Unit 5- Musculoskeletal Disorders-ML8

The nurse is to apply a sequential compression device (intermittent pneumatic compression). Identify the area of the compression device that is placed on the client's calf.

The air cell should be centered on the back of the client's calf.

A nurse is assessing a client for neurologic impairment after a total hip replacement. Which finding would indicate impairment in the affected extremity?

inability to move Being unable to move the affected leg suggests neurologic impairment. A decrease in the distal pulse, diminished capillary refill, and coolness to touch of the affected extremity suggest vascular compromise.

Which action may a nurse on the orthopedic unit safely delegate to a licensed practical nurse (LPN)?

obtaining vital signs during blood administration The nurse may safely delegate obtaining vital signs during blood administration to the LPN. Teaching the client taking warfarin about follow-up care, assessing a hip wound, and taking a telephone order are actions that must be taken by the registered nurse because they aren't within the scope of LPN practice.

After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis?

fat embolism Fat embolism is a relatively rare but life-threatening complication of pelvis and long-bone fractures, arising 24 to 48 hours after the injury. It occurs when fat droplets released at the fracture site enter the circulation, become lodged in pulmonary capillaries, and break down into fatty acids. Because these acids are toxic to the lung parenchyma, capillary endothelium, and surfactant, the client may develop pulmonary hypertension. Signs and symptoms of fat embolism include an altered mental status, fever, tachypnea, tachycardia, hypoxemia, and petechiae. Compartment syndrome and infection may complicate any fracture and aren't specific to a pelvis fracture. Volkmann's ischemic contracture is a potential complication of a hand or forearm fracture.

The nurse is evaluating the outcome of therapy for a client with osteoarthritis. Which finding indicates goals of therapy have been met?

joint range of motion improved One outcome criterion for the client with osteoarthritis is improved joint mobility. It is probably not possible to arrest the disease. Gold compound is administered to clients with rheumatoid arthritis, not osteoarthritis. Outcome criteria should be specific; feeling better is too general to be useful.

The nurse should plan to use an abduction pillow (or splint) after a total hip replacement to:

prevent dislocation of the prosthesis. After a total hip replacement, it is important to maintain the hip in a state of abduction to prevent dislocation of the prosthesis.Use of an abduction pillow or splint will not prevent hip flexion or the formation of sacral pressure ulcers, nor will it increase peripheral circulation.

The nurse is providing teaching for a client being discharged after a fiberglass cast application for a fractured tibia. Which statement by the client indicates need for further teaching?

"Hot, painful, areas on the cast are normal and can be treated with ice packs." Teaching should include recognition of important signs and symptoms that would indicate circulation impairment; these include pale skin and coolness of the extremity. Additionally, the nurse teaches the client that hot, painful areas can be a sign of infection and should be addressed. Pain from the fracture and a small amount of swelling is normal. The client should be able to wiggle toes and can shower but should avoid getting the cast wet or getting water inside the cast.

A client who had a total hip replacement 4 days ago is worried about dislocation of the prosthesis. How should the nurse respond to the client's concern?

"Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid them." 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 is teaching a client with osteoporosis about optimal dietary choices to reduce the severity of the condition. What instruction should the nurse provide?

"Eat more dairy products such as cheese and yogurt." Osteoporosis causes a severe, general reduction in skeletal bone mass. To offset this reduction, the client should be advised to increase calcium intake by consuming more dairy products, which provide about 75% of the calcium in the average diet. Changing intake of red meat, nuts, seeds, or fruit would not prevent osteoporosis from worsening.

A client with a broken ulna reports having pain in the casted arm that is unrelieved by pain medication. The nurse assesses the arm and notes that the fingers are swollen and difficult to separate. What should the nurse do first?

Call the health care provider (HCP) to report swelling and pain. The most appropriate action is to report the swelling, loss of mobility, and unrelieved pain to the HCP. These symptoms are indicators of neurovascular impairment. Administering opioids will not eliminate the cause of the problem, which is unrelieved pressure on nerves and blood supply. If prompt action (cutting the cast) is not taken to relieve the pressure, permanent muscular and neurologic injury may result. Applying the ice bag would have been appropriate earlier to decrease or prevent swelling, but applying it at this time could actually lead to further decreased circulation. The arm should be elevated, but the nurse cannot wait 30 minutes to reassess the client without risking permanent damage.

An older adult with a hip fracture is to use an alternating air pressure mattress at home to prevent pressure ulcers while recovering from surgery. The nurse is showing the client's family how to place the mattress (see below). What should the nurse instruct the family to do?

Make the bed with the bedsheet on top of the pressure mattress. To obtain best results, one sheet should be used to cover the mattress. The air cells should be facing up as shown. Thick pads should not be used; if the client is incontinent, a "breathable" incontinent pad can be added. The client can use a pillow as needed.

A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then

advance both crutches. The nurse should instruct the client to advance both crutches to the step below, then transfer their body weight to the crutches as they bring the affected leg to the step. The client should then bring the unaffected leg down to the step.

A diet plan is developed for a client with gouty arthritis. The nurse should advise the client to limit his intake of

organ meats. Gouty arthritis is a disorder of purine metabolism. High-purine foods include organ meats, anchovies, sardines, shellfish, and meat extracts. Citrus fruits, green vegetables, and fresh fish are appropriate foods for a client with gouty arthritis.

The nurse is planning care for the client with a femoral fracture who is in balanced suspension traction. Which nursing care can be included in the plan of care?

using a fracture bedpan when the client uses the trapeze to raise the hips The client with a femoral fracture in balanced suspension traction can raise the hips using a trapeze in order to use the fracture bedpan while maintaining the line of the traction. The client should not turn side to side as it will disrupt the line of traction. The nurse can give back care when the client raises the body using the trapeze. The client 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. 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.

A client is recovering from an attack of gout. Client teaching should include the need to lose weight because

weight loss will reduce uric acid levels and reduce stress on joints. Weight loss will reduce uric acid levels and reduce stress on joints. Weight loss won't reduce purine levels, reduce inflammation or increase uric acid levels.

A client with osteoarthritis asks for information concerning activity and exercise. When assisting the client, which concept should be included?

Exercising at least 1 hour after awakening allows the client to participate in exercise after some of the morning-related stiffness has subsided. A client with osteoarthritis has increased stiffness in the morning upon awakening. Exercise should be scheduled at least 1 hour after awakening. Exercising in the evening interferes with the client's ability to rest at bedtime.

A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be?

administering ordered analgesics and monitoring their effects An acute exacerbation of rheumatoid arthritis can be very painful, and the nurse should make pain management the priority. Client teaching, skin care, and supplying adaptive devices are important, but these actions do not take priority over pain management.

What is the most important assessment for the nurse to make when assessing peripheral pulses on a client who is post limb fracture?

amplitude and symmetry of both extremities Assessment of any peripheral pulse should include the characteristics of the pulse (e.g., amplitude, rhythm, and rate). The presence or lack of symmetry in the peripheral pulses must also be assessed. The other answers are incorrect because they are not based on assessment of pulses distal to the fracture site.

When planning a health promotion class with a group of women, the nurse should include which information about reducing the risk of developing osteoarthritis?

Maintain a normal weight. Obesity is a risk factor for osteoarthritis because it places increased stress on the joints. A high-protein diet, regular exercise, and vitamin supplements do not reduce a client's risk of developing osteoarthritis.

Which goal is the priority for a client with a fractured femur who is in traction?

Prevent effects of immobility while in traction. The priority for this client is to prevent the effects of prolonged immobility, such as preventing skin breakdown and encouraging the client to take deep breaths, and use active range-of-motion exercises for the joints that are not immobilized. Although not the priority, the nurse also should seek ways to help the client adjust to and cope with the present state of immobility. Emphasis should be placed on what the client can do, such as participating in daily care and exercises to maintain muscle strength. Finding diversional activities is not a priority at this moment. Although the client must adapt to the inactivity, helping the client develop coping skills is the priority at this time.

A client diagnosed with arthritis doesn't want to take medications. Physical therapy and occupational therapy have been consulted for nonpharmacologic measures to control pain. What might physical and occupational therapy include in the care plan to help control this client's pain?

an exercise routine that includes range-of-motion (ROM) exercises Physical and occupational therapy will most likely develop an exercise routine that includes ROM exercises to control the client's pain. Acupuncture may help relieve the client's pain; however, it isn't within the scope of practice for physical and occupational therapists. Heat therapy may help the client, but it's coupled with NSAIDs in this option, which goes against the client's wishes. Cold therapy aggravates joint stiffness and causes pain.

A client has a plaster cast applied to the lower extremity that is still wet to touch. In which way should the nurse move the casted limb to elevate it on a pillow?

Place the palms on both sides of the cast. When moving a client with a wet plaster cast, only the palms of the hands should be used so that indentations in the cast from the fingers may be prevented. Indentations can result in areas of pressure on the skin. The limb should be supported at both the ankle and the knee because a plaster cast is heavy when wet.

A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis?

Prevent internal rotation of the affected leg. The nurse and other caregivers should prevent internal rotation of the affected leg. However, external rotation and abduction of the hip will help prevent dislocation of a new hip joint. Postoperative total hip replacement clients may be turned onto the unaffected side. The hip may be flexed slightly, but it shouldn't exceed 90 degrees. Maintenance of flexion isn't necessary.

To protect a client's skin under a back brace, the nurse should:

have the client wear a close-fitting thin cotton shirt under the back brace. Having the client wear a thin cotton shirt that is close fitting to avoid having extra folds that could cause pressure under a back brace helps to protect the skin and to keep the brace free of skin oils and perspiration.Using padding may increase pressure points.Lubricating or powdering the skin under the back brace will not provide protection from irritation by the brace.

A client who has skeletal traction to stabilize a fractured femur has not had a bowel movement for 2 days. The nurse should:

increase the client's fluid intake to 3,000 mL/day. The most appropriate nursing action is to first increase the client's fluid intake to 3,000 mL/day to soften stool.A stool softener would be prescribed before resorting to an enema. Oil retention enemas are used to soften and lubricate impacted stool.Placing the client on the bedpan every 3 to 4 hours is not enough to stimulate a bowel movement.While activity can stimulate peristalsis, passive range of motion is not likely to provide enough stimulation to the abdominal muscles to stimulate a bowel movement.

A client is admitted to the hospital with a diagnosis of a right hip fracture. The client has right hip pain and cannot move the right leg. The nurse should further assess the right leg to determine if the leg is:

shorter than the leg on the unaffected side. After a hip fracture, the leg on the affected side is characteristically shorter than the unaffected leg.A fractured hip usually rotates externally.Holding the leg in a flexed position is seen in clients with a dislocated hip, not a fractured hip.Typically, the fractured hip is in an abducted position.

A client is scheduled for a laminectomy to repair a herniated intervertebral disk. When developing the postoperative care plan, the nurse should include which action?

Turning the client from side to side, using the logroll technique To avoid twisting the spine or hips when turning a client onto the side, the nurse should use the logroll technique. (Twisting after a laminectomy could injure the spine.) After surgery, the nurse shouldn't put anything under the client's knees or place the client in semi-Fowler's position because these actions increase the risk of deep vein thrombosis. Typically, the client is allowed out of bed by the first or second day after a laminectomy.

A child is to receive IV antibiotics for osteomyelitis. Before the initial dose of antibiotics can be given, the nurse confirms that a blood sample for which test has been drawn?

culture Cultures are used to determine exactly what organism is causing the inflammation. From the culture, sensitivities to various antibiotics may be determined. If the antibiotics are given before obtaining the culture, the antibiotics may inhibit the growth of the organism in the culture medium. This may lead to a delay in the most appropriate treatment. Unless a child has a known renal problem, baseline creatinine levels are not typically needed. However, levels may be needed during treatment depending on the medication. A complete blood count (CBC) with hemoglobin and white blood cell count is typically prescribed for any suspected infection, but these tests do not identify the causative organism.

A client seeks care for lower back pain of 2 weeks duration. Which assessment finding suggests a herniated intervertebral disk?

pain radiating down the posterior thigh A herniated intervertebral disk may compress the spinal nerve roots, causing sciatic nerve inflammation that results in pain radiating down the leg. Slight knee flexion should relieve, not precipitate, lower back pain. If nerve root compression remains untreated, weakness or paralysis of the innervated muscle group may result; lower leg atrophy may occur if muscles aren't used. Homans' sign is more typical of phlebothrombosis.

When admitting a client with a fractured extremity, what area should the nurse assess first?

the area distal to the fracture 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.

A client is to have a total hip replacement. What nursing actions should the preoperative plan include? Select all that apply.

Administer antibiotics as prescribed to ensure therapeutic blood levels. Request a trapeze be added to the bed. Teach isometric exercises of quadriceps and gluteal muscles. 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 antiembolism 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 prescription.

A client is in balanced suspension traction to maintain alignment of a fractured tibia. Which activities are safe for the client?

Raise the hips using trapeze. The client in balanced suspension traction can raise the hips using a trapeze. The client can then use the bedpan. The client can be in a sitting position to eat. The client should not move side to side but can turn toward the affected side. The client should not flex or extend the ankle on the affected side.

To promote early and efficient ambulation for a client after an above-the-knee amputation, the nurse is aware that the leg will need to be positioned in which way?

in functional alignment Muscles that originate at the vertebrae or pelvic girdle and insert on the femur act to abduct, adduct, flex, extend, and rotate the femur. Normal body alignment should be maintained because it facilitates the safe and efficient use of muscle groups for balance and stability. Functional alignment is essential for all bone repair.

A client undergoes hip-pinning surgery to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan?

keeping a pillow between the client's legs at all times After hip pinning, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After hip pinning, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.

The nurse is assessing the home environment of an elderly client who is using crutches during the postoperative recovery phase after hip pinning. Which poses the greatest hazard to the client as a risk for falling at home?

scatter rugs Although pets and furniture, such as snack tables and rocking chairs, may pose a problem, scatter rugs are the single greatest hazard in the home, especially for elderly people who are unsure and unsteady with walking. Falls have been found to account for almost half the accidental deaths that occur in the home. The risk of falls is further compounded by the client's need for crutches.

A child diagnosed with osteomyelitis will be discharged on IV nafcillin. After teaching the parents about adverse effects that are important to report, which effects as stated by the parents indicate that they understand the teaching? Select all that apply.

sore mouth stomach upset fever Common adverse effects of nafcillin include vomiting, diarrhea, sore mouth, fever, and gastritis (stomach upset). Pain with urination and headache are not associated with this drug.

The nurse is instructing a female client recently diagnosed with osteoporosis about health promotion activities. The client has a 20-year history of smoking and has a sedentary life style. Which information should the nurse include in the teaching plan? Select all that apply.

Increase calcium and vitamin D intake using dietary supplements as prescribed. Begin walking for 20 to 30 minutes 5 times a week. Join a smoking cessation program. Enroll in a balance training program. Osteoporosis involves a weakness of the bones and presents a risk for fractures. The goal of health promotion is to strengthen the bones and prevent fractures. The nurse should instruct the client to increase calcium and vitamin D intake with supplements as prescribed. The client should begin weight-bearing exercises such as walking. Swimming is not a weight-bearing exercise. The client should stop smoking because smoking is a risk factor for osteoporosis. Balance training helps prevent falls. It is not necessary to do range-of-motion exercises; these exercises are appropriate for clients with arthritis.

The nurse is caring for a client on a second course of antibiotics to eliminate osteomyelitis. It is most essential for the nurse to instruct on which aspect of daily care?

a diet high in protein and nutrients It is essential for the nurse to instruct on a diet that is high in protein and nutrients to increase healing and strengthen the immune system. This, in addition to the second course of antibiotics, may be sufficient to eliminate the osteomyelitis. Opioids may be needed for pain management but this is not most essential. Bed rest is not common in care and assistive devices are used only in the acute period.

A client who has had a lumbar laminectomy with a spinal fusion is sitting in a chair. Which is the correct position for this client's feet?

on the floor with the feet flat A client who has had back surgery should place his feet flat on the floor to avoid strain on the incision. Placing the feet on a low or high footstool or in any other position of comfort with the legs uncrossed increases the pressure on the suture line and increases the inflammation around the involved nerve root, thereby increasing the risk of possible rerupture of the disc site.

The nurse is planning care for a client recovering from total hip replacement surgery. Which intervention should the nurse add to the client's plan of care?

Instruct the client not to lean forward at the waist when sitting up in a chair. The client should be instructed to limit the flexion of the replaced hip to 90 degrees when sitting. Bending forward while seated increases flexion to greater than 90 degrees. Even though extending the afffected leg can help reduce flexion while lowering into a seated position, an elevated toilet seat should be provided so that the client can sit without having to flex the hip greater than 90 degrees. The client should be instructed to avoid crossing the legs to prevent dislodgment or dislocation of the prosthesis. The client should be cautioned to avoid sitting in chairs that are too low or too soft because these chairs can increase hip flexion, which can accidentally dislodge or dislocate the replaced hip.

A nurse is developing a teaching plan for a client diagnosed with osteoarthritis. To minimize injury to the osteoarthritic client, the nurse should instruct the client to

install safety devices in the home. Most accidents occur in the home, and safety devices such as hand rails are the most important element in minimizing injury. Shoes should be supportive and not too worn. The client needs to use proper body mechanics when stooping or lifting objects. Protective devices aren't usually necessary when the client exercises.

The client is being discharged today after having an above-the-knee amputation a week ago. Which complications should the nurse include in the discharge directions? Select all that apply.

new openings in wound or skin around the wound pulling away worsening pain not controlled by medication skin around the stump or wound dark or turning black Complications for above-the-knee amputaton include new openings in wound or skin around the wound is pulling away; skin around the stump or wound is dark or is turning black; and pain is worse and is not controlled by medication. Other complications include swelling, new drainage or bleeding from the wound; temperature 38.6° C or higher, foul smell, red streaking up the extremity; if stump is redder, feels warmer, is bulging, or if it has gotten bigger. Pink, fleshy tissue and temperature of 36.8° C are normal findings.

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician?

a small amount of yellow drainage at the left pin insertion site The nurse should report the presence of yellow drainage, which indicates the presence of infection, at the left pin insertion site. Crust formation around the pin site is a natural response to the trauma caused by the pin insertion. Redness at the insertion site may be an early sign of infection; the nurse should continue to monitor the area, but this finding doesn't need to be reported to the physician. The client may experience pain at the pin insertion sites; therefore, the nurse should administer pain medications as ordered. It's necessary to notify the physician only if the pain medication is ineffective.

A client, age 50, visits the physician for a routine checkup. The history reveals that the client was diagnosed with a spinal curvature at age 45. The nurse knows that life-threatening complications can occur if the progressive spinal curvature exceeds 65 degrees. Which region of the spine should the nurse assess for complications?

Thoracic The nurse should assess the thoracic region of the spine because a progressive curvature of more than 65 degrees in this region may lead to cardiopulmonary failure as well as less serious signs and symptoms, such as fatigue, back pain, decreased height, and cosmetic deformity. Although a curvature may affect any part of the spine, life-threatening complications aren't associated with curvature of the cervical, lumbar, or sacral regions.

A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position?

head of the bed elevated 45 degrees After a myelogram, positioning depends on the dye injected. When a water-soluble dye such as metrizamide is injected, the head of the bed is elevated to a 45-degree angle to slow the upward dispersion of the dye. The prone and supine positions are contraindicated when a water-soluble contrast dye is used. The client should be positioned supine with the head lower than the trunk after an air-contrast study.

A client has been diagnosed with osteoporosis after a bone density test and is asking what has caused it. Discussion of risk factors would include:

heavy smoking, sedentary lifestyle, and high intake of carbonated drinks Osteoporosis has been linked to heavy smoking. A sedentary lifestyle results in more osteoclastic or breakdown activity rather than bone building or osteoblastic activity. Because carbonated drinks tend to have high phosphate levels, the inverse relationship of phosphorus to calcium results in a depletion of calcium. Sunlight exposure for vitamin D and calcium intake all promote bone density. Regular exercise and weight-bearing activities also preserve bone mass. A deficient diet has not been proven to contribute to osteoporosis.

After a right total knee replacement, the client's right leg is placed in a continuous passive motion (CPM) machine. Nursing responsibilities when caring for a client with this apparatus should include:

maintaining proper positioning of the leg on the CPM machine. he nurse must frequently evaluate the positioning of the client's leg, the range-of-motion setting, and the client's response to the therapy. Using a CPM machine will likely produce initial discomfort for the client. If the client cannot tolerate the discomfort, the nurse should notify the health care provider for a prescription to adjust the settings. The settings for the machine are determined by the health care provider and cannot be changed without a prescription. Therapy will continue until the client regains 90-degree flexion in the knee.

The client returns from surgery for a below-the-knee amputation with the residual limb covered with dressings and a woven elastic bandage. At first, the bandage was dry. Now, 30 minutes later, the nurse notices a small amount of bloody drainage. The nurse should first:

mark the area of drainage. The nurse should mark the bloody drainage and observe it again in 10 minutes to assess if the bleeding is continuing.There is no need to notify the health care provider immediately because some oozing and bloody drainage are expected.A fresh postoperative dressing should not be changed unless the health care provider prescribes it. Although the wound edges will be closed, no epithelialization has occurred yet to protect the deep tissues. Undressing the wound at this point increases the risk of a wound infection.Given the slight amount of drainage, there is no need to reinforce the dressing.

The nurse is preparing a primary prevention program to reduce the incidence of osteoporosis in a population. For which risk factors will the nurse screen to identify the subgroup of the population who is at greatest risk for developing osteoporosis?

postmenopausal women who are inactive In primary osteoporosis, the rate of bone resorption accelerates while bone formation slows. Although the cause of primary osteoporosis is unknown, an important contributing factor may be faulty protein metabolism resulting from estrogen deficiency and a sedentary lifestyle and is more common in underweight, rather than overwieght women. Typically, primary osteoporosis would occur in females who are postmenopausal. Although smoking does increase the risk for primary osteoporosis, this is not as signficant as being postmenopausal and decreased activity level. Hyperthyroidism increases the risk for secondary osteoporosis but hypothyroidism is not a significant risk factor unless it is overtreated.

To assess the joints, a nurse asks a client to perform various movements. As the client moves their arm away from the midline, the nurse evaluates their ability to perform

abduction. A client performs abduction when moving a body part away from the midline. Protraction refers to drawing out or lengthening of a body part. Retraction, the opposite of protraction, refers to drawing back or shortening of a body part. Adduction, the opposite of abduction, is movement of a body part toward the midline.

On a visit to the family physician, a client is diagnosed with a bunion on the lateral side of the great toe, at the metatarsophalangeal joint. Which statement should the nurse include in the teaching session?

"Some bunions are congenital; others are caused by wearing shoes that are too short or narrow." Bunions may be congenital or may be acquired by wearing shoes that are too short or narrow, which increases pressure on the bursa at the metatarsophalangeal joint. Acquired bunions can be prevented. Wearing shoes that are too big may cause other types of foot trauma but not bunions. Gout doesn't cause bunions. Although a client with gout may have pain in the big toe, such pain doesn't result from a bunion.

The client with rheumatoid arthritis has been taking large doses of aspirin to relieve joint pain. The nurse should assess the client for:

tinnitus. Tinnitus (ringing in the ears) is a common symptom of aspirin toxicity.Dysuria, chest pain, and drowsiness are not associated with aspirin toxicity.

To prevent external rotation of the client's hips while lying on the back, it would be best for the nurse to place:

trochanter rolls alongside the legs from ilium to midthigh. Trochanter rolls placed alongside the client's legs from the ilium to midthigh are recommended to prevent external rotation of the hips.Pillows can be used only as a temporary measure because they cannot hold the legs and hips in proper alignment over a prolonged period.Placing sandbags from the knees to the ankle will not effectively support the hips in proper alignment.A footboard does not help to keep the legs and hips in proper alignment.

A client is brought to the emergency department with a painful swollen ankle. What is the nurse's most appropriate action?

Elevate the ankle. Soft tissue injuries should be treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase the risk of further injury. Morphine is not the drug of choice for pain due to inflammation.

After surgery to treat a hip fracture, a client returns from the postanesthesia care unit to the medical-surgical unit. Postoperatively, how should the nurse position the client?

with the leg on the affected side abducted The nurse must keep the leg on the affected side abducted at all times after hip surgery to prevent accidental dislodgment of the affected hip joint. Placing a pillow or an A-frame between the legs helps maintain abduction and reminds the client not to cross the legs. The nurse should avoid acutely flexing the client's affected hip (for example, by elevating the head of the bed excessively), adducting the leg on the affected side (such as by moving it toward the midline), or externally rotating the affected hip (such as by removing support along the outer side of the leg) because these positions may cause dislocation of the injured hip joint.

A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction?

"Apply ice packs for the first 24 to 48 hours, then apply heat packs." The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing. Applying ice for only 12 to 18 hours may not keep swelling from recurring. Applying heat for the first 24 to 48 hours would worsen, not ease, swelling. Applying ice 48 hours after the injury would be less effective because swelling already has occurred by that time.

The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which statement indicates that the client still has a knowledge deficit?

"Heat-producing liniments can be used with other heat devices." Heat-producing liniment can produce a burn if used with other heat devices that could intensify the response to the heat. 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.

Which statement by the client with rheumatoid arthritis would indicate the need for additional teaching to safely receive the maximum benefit of aspirin therapy?

"I try to take aspirin only on days when the pain seems particularly bad." Aspirin therapy in rheumatoid arthritis involves continuous ongoing administration to establish and maintain therapeutic blood levels. Aspirin should not be used on an as-needed basis.Aspirin should always be buffered with food.Generic aspirin is acceptable.Clients should be instructed to observe for symptoms of bleeding.

A client takes prednisone for an acute exacerbation of rheumatoid arthritis. The nurse determines the client understands how to take the prednisone when the client says:

"It is best if I take this medication with some food." Prednisone is a gastrointestinal irritant that is best taken with food.The client should not abruptly stop taking the prednisone when her joints feel better. Rather, the drug must be tapered slowly. Abrupt withdrawal can precipitate a return of the symptoms.Sodium intake should be reduced, not increased.The client will most likely retain fluids and demonstrate some weight gain.

A client has a fiberglass cast on the right arm which was placed after internal fixation 1 week ago. The nurse notes a warm area on the cast. What priority action should the nurse take?

Assess client's temperature and interview about pain at the site. The nurse noting a warm area on the cast should alert to the possibility of infection. Internal fixation involves surgical intervention, and once the cast is applied, the surgical site is not readily visible. The warm area may indicate inflammation at the site. Additional signs of infection include fever and increased pain. A fiberglass cast can get wet, and being wet does not increase warmth. If swelling and pain is present, ice and elevation is recommended but is not the priority over assessing for signs of infection.

A nurse is caring for a client who fell and fractured the neck of femur. When documenting the site for the family members, indicate on the image the area where the fracture occurred.

The neck of the femur is a flattened pyramidal process of bone connecting the femoral head with the femoral shaft just below the ball and socket. When a femoral neck fracture occurs, the ball is disconnected from the rest of the thigh bone.

A nurse is teaching a female client about preventing osteoporosis. Which teaching point is correct?

The recommended daily allowance of calcium may be found in a wide variety of foods. Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. Clients usually can get the recommended daily requirement of calcium by eating a varied diet. Osteoporosis doesn't show up on ordinary X-rays until 30% of bone has been lost. Bone densitometry, however, can detect bone loss of 3% or less. This test is sometimes recommended routinely for women older than 35 who are at risk for osteoporosis. Strenuous exercise won't cause fractures. Although supplements are available, they aren't always necessary.

The nurse is evaluating a client in skin traction. Which observation indicates the traction is applied for maximum effectiveness?

The ropes are in the wheel grooves of the pulleys. or the weights to maintain the therapeutic effect of the traction, they must be properly positioned, free hanging, and should be removed only in life-threatening situations. Effective traction depends on the client being positioned at the head of the bed. Sufficient weight is applied initially to overcome spasm in affected muscles. As the muscles relax, the weight may be reduced.The amount of weight used is determined by the health care provider and is not changed each shift.

In preparation for total knee surgery, a 200-lb (90.7 kg) client with osteoarthritis must lose weight. Which exercise should the nurse recommend as best if the client has no contraindications?

aquatic exercise 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 total hip replacement, a client is receiving epidural analgesia to relieve pain. Which action is a nursing priority for this client?

assessing for sensation in the legs For epidural analgesia, a catheter is placed outside the dura mater in the epidural space. Catheter displacement, which may cause spinal injury, is signaled by loss of motion and sensation in the legs. Therefore, the nurse should assess closely for sensation and ask about numbness of the legs. The nurse should change the catheter site dressing every day or every other day. Capillary refill time has no bearing on epidural analgesia. A client with an epidural catheter may ambulate and need not be confined to bed.

To prevent back injury, the nurse should instruct the client to:

avoid prolonged sitting and standing. Prolonged sitting and standing should be avoided because they strain the lower back.Pushing objects rather than pulling them will help decrease back strain.Clients should select a semi-firm to firm mattress to provide back support.When sitting, the client should choose a chair with good support and a straight back. The client should sit with feet flat on the floor.

After the application of an arm cast, the client has pain on passive stretching of the fingers, finger swelling and tightness, and loss of function. Based on these data, the nurse anticipates that the client may be developing:

compartment syndrome. Compartment syndrome, caused by compression of blood vessels and nerves, can lead to irreversible muscle and nerve damage if not detected early. Common signs of compartment syndrome in the arm include pain unrelieved by analgesics, pain on passive extension of fingers, loss of function, numbness and tingling, pallor, coolness of the extremity, and decreased or absent peripheral pulse. Delayed bone union does not cause symptoms of neurovascular impairment. Fat embolism is characterized primarily by confusion and respiratory symptoms. Osteomyelitis is a bone infection and is manifested by signs and symptoms of inflammation and infection.

A client is 4 days postoperative from a tibia fracture and has a long leg cast. The nurse is conducting initial teaching for walking with crutches. What is the most important activity for the nurse to encourage the client to do prior to discharge from the hospital?

conduct exercises in bed to strengthen the upper extremities, as this will assist the client in crutch use. When walking with crutches, the client engages the triceps, trapezius, and latissimus muscles. A client who has been immobilized may need to implement an exercise program to strengthen these shoulder and upper arm muscles before initiating crutch walking. The other choices are incorrect based on functionality and muscle use.

The nurse should instruct a client who is using crutches to bear weight primarily on which part of the body?

hands The proper use of crutches requires supporting the body weight primarily on the hands. Improper use of crutches can cause nerve damage from excess pressure on the axillary nerve.

The nurse is providing information to the parents of a child newly diagnosed with juvenile arthritis. Which statements by the parents indicate understanding of the teaching? Select all that apply.

"I help my child perform daily range-of-motion exercises." "I give my child NSAIDs three times a day." "I apply heat pads to the joints when my child is having pain." NSAIDs are taken one to four times a day by children with juvenile arthritis and are given to control pain and inflammation as well as malaise and irritability. NSAIDs should be given even when the child is pain free because the anti-inflammatory properties of the drugs are key to preventing pain. Assisting the child to perform daily range-of-motion exercises and applying heat pads to joints when in pain are also correct interventions. The child should be encouraged to attend school regularly and to exercise.

The client was recently diagnosed with a musculoskeletal disorder and ordered carisoprodol. The nurse completes teaching about the medication. Which statement by the client indicates a need for more teaching about carisoprodol?

"I will stop the medication as soon as the muscle spasticity goes away." The nurse must clarify that muscle spasticity will return when medication is suspended. Carisoprodol is to be taken with food and fluid, should not be used with alcohol, and activities such as driving should be avoided only if drowsy/dizzy.

A client is diagnosed with rheumatoid arthritis and is ordered indomethacin. What should the nurse include in the client's teaching concerning the administration of indomethacin? Select all that apply.

"Take the drug at bedtime." "Do not use aspirin while taking this drug." Client teaching regarding indomethacin includes not using aspirin or NSAIDs, taking the drug immediately following meals or at bedtime, and notifying the provider of visual disturbances, tinnitus, weight gain, or edema. The client should notify their healthcare provider if needing a pain reliever. Additionally the client should have periodic eye exams, not ear exams, and take the medication immediately after, meals not before.

A nurse is caring for a client in skeletal traction to the left leg. The client reports pain of 8 on the 0- to-10 pain scale while the nurse is in the client's room. Which action would the nurse take first?

Assess the client's alignment in bed. The client in traction who reports moderate-to-severe pain may need realignment in bed. This also requires assessment of the client, which is completed prior to all other options. The traction weight is prescribed and the nurse will not change this independently. The health care provider would not be notified until an assessment is completed. Retrieving the medication means leaving the client's bedside. The nurse should assess the client's position first while at the bedside.

When developing a care plan for a client newly diagnosed with scleroderma, which nursing diagnosis has the highest priority?

Impaired skin integrity Impaired skin integrity is a concern for the client with scleroderma in its earlier stages. Meticulous skin care is required to prevent complications. Although Risk for constipation may also be appropriate, this nursing diagnosis isn't the priority. Clients with scleroderma are at risk for Imbalanced nutrition: Less than body requirements. The client with advanced scleroderma, not newly diagnosed scleroderma, is at increased risk for developing respiratory complications.

A client who has had a total hip replacement has a dislocated hip prosthesis. What should the nurse do first?

Notify the orthopedic surgeon. 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 prescribed by the surgeon, an ice pack may be applied postreduction to limit edema, although caution must be utilized due to potential muscle spasms. Some orthopedic surgeons may prescribe the client be turned toward the side of the reduced hip, but that is not the nurse's first response.

A client is diagnosed with osteoporosis. Which statements would the nurse include when teaching the client about the disease? Select all that apply.

Osteoporosis is common in females after menopause. Osteoporosis is a degenerative disease characterized by a decrease in bone density. Osteoporosis can cause pain and injury. Osteoporosis is a degenerative metabolic bone disorder in which the rate of bone resorption accelerates and the rate of bone formation decelerates, thus decreasing bone density. Postmenopausal women are at increased risk for this disorder because of their loss of estrogen. Osteoporosis is a treatable disease but there is no cure. The decrease in bone density can cause pain and injury. Osteoporosis is not an inherited disorder; however, low calcium intake because of an intolerance of milk products does contribute to it. Passive ROM exercises may be performed, but they will not promote bone growth. The client should be encouraged to participate in weight-bearing exercise because it promotes bone growth.

The nurse is receiving a client in the operating room for a right leg amputation. Which steps will the nurse follow during the timeout procedure? Select all that apply.

Review the surgical site marking of the right leg. Note preparation for the removal of the limb disposal. Assess the completed surgical consent. Confirm the client's name band. The time out procedure includes reviewing surgical site marking, noting preparation for the removal limb disposal, assessing the completed surgical consent, and confirming the client's name band. The time out procedure does not include identifying past medical history.

A client with an extracapsular hip fracture is scheduled for surgical internal fixation with the insertion of a pin. What can the nurse can tell the client about the reason for this type of treatment for the fracture?

The client is able to be mobilized sooner. Insertion of a pin for the internal fixation of an extracapsular fractured hip provides good fixation of the fracture. The fracture site is stabilized, and fractured bone ends are well approximated. As a result, the client is able to be mobilized sooner, thus reducing the risks of complications related to immobility. Internal fixation with a pin insertion does not prevent hemorrhage or decrease the risk of neurovascular impairment, which are potential complications associated with any joint or bone surgery. It does not lessen the client's risk of infection at the site.

Unlicensed assistive personnel (UAP) are helping a client who has had knee surgery 2 days ago get into bed. As the nurse makes rounds, which information requires the nurse to intervene?

The side rails on the head and foot of the bed are in the up position. Side rails are considered restraints and are not used at both the head and foot of the bed. Using side rails at the head of the bed will aid the client in sitting up and are safe, but using side rails at both the head and the foot of the bed presents risks for a client who might become wedged between the rail and the bed or attempt to climb over them. The nurse discusses side rail use with the UAP and lowers the side rail at the foot of the bed. The nurse assures the bed is placed in low position. The accessible call light, dim lighting, and clear path to the bathroom are factors that contribute to fall prevention.

A pediatric client has just had a plaster cast placed on his lower left leg. Which action should the nurse take to provide safe cast care?

Use only the palms of the hand when handling the cast. The wet plaster cast should be handled using only the palms of the hands to prevent indentations of the cast surface. Petaling a cast should be done only when the edges of the cast are rough and are causing irritation to the client's skin. The nurse should not keep the child in the same position until the cast is dry. Doing so would prohibit proper toileting and elimination and would produce undue pressure on the coccyx. The cast typically emits heat as it dries, so notifying a health care provider (HCP) is not necessary in this instance. If needed, a fan can be used to circulate the room air.

The initial postoperative assessment is completed on a client who had an arthroscopy of the knee. Which information is not necessary to obtain every 15 minutes during the first postoperative hour?

urine output The urine output does not have to be checked every 15 minutes for a client who has had an arthroscopy because this client probably does not have a catheter in place. If the client voids, the output would be recorded. Assessments every 15 minutes during the first hour would include vital signs, pulse oximeter values, and pain to monitor the client's comfort level and check for compartment syndrome. Neurovascular checks distal to the operative site are especially vital because a tourniquet was used proximal to the operative site during the surgical procedure and because edema may develop during the postoperative period.

A client with an amputation is learning how to apply a prosthetic limb. Which statement(s) made by the client indicates an increased risk for skin impairment? Select all that apply.

"I can clean and inspect the skin of my amputated leg weekly." "I will make sure the padding is all placed in the front of the stump." "I can wear a cotton garment with seams over the stump." The client with a prosthetic limb would want to clean and inspect the skin of the amputated limb daily to ensure skin integrity is maintained. Having the padding of the device distributed evenly can help prevent pressure on the skin with the device. Wearing a cotton garment between the skin and prosthesis that does not have seams also helps decrease pressure and friction on the limb. The client would not want the device to fit too tightly as this can create pressure on the skin that could lead to skin breakdown. While the client needs emotional support with the use of prosthetic limbs, this is not part of skin protection and prevention of skin breakdown.

A client with osteoarthritis tells the nurse they are concerned that the disease will prevent them from doing their chores. Which suggestion should the nurse offer?

"Pace yourself and rest frequently, especially after activities." A client with osteoarthritis must adapt to this chronic and disabling disease, which causes deterioration of the joint cartilage. The most common symptom of the disease is deep, aching joint pain, particularly in the morning and after exercise and weight-bearing activities. Because rest usually relieves the pain, the nurse should instruct the client to rest frequently, especially after activities, and to pace themself during daily activities. Telling the client to do the chores in the morning is incorrect because the pain and stiffness of osteoarthritis are most pronounced in the morning. Telling the client to do all chores after performing morning exercises or in the evening is incorrect because the client should pace themself and take frequent rests rather than doing all chores at once.

A client recovering from hip replacement surgery questions the need for admission to a rehabilitation center because there are family members available at home to provide care. Which response by the nurse is best?

"The rehabilitation staff can evaluate your progress and help you recover without risking injury." The nurse should respond by emphasizing that the rehabilitation center can evaluate progress and make sure that exercises are performed without risking injury. This response points out that the goal of rehabilitation is safely achieving mobility and not providing total care. Stating that the client will need help with bathing and meals for a long period does not provide adequate information about the role of rehabilitation or the client's future needs. The rehabilitation center will help the client learn to provide self-care. Telling the client that the rehabilitation staff can provide better care than family is judgmental about care the family might provide and does not adequately explain the role of a rehabilitation center. Telling the client that the heathcare provider wants the client to go does not explain the importance of a rehabilitation center.

Which sign indicates that a client with a fracture of the right femur may be developing a fat embolus?

acute respiratory distress syndrome 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.

Passive range-of-motion (ROM) exercises for the legs and assisted ROM exercises for the arms are part of the care regimen for a client with a spinal cord injury. Which observation by the nurse would indicate a successful outcome of this treatment?

free, easy movement of the joints ROM exercises help preserve joint motion and stimulate circulation. Contractures develop rapidly in clients with spinal cord injuries, and the absence of this complication indicates treatment success.Range of motion will keep the ankle joints freely mobile. Footdrop, however, is prevented by proper positioning of the ankle and foot, which is usually accomplished with high-top sneakers or splints.External rotation of the hips is prevented by using trochanter rolls.Local ischemia over bony prominences is prevented by following a regular turning schedule.

A client recovering from surgery to repair a fracture of the tibia and fibula of the left leg is reporting increased pain at the site. What sign must the nurse be alert to that would indicate compromised circulation to the leg?

increased edema in the toes of the affected leg Constriction of circulation decreases venous return and increases pressure within the vessels. The increased pressure in the venous side of the capillary prevents reabsorption of fluid from the interstitial spaces, causing edema. Foul odor, increased body temperature, and purulent drainage from the incision site indicate the presence of an infection.

Which condition should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis?

local joint pain Osteoarthritis is a degenerative joint disease with local manifestations such as local joint pain. Rheumatoid arthritis has systemic manifestation such as anemia and osteoporosis. Weight loss occurs in rheumatoid arthritis, whereas most clients with osteoarthritis are overweight.

A client had a posterolateral total hip replacement 2 days ago. What information should the nurse include in the client's plan of care? Select all that apply.

Position a pillow between the legs to maintain abduction. Allow the client to be in the supine position or lateral position on the unoperated side. Do not allow the client to bend down or to tie or slip on shoes. Place ice on the incision after physical therapy. A client who has had a posterolateral total hip replacement should not adduct the hip joint, which would lead to dislocation of the ball out of the socket; therefore, the client should be encouraged to keep the toes pointed slightly outward when using a walker. An abduction pillow should be kept between the legs to keep the hip joint in an abducted position. The client should rotate between lying supine and lateral on the unoperated side, but not on the operated side. Ice is used to reduce swelling on the operative side. The client should not flex the operated hip beyond a 90-degree angle, such as when bending down to tie or slip on shoes. Doing so could lead to joint dislocation.

The client with an above-the-knee amputation is to be fitted with a functioning prosthesis. The nurse has been teaching the client how to care for the residual limb. Which behavior would demonstrate that the client has an understanding of proper residual limb care? The client:

washes and dries the residual limb daily. Washing and thoroughly drying the residual limb daily are important hygiene measures to prevent infection.Nothing should be applied to the residual limb after it is cleansed. Powder may cause excessive drying and cracking of the skin, and cream may soften the skin excessively.The residual limb should be inspected daily with a mirror for early signs of skin breakdown.To reduce residual limb swelling, the prosthesis should be removed only at night.

The nurse assigns an unlicensed assistive personnel (UAP) to care for a client who has a newly applied long-leg plaster cast. What should the nurse tell the UAP about proper care of the cast while it is drying?

"Turn the client every 2 hours to promote even drying of the cast." The client should be repositioned every 2 hours to promote even drying of the cast.The cast should be kept uncovered while drying to allow air to circulate around the cast and prevent heat from building up within it.It takes 24 to 72 hours for a plaster cast to dry; using a blow dryer may cause a heat burn and does not reduce the time for the cast to dry.The palms of the hands, not the fingers, should be used to move a drying cast in order to prevent indentations that can cause pressure points to develop.

A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan?

elevating the stump for the first 24 hours Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility. Heat application would be inappropriate because it promotes vasodilation, which may cause hemorrhage and increase pain. The initial pressure dressing usually remains in place for 48 to 72 hours after surgery.

A male client underwent a lumbar spinal fusion yesterday. Which nursing assessment should alert the nurse to the development of a possible complication?

clear yellowish fluid on the dressing Clear yellowish fluid on the dressing may be cerebrospinal fluid (CSF). This fluid must be tested for glucose to determine whether it is CSF. If so, the client is at great risk for an infection of the central nervous system, which has a high mortality rate. The client should be able to laterally rotate the head and neck, which is above the surgical site in the spinal column. During the nursing postoperative neuromuscular-vascular assessment of movement of the head and neck, the nurse should find results consistent with the preoperative baseline status. Using the standing position to void is normal for a male client. Coughing is the body's defense mechanism to help clear the lungs of the anesthetic agents and to ventilate the lungs in response to a sustained deep inspiration for ventilation of the lower lobes of the lungs. A frequent cough could place a strain on the incision site and should be avoided. Also, a productive cough of thick, yellow sputum would indicate the complication of a respiratory infection.

A client has a total hip replacement. Which of the following client statements indicates a need for further teaching before discharge?

"I can't wait to take a tub bath when I get home." The client will need to avoid extremes of motion in the hip to avoid dislocation. The hip should not be flexed more than 90 degrees, internally rotated, or legs crossed. It is not possible to safely sit in the bathtub without flexing the hip beyond the recommended 90 degrees. The client can implement the prescribed exercise program at the time of discharge home. The client should take care not to stress the hip for 3 to 6 months after surgery. An elevated toilet seat will be necessary during the recovery from surgery.

A client is suspected of having carpal tunnel syndrome. The nurse assesses for Tinel's sign. Identify the area where the nurse would percuss in an attempt to elicit Tinel's sign.

Carpal tunnel syndrome is compression of the median nerve in the wrist that supplies feeling and movement to parts of the hand. Tinel's sign may be used to help identify carpal tunnel syndrome. It is elicited by percussing lightly over the median nerve, located on the inner aspect of the wrist. If the client reports tingling, numbness, and pain, the test is considered positive.

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. What should the nurse do first?

Draw a mark around the site. 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 is planning care for a client with osteomyelitis. The client is taking an antibiotic, but the infection has not resolved. What should the nurse advise the client to do?

Eat a diet high in protein and vitamins C and D. 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.

What would be the most important nursing intervention in caring for the client's residual limb during the first 24 hours after amputation of the left leg?

Elevate the residual limb on a pillow. Elevating the residual limb on a pillow for the first 24 hours after surgery helps prevent edema and promotes comfort by increasing venous return. Elevating the residual limb for longer than the first 24 hours is contraindicated because of the potential for developing a hip flexion contracture. Keeping the limb flat will be an important intervention after the first 24 hours. Preventing excessive swelling, however, is a priority in the first 24 hours. Adducting the residual limb on a scheduled basis prevents abduction contracture. Traction may be used to prevent or treat a hip flexion contracture—however, not in the first 24 hours.

Following a client's total hip replacement, what should the nurse do? Select all that apply.

Encourage the client to use the overhead trapeze to assist with position changes. Use a fracture bedpan when needed by the client. When the client is in bed, prevent thromboembolism by encouraging the client to do toe-pointing exercises. 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.

The nurse is counseling a client with osteoporosis about dietary choices to slow bone loss. What foods should the nurse teach the client to avoid?

Foods and beverages high in caffeine Caffeine may decrease calcium absorption and contribute to bone loss so should be avoided in high amounts. To help prevent osteoporosis, the nurse should encourage the client to consume at least the recommended daily allowance (RDA) of calcium. Before menopause, the RDA is 1,000 mg; after menopause, it is 1,500 mg. Foods high in calcium included canned fish (especially with bones) and dairy products. Uric acid levels are controlled with decreased purine intake, and this is related to risk for gout and does not relate to osteoporosis. Soy products have not been proven to reduce bone loss but may confer some benefits and do not need to be avoided.

A nurse is teaching a client with osteomalacia how to take ordered vitamin D supplements. Which adverse effects should the nurse instruct the client to report?

GI upset and metallic taste The nurse should instruct the client to report GI upset and metallic taste because these are early signs and symptoms of vitamin D toxicity. Such toxicity also may cause headache, weakness, renal insufficiency, renal calculi, hypertension, arrhythmias, muscle pain, and conjunctivitis. Dry skin, hair loss, and inflamed mucous membranes suggest vitamin A toxicity. Flushing and orthostatic hypotension (effects of vasodilation) may result from nicotinic acid and nicotinamide supplements, which are used to correct niacin deficiency. Sensory neuropathy and difficulty maintaining balance suggest pyridoxine toxicity.

The nurse is going to lunch and is conducting a "hand-off of care" to the charge nurse. Which information should the nurse communicate to the charge nurse during the "hand-off of care" communication?

Give the charge nurse information about what care should be given while the nurse is at lunch. Hand-off of care communication is an interactive communication allowing the opportunity for questioning between the giver and receiver of client information, including up-to-date information regarding the client's care, treatment, and services, as well as the client's current condition and any recent or anticipated changes. "Hand-off" communication does occur when a nurse is leaving the nursing unit, but the purpose is not to let the charge nurse know that the nurse is going to lunch or to have someone else assigned to care for the client. "Hand-off" communication focuses on current information, not the client's history.

A client is brought to the emergency department after injuring their right arm in a bicycle accident. The orthopedic surgeon tells the nurse that the client has a greenstick fracture of the arm. What does this mean?

One side of the bone is broken and the other side is bent. In a greenstick fracture, one side of the bone is broken and the other side is bent. A greenstick fracture also may refer to an incomplete fracture in which the fracture line extends only partially through the bone substance and doesn't disrupt bone continuity completely. (Other terms for greenstick fracture are willow fracture and hickory-stick fracture.) The fracture line extends through the entire bone substance in a complete fracture. A fracture that results from an underlying bone disorder, such as osteoporosis or a tumor, is a pathologic fracture, which typically occurs with minimal trauma. Bone fragments are separated at the fracture line in a displaced fracture.

The school nurse is planning an educational session to prevent injuries in children with juvenile arthritis. Which information should the nurse include in the teaching?

Schedule the completion of daily range-of-motion exercises to support joint mobility. Daily range-of-motion exercises are required to help a child with juvenile arthritis strengthen the muscles and use the joints to their full range of motion. Participation in group sports may be too strenuous for the child with juvenile arthritis and may increase the risk for injuries. Excessive exercise, such as running and jumping during play, should be discouraged because it places an excessive amount of pressure on the joints. The child should remain active and independent, but avoid overexertion during activities. Homeschooling to avoid activity and walking would not support the child's need for exercise to maintain joint flexibility.

The client in balanced suspension traction is transported to surgery for closed reduction and internal fixation of a fractured femur. What should the nurse do when transporting the client to the operating room?

Send the client on the bed with extra help to stabilize the traction. The nurse should send the client to the operating room on the 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.

A client is admitted with a possible diagnosis of osteomyelitis. Based on the documentation, which laboratory result is the priority for the nurse to report to the physician?

blood culture Osteomyelitis is a bacterial infection of the bone and soft tissue that occurs by extension of soft tissue infection, direct bone contamination following surgery, or spreading from other infection sites in the body. A positive blood culture would be reported immediately to the physician so that specific antibiotic therapy can begin or be adjusted based on the positive culture. A negative rheumatoid factor would be expected in a possible diagnosis of osteomyelitis. An alkaline phosphatase level of 60 IU/L (1.0 nkat/L) is within the normal range, and an ESR of 10 mm/hour is also within the normal range.

Two days after being placed in a cast for a fractured femur, the client suddenly has chest pain and dyspnea. The client is confused and has an elevated temperature. The nurse should assess the client for which health problem?

fat embolism syndrome Clients with fractures of the long bones such as the femur are particularly susceptible to fat embolism syndrome (FES). Signs and symptoms include chest pain, dyspnea, tachycardia, and cyanosis. Changes in mental status are caused by hypoxemia and can be the first symptoms noted in FES. The client can also be restless and febrile and can develop petechiae. Osteomyelitis is infection of the bone; signs and symptoms of osteomyelitis do not include respiratory symptoms. Compartment syndrome causes signs of localized neurovascular impairment, not systemic symptoms. Venous thrombosis occurs in the lower extremities and is caused by venous stasis.

The nurse teaches a client about using crutches, instructing the client to support the weight primarily on which part of the upper body?

hands When using crutches, the client is taught to support 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.

The client with an open femoral fracture was discharged to home and reports having a fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg. The nurse should interpret these findings as the client may be experiencing which complication?

osteomyelitis 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.

A client is admitted to the orthopedic unit in balanced skeletal traction using a Thomas splint and Pearson attachment. The primary purpose of traction is to:

realign fracture fragments. Traction promotes realignment of the bone fragments. This will facilitate subsequent internal fixation. Traction immobilizes the fracture site and may increase the client's comfort. Mobilization could result in further damage.The use of traction does not prevent neurologic damage and can, in fact, cause pressure that leads to nerve damage.Traction increases circulation to the affected part but does not control internal bleeding.Traction may create, rather than prevent, a problem with skin integrity.

A client has an intracapsular hip fracture. The nurse should conduct a focused assessment to detect which change near the fracture?

shortening of the affected leg With an intracapsular hip fracture, the affected leg is shorter than the unaffected leg because of the muscle spasms and external rotation. The client also experiences severe pain in the region of the fracture.

Which activities should the nurse teach the client to do to strengthen the hand muscles in preparation for using crutches?

squeezing a rubber ball A client being prepared for crutch walking should be taught to support weight with the hands when crutch walking. Supporting weight in the axillae is contraindicated owing to the risk of possible nerve damage and circulatory obstruction. The client should be taught to squeeze a ball vigorously to help strengthen the hands in preparation for weight bearing with the hands.Hair combing is not likely to strengthen the hands.Wrist flexion and extension may help with wrist joint mobility but will not strengthen the hands.Using the hands to push into the mattress will not be helpful because the mattress will not provide sufficient resistance to strengthen the hands.

The nurse assigns an unlicensed assistive personnel (UAP) to the care of a client who has just returned from surgery for repair of a fractured right wrist and application of an arm cast. The nurse should stress to the UAP the importance of reporting:

the client cannot move the fingers on the right hand. The UAP should report immediately to the nurse any sign that the client cannot move the fingers on the casted arm, numbness or tingling, or feelings of tightness because these may indicate impaired neurovascular status.The nurse, not the UAP, is responsible for neurovascular assessments.Intake and output would usually not be particularly significant in a client with a fractured arm.It is normal for the client to feel heat immediately after application of a plaster cast.

A client has the leg immobilized in a long leg cast. Which finding indicates the beginning of circulatory impairment?

tingling of toes Tingling and numbness of the toes would be the earliest indication of circulatory impairment. Inability to move the toes and cyanosis are later indicators. Cast tightness should be investigated because cast tightness can lead to circulatory impairment; it is not, however, an indicator of impairment.