suspension traction using a half-ring Thomas splint with a Pearson attachment that suspends the lower extremity and applies direct skeletal traction for a hip fracture. Which of the following nursing assessments would not be appropriate? 1. Greater trochanter skin checks. 2. Pin site inspection. 3. Neurovascular checks proximal to the splint. 4. Foot movement evaluation.
3. Neurovascular checks should be performed distal or past the site of the splint, not proximal or above the site of the splint, at least every 4 hours. An injury or compromise to the peripheral nervous innervation or blood flow will reflect a change on the site of the splint after the pathway from the heart and brain. Checking the skin over the greater trochanter is appropriate because the half-ring of the Thomas splint can slide around the greater trochanter area where the traction is applied; it should be checked routinely along with other areas at high risk for pressure necrosis, such as the fibular head, ischial tuberosity, malleoli, and hamstring tendons. Inspecting the pin site is appropriate because any drainage or redness might indicate an infection in the bone in which the pin is inserted. Immediate treatment is imperative to avoid osteomyelitis and possible loss of the limb. Evaluation of the foot for movement is important to obtain neuromuscular-vascular data for assessment in comparison with the baseline data of the affected extremity and with the opposite extremity to detect any compromise of the client's condition.
A client with absent peripheral pulses and pain at rest is scheduled for an arterial Doppler study of the affected extremity. When preparing the client for this test, the nurse should: 1. Have the client sign a consent form for the procedure. 2. Administer a pretest sedative as appropriate. 3. Keep the client tobacco-free for 30 minutes before the test. 4. Wrap the client's affected foot with a blanket.
3. The client should be tobacco-free for 30 minutes before the test to avoid false readings related to the vasoconstrictive effects of smoking on the arteries. Because this test is noninvasive, the client does not need to sign a consent form. The client should receive an opioid analgesic, not a sedative, to control the pain as the blood pressure cuffs are inflated during the Doppler studies to determine the ankle-to-brachial pressure index. The client's ankle should not be covered with a blanket because the weight of the blanket on the ischemic foot will cause pain. A bed cradle should be used to keep even the weight of a sheet off the affected foot.
After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse correctly interprets these findings as indicating which of the following? 1. A developing infection. 2. Bleeding in the operative site. 3. Joint dislocation. 4. Glue seepage into soft tissue.
3. The joint has dislocated when the client with a total joint prosthesis develops severe sudden pain and an inability to move the extremity. Clinical manifestations of an infection would include inflammation, redness, erythema, and possibly drainage and separation of the wound. Bleeding could be external (e.g., blood visible from the wound or on the dressing) or internal and manifested by signs of shock (e.g., pallor, coolness, hypotension, tachycardia). The seepage of glue into soft tissue would have occurred in the operating room, when the glue is still in the liquid form. The glue dries into the hard, fixed form before the wound is closed.
The client in balanced suspension traction is transported to surgery for closed reduction and internal fixation of his fractured femur. Which of the following should the nurse do when transporting the client to the operating room? 1. Transfer the client to a cart with manually suspended traction. 2. Call the surgeon to request an order to temporarily remove the traction. 3. Send the client on his bed with extra help to stabilize the traction. 4. Remove the traction and send the client on a cart.
3. The nurse should send the client to the operating room on his bed with extra help to keep the traction from moving to maintain the femur in the proper alignment before surgery. Transferring the client to a cart with manually suspended traction is inappropriate because doing so places the client at risk for additional trauma to the surrounding neurovascular and soft tissues, as would removing the traction. The surgeon need not be called because the decision about transferring the client is an independent nursing action.
When admitting a client with a fractured extremity, the nurse should first focus the assessment on which of the following? 1. The area proximal to the fracture. 2. The actual fracture site. 3. The area distal to the fracture. 4. The opposite extremity for baseline comparison.
3. The nursing assessment is first focused on the region distal to the fracture for neurovascular injury or compromise. When a nerve or blood vessel is severed or obstructed at the actual fracture site, innervation to the nerve or blood flow to the vessel is disrupted below the site; therefore, the area distal to the fracture site is the area of compromised neurologic input or vascular flow and return, not the area above the fracture site or the fracture site itself. The nurse may assess the opposite extremity at the area proximal to the fracture site for a baseline comparison of pulse quality, color, temperature, size, and so on, but the comparison would be made after the initial neurovascular assessment.
Which of the following should the nurse identify as the least likely factor contributing to a client's peripheral vascular disease? 1. Uncontrolled diabetes mellitus for 15 years. 2. A 20-pack-year history of cigarette smoking. 3. Current age of 39 years. 4. A serum cholesterol concentration of 275 mg/ dL.
3. Typically, peripheral vascular disease is considered to be a disorder affecting older adults. Therefore, an age of 39 years would not be considered as a risk factor contributing to the development of peripheral vascular disease. Uncontrolled diabetes mellitus is considered a risk factor for peripheral vascular disease because of the macroangiopathic and microangiopathic changes that result from poor blood glucose control. Cigarette smoking is a known risk factor for peripheral vascular disease. Nicotine is a potent vasoconstrictor. Serum cholesterol levels greater than 200 mg/ dL are considered a risk factor for peripheral vascular disease.
The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which of the following should be the nurse's first step in planning the dietary instructions? 1. Determining the client's knowledge level about cholesterol. 2. Asking the client to name foods that are high in fat, cholesterol, and salt. 3. Explaining the importance of complying with the diet. 4. Assessing the client's and family's typical food preferences.
4. Before beginning dietary instructions and interventions, the nurse must first assess the client's and family's food preferences, such as pattern of food intake, life style, food preferences, and ethnic, cultural, and financial influences. Once this information is obtained, the nurse can begin teaching based on the client's current knowledge level and then building on this knowledge base.
Prior to surgery, the nurse is instructing a client who will have a total hip replacement tomorrow. Which of the following information is most important to include in the teaching plan at this time? 1. Teaching how to prevent hip flexion. 2. Demonstrating coughing and deep-breathing techniques. 3. Showing the client what an actual hip prosthesis looks like. 4. Assessing the client's fears about the procedure.
4. Before implementing a teaching plan, the nurse should determine the client's fears about the procedure. Only then can the client begin to hear what the nurse has to share about the individualized teaching plan designed to meet the client's needs. In the preoperative period, the client needs to learn how to correctly prevent hip flexion and to demonstrate coughing and deep breathing. However, this teaching can be effective only after the client's fears have been assessed and addressed. Although the client may appreciate seeing what a hip prosthesis looks like, so as to understand the new body part, this is not a necessity.
After teaching the client with rheumatoid arthritis about measures to conserve energy in activities of daily living involving the small joints, which of the following, if stated by the client, would indicate the need for additional teaching? 1. Pushing with palms when rising from a chair. 2. Holding packages close to the body. 3. Sliding objects. 4. Carrying a laundry basket with clinched fingers and fists.
4. Carrying a laundry basket with clinched fingers and fists is not an example of conserving energy of small joints. The laundry basket should be held with both hands opened as wide as possible and with outstretched arms so that pressure is not placed on the small joints of the fingers. When rising from a chair, the palms should be used instead of the fingers so as to distribute weight over the larger area of the palms. Holding packages close to the body provides greater support to the shoulder, elbow, and wrist joints because muscles of the arms and hands are used to stabilize the weight against the body. This decreases the stress and weight or pull on small joints such as the fingers. Objects can be slid with the palm of the hand, which distributes weight over the larger area of the palms instead of stressing the small joints of the fingers to pick up the weight of the object to move it to another place.
A client who has had a total hip replacement has a dislocated hip prosthesis. The nurse should first? 1. Stabilize the leg with Buck's traction. 2. Apply an ice pack to the affected hip. 3. Position the client toward the opposite side of the hip. 4. Notify the orthopedic surgeon.
4. If a prosthesis becomes dislocated, the nurse should immediately notify the surgeon. This is done so the hip can be reduced and stabilized promptly to prevent nerve damage and to maintain circulation. After closed reduction, the hip may be stabilized with Buck's traction or a brace to prevent recurrent dislocation. If ordered by the surgeon, an ice pack may be applied post reduction to limit edema, although caution must be utilized due to potential muscle spasms. Some orthopedic surgeons may order the client be turned toward the side of the reduced hip but that is not the nurse's first response.
Which of the following should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis? 1. Anemia. 2. Osteoporosis. 3. Weight loss. 4. Local joint pain.
4. Osteoarthritis is a degenerative joint disease with local manifestations such as local joint pain, unlike rheumatoid arthritis, which has systemic manifestation such as anemia and osteoporosis. Weight loss occurs in rheumatoid arthritis, whereas most clients with osteoarthritis are overweight.
A client with a fractured right femur has not had any immunizations since childhood. Which of the following biologic products should the nurse administer to provide the client with passive immunity for tetanus? 1. Tetanus toxoid. 2. Tetanus antigen. 3. Tetanus vaccine. 4. Tetanus antitoxin.
4. Passive immunity for tetanus is provided in the form of tetanus antitoxin or tetanus immune globulin. An antitoxin is an antibody to the toxin of an organism. Administering tetanus toxoid, antigen, or vaccine would provide active immunity by stimulating the body to produce its own antibodies.
The teaching plan for the client with rheumatoid arthritis includes rest promotion. Which of the following would the nurse expect to instruct the client to avoid during rest periods? 1. Proper body alignment. 2. Elevating the part. 3. Prone lying positions. 4. Positions of flexion.
4. Positions of flexion should be avoided to prevent loss of functional ability of affected joints. Proper body alignment during rest periods is encouraged to maintain correct muscle and joint placement. Lying in the prone position is encouraged to avoid further curvature of the spine and internal rotation of the shoulders.
After teaching the client with a femoral fracture about the purpose of treatment with skeletal traction, which of the following, if stated by the client, would indicate the need for additional teaching? 1. To align injured bones. 2. To provide long-term pull. 3. To apply 25 lb of traction. 4. To pull weight with a boot.
4. Skeletal traction is not used to pull weight with a boot. Skeletal traction involves the insertion of a wire or a pin into the bone to maintain a pull of 5 to 45 lb on the area, promoting proper alignment of the fractured bones over a long term.
A client with rheumatoid arthritis tells the nurse, "I know it is important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which of the following responses by the nurse would be most appropriate? 1. "You are probably exercising too much. Decrease your exercise to every other day." 2. "Tell the physician about your symptoms. Maybe your analgesic medication can be increased." 3. "Stiffness and pain are part of the disease. Learn to cope by focusing on activities you enjoy." 4. "Take a warm tub bath or shower before exercising. This may help with your discomfort."
4. Superficial heat applications, such as tub baths, showers, and warm compresses, can be helpful in relieving pain and stiffness. Exercises can be performed more comfortably and more effectively after heat applications. The client with rheumatoid arthritis must balance rest with exercise every day, not every other day. Typically, large doses of analgesics, which can lead to hepatotoxic effects, are not necessary. Learning to cope with the pain by refocusing is inappropriate.
The nurse is planning care for the client with a femoral fracture who is in balanced suspension traction. Which of the following would the nurse be least likely to include in the plan of care? 1. Use of a fracture bedpan. 2. Checks for redness over the ischial tuberosity. 3. Elevation of the head of bed no more than 25 degrees. 4. Personal hygiene with a complete bed bath.
4. The client with a femoral fracture in balanced suspension traction should not be given a complete bed bath. Rather, the client is encouraged to participate in self-care and movement in bed, such as with a trapeze triangle. Use of a fracture bedpan is appropriate. A fracture bedpan is lower, and it is easier for the client to move on and off the bedpan without altering the line of traction. Checking for areas of redness or pressure over all areas in contact with the traction or bed, including the ischial tuberosity, is important to prevent possible skin breakdown. The client should be positioned so that the feet do not press against the footboard. Therefore, elevating the head of the bed no more than 25 degrees is recommended to keep the client from moving down in the bed.
On the evening of surgery for total knee replacement, a client wants to get out of bed. To safely assist the client the nurse should do which of the following? 1. Encourage the client to apply full weight-bearing. 2. Order a walker for the client. 3. Place a straight-backed chair at the foot of the bed. 4. Apply a knee immobilizer.
4. The knee is usually protected with a knee immobilizer (splint, cast, or brace) and is elevated when the client sits in a chair. Pre- and post-surgery, the physician prescribes weight-bearing limits and use of assistive devices for progressive ambulation. Positioning a straight-backed chair at the foot of the bed is not an action conducive for getting the client out of bed on the evening of surgery for a total knee replacement.
A client in the postanesthesia care unit with a left below-the-knee amputation has pain in her left big toe. Which of the following should the nurse do first? 1. Tell the client it is impossible to feel the pain. 2. Show the client that the toes are not there. 3. Explain to the client that her pain is real. 4. Give the client the prescribed opioid analgesic.
4. The nurse's first action should be to administer the prescribed opioid analgesic to the client, because this phenomenon is phantom sensation and interventions should be provided to relieve it. Pain relief is the priority. Phantom sensation is a real sensation. It is incorrect and inappropriate to tell a client that it is impossible to feel the pain. Although it does relieve the client's apprehensions to be told that phantom sensations are a real phenomenon, the client needs prompt treatment to relieve the pain sensation. Usually phantom sensation will go away. However, showing the client that the toes are not there does nothing to provide the client with relief.
The client with rheumatoid arthritis tells the nurse, "I have a friend who took gold shots and had a wonderful response. Why didn't my physician let me try that?" Which of the following responses by the nurse would be most appropriate? 1. "It's the physician's prerogative to decide how to treat you. The physician has chosen what is best for your situation." 2. "Tell me more about your friend's arthritic condition. Maybe I can answer that question for you." 3. "That drug is used for cases that are worse than yours. It wouldn't help you, so don't worry about it." 4. "Every person is different. What works for one client may not always be effective for another."
4. The nurse's most appropriate response is one that is therapeutic. The basic principle of therapeutic communication and a therapeutic relationship is honesty. Therefore, the nurse needs to explain truthfully that each client is different and that there are various forms of arthritis and arthritis treatment. To state that it is the physician's prerogative to decide how to treat the client implies that the client is not a member of his or her own health care team and is not a participant in his or her care. The statement also is defensive, which serves to block any further communication or questions from the client about the physician. Asking the client to tell more about the friend presumes that the client knows correct and complete information, which is not a valid assumption to make. The nurse does not know about the client's friend and should not make statements about another client's condition. Stating that the drug is for cases that are worse than the client's demonstrates that the nurse is making assumptions that are not necessarily valid or appropriate. Also, telling the client not to worry ignores the underlying emotions associated with the question, totally discounting the client's feelings.
A client who has had an above-the-knee amputation develops a dime-sized bright red spot on the dressing after 45 minutes in the postanesthesia recovery unit. The nurse should: 1. Elevate the stump. 2. Reinforce the dressing. 3. Call the surgeon. 4. Draw a mark around the site.
4. The priority action is to draw a mark around the site of bleeding to determine the rate of bleeding. Once the area is marked, the nurse can determine whether the bleeding is increasing or decreasing by the size of the area marked. Because the spot is bright red, the bleeding is most likely arterial in origin. Once the rate and source of bleeding are identified, the surgeon should be notified. The stump is not elevated because adhesions may occur, interfering with the ability to fit a prosthesis. The dressing would be reinforced if the bleeding is determined to be of venous origin, characterized by slow oozing of darker blood that ceases with the application of a pressure dressing. Typically, operative dressings are not changed for 24 hours. Therefore, the dressing is reinforced to prevent organisms from penetrating through the blood-soaked areas of the initial postoperative dressing.
The nurse teaches a client about using the crutches, instructing the client to support her weight primarily on which of the following body areas? 1. Axillae. 2. Elbows. 3. Upper arms. 4. Hands.
4. When using crutches, the client is taught to support her weight primarily on the hands. Supporting body weight on the axillae, elbows, or upper arms must be avoided to prevent nerve damage from excessive pressure.
A client returned from surgery with a debrided open tibial fracture and has a three-way drainage system. The nurse should first: 1. Review the results of culture and sensitivity testing of the wound. 2. Look for the presence of a pressure dressing over the wound. 3. Determine if the client has increased pain from exposed nerve endings. 4. Check the client's blood pressure for hypotension resulting from additional vessel bleeding.
1. The wound was left open with a three-way drainage system in place to irrigate the debrided wound with normal saline or an antibiotic. Before the debridement, a sample of the wound would be taken for culture and sensitivity testing so that an organism-specific antibiotic could be administered to prevent possible serious sequelae of osteomyelitis. Therefore, the nurse should review the results of the culture and sensitivity report. A pressure dressing would not be applied to an open wound. Rather, a wet-to-dry dressing most likely would be used. There should not be increased pain related to the exposure of nerve endings in the subcutaneous tissue of the wound that was left open to the environment. The bleeding of vessels should be controlled as it would have been if the wound had been closed. Therefore, additional vessel bleeding should not be a problem.
Following a total hip replacement, the nurse should do which of the following? Select all that apply. 1. With the aid of a coworker, turn the client from the supine to the prone position every 2 hours. 2. Encourage the client to use the overhead trapeze to assist with position changes. 3. For meals, elevate the head of the bed to 90 degrees. 4. Use a fracture bedpan when needed by the client. 5. When the client is in bed, prevent thromboembolism by encouraging the client to do toe-pointing exercises.
2, 4, 5. Following total hip replacement, the client should use the overhead trapeze to assist with position changes. The head of the bed should not be elevated more than 45 degrees; any height greater than 45 degrees puts a strain on the hip joint and may cause dislocation. To use a fracture bedpan, instruct the client to flex the unoperated hip and knee to lift buttocks onto pan. Toe-pointing exercises stimulate circulation in the lower extremities to prevent the formation of thrombi and potential emboli. The prone position is avoided shortly after a total hip replacement.
Which of the following interventions would be least appropriate for a client who is in a double hip spica cast? 1. Encouraging the intake of cranberry juice. 2. Advising the client to eat large amounts of cheese. 3. Establishing regular times for elimination. 4. Having the client dangle at the bedside.
2. The client in a double hip spica cast should avoid eating foods that can be constipating, such as cheese. Rather, fresh fruits and vegetables should be encouraged and the client should be encouraged to drink at least 2,500 mL/ day. Drinking cranberry juice, which helps keep urine acidic, thereby avoiding the development of renal calculi, is encouraged. The client should be encouraged to establish regular times for elimination to promote regularity in bowel and bladder habits. The client will develop orthostatic hypotension unless the circulatory system is reconditioned slowly through dangling and standing exercises.
A client with a fracture develops compartment syndrome. Which of the following signs should alert the nurse to impending organ failure? 1. Crackles. 2. Jaundice. 3. Generalized edema. 4. Dark, scanty urine.
4. The client with compartment syndrome may release myoglobin from damaged muscle cells into the circulation. This becomes trapped in the renal tubules, resulting in dark, scanty urine, possibly leading to acute renal failure. Crackles may suggest respiratory complications; jaundice suggests liver failure; and generalized edema may suggest heart failure. However, these are not associated with compartment syndrome.
Which of the following client statements identifies a knowledge deficit about cast care? 1. "I'll elevate the cast above my heart initially." 2. "I'll exercise my joints above and below the cast." 3. "I can pull out cast padding to scratch inside the cast." 4. "I'll apply ice for 10 minutes to control edema for the first 24 hours."
3. Clients should not pull out cast padding to scratch inside the cast because of the hazard of skin breakdown and subsequent potential for infection. Clients are encouraged to elevate the casted extremity above the level of the heart to reduce edema and to exercise or move the joints above and below the cast to promote and maintain flexibility and muscle strength. Applying ice for 10 minutes during the first 24 hours helps to reduce edema.
At which of the following times should the nurse instruct the client to take ibuprofen (Motrin), prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation? 1. At bedtime. 2. On arising. 3. Immediately after a meal. 4. On an empty stomach.
3. Drugs that cause gastric irritation, such as ibuprofen, are best taken after or with a meal, when stomach contents help minimize the local irritation. Taking the medication on an empty stomach at any time during the day will lead to gastric irritation. Taking the drug at bedtime with food may cause the client to gain weight, possibly aggravating the osteoarthritis. When the client arises, he is stiff from immobility and should use warmth and stretching until he gets food in his stomach.
In preparation for total knee surgery, a 200-lb client with osteoarthritis must lose weight. Which of the following exercises should the nurse recommend as best if the client has no contraindications? 1. Weight lifting. 2. Walking. 3. Aquatic exercise. 4. Tai chi exercise.
3. When combined with a weight loss program, aquatic exercise would be best because it cushions the joints and allows the client to burn off calories. Aquatic exercise promotes circulation, muscle toning, and lung expansion, which promote healthy preoperative conditioning. Weight lifting and walking are too stressful to the joints, possibly exacerbating the client's osteoarthritis. Although tai chi exercise is designed for stretching and coordination, it would not be the best exercise for this client to help with weight loss.
After knee arthroplasty, the client has a sequential compression device (SCD). The nurse should do which of the following? 1. Elevate the sequential compression device (SCD) on two pillows. 2. Change the settings on the SCD to make the client more comfortable. 3. Stop the SCD to remove dressings and bathe the leg. 4. Discontinue the SCD when the client is ambulatory.
4. After knee arthroplasty, the knee will be extended and immobilized with a firm compression dressing and an adjustable soft extension splint in place. A sequential compression device (SCD) will be applied. The SCD can be discontinued when the client is ambulatory, but while the client is in bed the SCD needs to be maintained to prevent thromboembolism. The SCD should be positioned on the bed, but not on two pillows. Settings for the SCD are ordered by the orthopedic surgeon. Initial dressing changes are completed by the orthopedic surgeon and changed as needed per physician order.
Following a total hip replacement, the nurse should position the client in which of the following ways? 1. Place weights alongside of the affected extremity to keep the extremity from rotating. 2. Elevate both feet on two pillows. 3. Keep the lower extremities adducted by use of an immobilization binder around both legs. 4. Keep the extremity in slight abduction using an abduction splint or pillows placed between the thighs.
4. After total hip replacement, proper positioning by the nurse prevents dislocation of the prosthesis. The nurse should place the client in a supine position and keep the affected extremity in slight abduction using an abduction splint or pillows or Buck's extension traction. The client must not abduct or flex the operated hip because this may produce dislocation.
The client with an above-the-knee amputation is to use crutches while his prosthesis is being adjusted. In which of the following exercises should the nurse instruct the client to best prepare him for using crutches? 1. Abdominal exercises. 2. Isometric shoulder exercises. 3. Quadriceps setting exercises. 4. Triceps stretching exercises.
4. Use of crutches requires significant strength from the triceps muscles. Therefore, efforts are focused on strengthening these muscles in anticipation of crutch walking. Bed and wheelchair push-ups are excellent exercises targeted at the triceps muscles. Abdominal exercises, range-of-motion and isometric exercises of the shoulders, and quadriceps and gluteal setting exercises are not helpful in preparing for crutch walking.
