vSim Health Assessment | Kim Johnson (Musculoskeletal Assessment)
Ms. Johnson requires intermittent catheterization every 4 hours. Which nursing intervention is needed for the management of a commonly associated complication?
Assess temperature every 8 hours (presence of infection)
The nurse is collecting subjective data during a neurologic assessment when the patient reports numbness. Which nursing intervention will best assist in assessing this symptom?
Focus the questioning about the numbness using a recognized mnemonic Rationale: COLDSPA (character, onset, location, duration, severity, pattern, associated factors) and OLDCART (onset, location, duration, characteristic symptoms, associated manifestations, relieving/exacerbating factors, and treatment)
The nurse is performing a neurologic assessment. Which instruction will the nurse give a patient in preparation for testing "localization"?
Please close your eyes. Rationale: Testing "localization" requires that a patient close the eyes and identify where on an extremity the patient has been touched. Grip testing is the patient squeezing the nurse's hand. Pupils are checks by having the patient look straight ahead. General motor response and the ability to follow a simple command can be evaluate by asking the patient to stick out the tongue.
During an assessment of muscle strength, the patient is unable to effectively move the legs individually against the resistance provided by the nurse. Which instruction will the nurse provide to continue to evaluate the patient's muscle strength?
Please left your legs up off of the exam table. Rationale: Pushing against hands with both legs at the same time is resistance.
The nurse is educating Ms. Johnson's mother on how to effectively provide passive ROM exercises. Which instruction will have the greatest impact on the patient's potential risk for injury?
Provide the affected joint with support during exercise.
The nurse is caring for a patient newly admitted with a spinal cord injury. What is the primary goal the nurse will focus on after the patient has been physically stabilized?
Reduce the amount of cellular injury and tissue death
During an assessment of passive ROM, the patient reports pain in the left leg. Which action will the nurse take to ensure safety?
Stop the motion immediately
Ms. Johnson has been prescribed oral docusate sodium to help in managing bowel elimination. Which instruction will the nurse include to help support her medication adherence?
Take with a liquid that helps offset the medication's bitter taste
A patient has experienced a spinal cord injury at the T8 level. Which objective assessment data are associated with such trauma? (Select all that apply.)
a. Anesthesia (absence of touch) extending from the waist downward d. Analgesia (pain) extending from the waist downward hyperesthesia (enhanced senses) hyperalgesia (increased sensitivity to pain)
A patient who experienced a spinal cord injury is now undergoing passive ROM exercises to help maintain joint motion. The nurse will include which intervention in the patient's ROM routine? (Select all that apply.)
a. Dorsiflex and plantar flex the ankle joints. b. Perform the exercise at least three times at each joint d. Perform at least two times daily e. Incorporate as part of the bathing routine
Which nursing actions demonstrate an understanding of components that are required in the objective portion of a neurologic assessment? (Select all that apply.)
a. Evaluate pupils during a "neuro check" c. Assess the cranial nerves when evaluating the head, neck, eyes, and ears d. Evaluate the function of the cerebellar system by assessing balance
Which nursing actions are directly associated with possible complications of Ms. Johnson's spinal cord injury? (Select all that apply.)
a. Initiate a bowel management program b. Scan that bladder prior catheterization d. Perform passive ROM exercises with a bath e. Educate the patient regarding the need for high-fiber content in the diet
Considering Ms. Johnson's health considerations, which interventions will the nurse implement to assist her in minimizing a risk for skin breakdown? (Select all the apply.)
a. Monitor bony prominences for redness. b. Keep her skin clean and dry. c. Educate the patient to the need to change position every 2 hours.
Which topics will the nurse include when preparing education for a preparing education for a patient who has experienced a complete spinal cord injury at the T8 level? (Select all that apply).
c. Incontinence of bowel and bladder d. Increased risk of UTIs