Mobility

A client is brought to the emergency department triage by private car with an obvious compound fracture of the right lower leg. What is the initial assessment the triage nurse needs to perform?

Distal pulses right leg

An infant has a plaster cast applied for clubfoot correction. What nursing intervention will hasten drying of the cast?

Exposing the casted extremity

After an amputation, a client's residual limb is bandaged snugly throughout the postoperative period. The nurse teaches the client that the primary purpose of the rigid bandaging of the residual limb is to:

Promote shrinkage of the distal end of the residual limb

Nursing care of a client with a fractured hip should include the assessment of pedal pulses. The nurse should assess for which important characteristics of the pedal pulses

Amplitude and symmetry

The nurse is caring for a client with a cervical laminectomy. How is the nursing care different than the care provided to a client with a lumbar laminectomy?

Assist with the removal of oral secretions.

A client has surgery for an incarcerated hernia. The health care provider returns the incarcerated tissue to the abdominal cavity and uses a mesh to reinforce the muscle wall. What specific instructions should be included in the discharge instructions?

Avoid lifting heavy items

A nurse provides discharge teaching to a client that had a total hip replacement. The client states that the plan is to go swimming at the community pool the day after discharge. How should the nurse respond?

Explain that the incision should not be immersed in water until it has healed

A client who is to have a total hip arthroplasty with an uncemented prosthesis asks, "When will I be able to get up and walk?" On what information should the nurse base an answer?

Full weight-bearing may begin the day after surgery.

A jogger sustains multiple fractures of the femur after being hit by a motor vehicle. A nurse responds to the scene of the accident to assist with care. The nurse recalls that, for this type of fracture, immediate life-threatening systemic complications can be minimized by:

Handling and transporting the client gently

A client that is postoperative hip replacement is receiving morphine by patient-controlled analgesia and has a respiratory rate of 6 breaths/min. What intervention should the nurse anticipate?

Naloxone administration

The nurse is caring for a client who had a total knee replacement three days ago. During the morning assessment, the nurse notes that the client has purulent drainage and redness along the incision. The nurse should classify this type of infection as:

Nosocomial

A client with multiple sclerosis is informed that it is a chronic progressive neurological condition. The client asks the nurse, "Will I experience pain?" What is the nurse's best response?

Pain is not a characteristic symptom of this condition."

A nurse is caring for a client with a fracture of the head of the femur. The health care provider places the client in Buck's extension. What explanation does the nurse give the client for why the traction is being used?

Reduces muscle spasms

A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client?

The plan is formulated and implemented early in the client's care.

A nurse is completing the health history of a client admitted to the hospital with osteoarthritis. The nurse expects the client to report that which joints were involved initially? Select all that apply .

Hips Knees

What should the nurse do to promote early and efficient ambulation after a client has a mid-thigh amputation?

Turn the client to the prone position routinely.

A client has corrective surgery for a bladder laceration. What nursing intervention takes priority during this client's postoperative period?

Turning frequently

A client, admitted to the hospital with a fractured hip, is scheduled for surgery for a total hip replacement. In which position should the nurse place the client's affected limb after surgery?

Abduction and extension

The nurse is caring for a client four hours after the client's hip replacement surgery. When assisting the client out of bed, the nurse should:

Advise the client that the legs must continually be kept wide apart

A client who has just started on a regimen of haloperidol (Haldol) is observed pacing and shifting weight from one foot to another. What side effect does the nurse document in the client's chart?

Akathisia

A client who has an above-the-knee amputation is fitted with a prosthesis. The nurse evaluates the client's response to the prosthesis. Which indicates that the prosthesis fits the residual limb correctly?

Darkened skin areas surrounding the end of the residual limb

A woman who has severe rheumatoid arthritis becomes depressed and is admitted to the psychiatric unit. The nurse begins to work with her in one-on-one sessions to help her cope with her depressive episode. The best long-term goal for this client is that she will:

Decrease negative thinking about herself, others, and life.

A nurse completes an admission assessment on a client who is diagnosed with myasthenia gravis. Which clinical finding is the nurse most likely to identify?

Difficulty swallowing saliva

A client is admitted to the hospital with lower back pain and a tentative diagnosis of a herniated nucleus pulposus. When assessing the client's back pain, the nurse should ask:

Do you have any increase in pain during bowel movements?"

A client returns from surgery after a total hip arthroplasty. A pillow to maintain abduction is in place. Under what conditions should the nurse remove this pillow?

During the client's bed bath

A client has a fracture of the tibia and a cast is applied. When caring for the client, the nurse should:

Elevate the affected leg above the level of the heart

A nurse is caring for a client on the evening after the client had a below-the-knee amputation. What action should be implemented by the nurse?

Elevate the foot of the bed

To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care?

Encourage early mobility

The nurse is assisting a client with myasthenia gravis to bathe. The nurse identifies that the client's arms become weaker with sustained movement. What action should the nurse take?

Encourage the client to rest for short periods

A nurse is caring for a client who had a total hip replacement. What nursing action should be incorporated into the plan of care to prevent thrombus formation?

Encouraging the client to perform ankle exercises.

A nurse is demonstrating to a client how to manipulate the ankles through full range of motion. Which movements should the nurse use during this process? Select all that apply.

Eversion Inversion Dorsiflexion Plantar flexion

A client with a fractured hip is helped from the bed to a chair after surgery. The nurse instructs the client to bear most of the weight on the unaffected leg before sitting in a chair. The nurse should explain that the benefit of bearing most of the weight on the unaffected leg is to:

Help maintain the strength of the unaffected limb.

A client who had an above-the-knee amputation (AKA) has a pressure dressing on the end of the residual limb. The client asks, "Why do I have to have this tight dressing on my leg?" Which answer by the nurse is correct?

It decreases the swelling of the area.

A nurse is caring for a client who developed aseptic necrosis after a fracture of the head of the femur. The nurse understands that aseptic necrosis is associated with which factor?

Loss of blood supply to the head of the femur

A client is admitted with extensive bone and soft-tissue injuries to the leg. Sterile dressings are applied. Two days later, when removing the dressings, the nurse finds that one of the dressings has adhered to tissue in several places. To loosen the dressings, the nurse should:

Moisten the dressing with sterile saline

X-ray films reveal that a client has sustained an intracapsular fracture of the left hip as a result of a fall. The client is placed temporarily in Buck's traction. When providing care, the nurse should:

Monitor for tenderness in the left calf area

A client is admitted to the ambulatory care unit for a muscle biopsy. In preparation for discharge, what should the nurse teach the client to do?

Resume the usual diet as soon as desired.

A client who had a brain attack (stroke) is admitted to the hospital with right-sided hemiplegia. The nurse recognizes that it is important to identify restrictions of mobility or neuromuscular abnormalities because:

Shortening and eventual atrophy of the muscles will occur.

A client has a diskectomy and fusion for a herniated nucleus pulposis. When getting out of the bed for the first time since surgery, the client reports feeling faint and lightheaded. The nurses assisting with the ambulation should have the client:

Sit on the edge of the bed so they can hold the client upright

A client with severe varicose veins has surgery that involves ligation, dissection, and removal of incompetent vessels. In what position should the nurse place the client after surgery?

Supine with the legs elevated at a 15 degree angle

The client is admitted to the emergency department after a fall from a roof. After determining that the client sustained a head injury, the nurse observes clear fluid coming from the client's left ear. What will the nurse do next?

Test the drainage from the client's ear with a glucose reagent strip

A client with dementia is admitted with a fractured hip following a fall at home. The client's family member witnessed the fall. Four hours after admission, the client's blood pressure increases to a moderately severe hypertensive level. The client pulls on the bedclothes continuously. The client's family member asks for pain medication for the client. The nurse concludes that:

The client may be in pain and unable to respond appropriately

The practitioner prescribes no weight-bearing on a leg that has been casted because of a fracture of the femur. How should the nurse determine the appropriate length of the crutches for this child? Select all that apply

The crutches should reach 2 inches below the axillae. The tips of the crutches should rest 6 inches outside the feet.

Shoulder immobilization is prescribed after surgical repair of a client's rotator cuff. Which criterion should the nurse use to determine that appropriate alignment is achieved by the immobilizer device?

Upper arm lies close to the chest.

A nurse teaches self-care to a client who had a cast applied for a fracture of the right ulna and radius. The nurse instructs the client to notify the primary health care provider immediately if the client experiences:

Increasing pain at the injury site

A client with rheumatoid arthritis is scheduled to participate in an exercise program that is established at the extended care facility where the client resides. The nurse evaluates that the client understands the purpose of the program when the client states:

"After I eat breakfast, I do one set of exercises slowly, and then I space the rest of them throughout the day."

A client sustains a fractured right femur after an automobile accident and is admitted to the hospital's emergency department. How will the nurse assess this client for signs of circulatory impairment?

Take the client's pedal pulse in the affected extremity.

The nurse is getting a client out of bed to the chair for the first time since surgery 2 days ago. What is the most appropriate assessment the nurse should make first before moving the client?

Assessment of comfort and pain

The nurse teaches a client who developed degenerative joint disease of the vertebral column positioning techniques, including turning from back to side, keeping the spine straight. The nurse explains that the least effort will be exerted if the client crosses the arm over the chest and:

Bends the top knee to the side to which the client is turning

A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all that apply

Flaccid paralysis Lack of reflexes below the injury

Clients who have casts applied to the lower extremities must be monitored for complications. Which finding during assessment of the extremities of these clients is indicative of a complication? Select all that apply .

Numbness Prolonged capillary refill

Considerations when caring for a client with a total hip replacement should include which of the following? Select all that apply .

Pain control should include regularly scheduled analgesics and may necessitate use of as needed medications as well Frequent neurovascular assessment should be done distal to the surgical site and compared with the unaffected side. When turning, client should be log rolled to prevent leg from falling forward or backward.

Two weeks after sustaining a spinal cord injury, a client begins vomiting thick coffee-ground material and appears restless and apprehensive. What is the most important initial nursing action?

Prepare for insertion of a nasogastric tube.

A client with a ruptured appendix is scheduled for an appendectomy. Preoperatively, the nurse should place the client in which position?

Semi-Fowler

For which clinical indicator should the nurse assess a client who just had a microdiskectomy for a herniated lumbar disk?

Sensory loss in legs

After an open reduction and internal fixation of a fractured hip, what assessments of the client's affected leg should the nurse make? Select all that apply .

Skin temperature Sensation in the toes Presence of pedal pulse

A client had a cerebrovascular accident (also known as a "brain attack") and bed rest is prescribed. What can the nurse use to best prevent footdrop in this client?

Splints

A nurse is assessing an 18-month-old toddler with suspected developmental dysplasia of the left hip. In what position should the nurse place the toddler to elicit the Trendelenburg sign?

Standing on the affected leg

To reduce a hip fracture, the client is placed in traction before surgery for an open reduction and internal fixation. Because the client keeps slipping down in bed, increased countertraction is prescribed. How does the nurse increase the countertraction?

Use a slight Trendelenburg position.

When assessing the progress of a client being treated for myasthenia gravis, the nurse expects what change in muscle strength?

Fluctuating weakness of muscles innervated by the cranial nerves

What clinical finding does the nurse expect when assessing a client with myasthenia gravis?

Fluctuating weakness of muscles innervated by the cranial nerves.

A client with an above-the-knee amputation asks why the residual limb needs to be wrapped with an elastic bandage. The nurse explains the purpose is to:

Support the soft tissue and minimize swelling

The nurse is caring for a client with a long leg cast. Which clinical findings indicate compromised circulation? Select all that apply .

Swelling of the toes Prolonged capillary refill

A client with cholelithiasis has a laser laparoscopic cholecystectomy. Postoperatively it is most appropriate for the nurse to:

Ambulate the client when the client is alert and oriented

Which statement by a client with multiple sclerosis indicates to the nurse that the client needs further teaching?

I will take a hot bath to help relax my muscles.

The nurse is caring for a client with a distal femoral shaft fracture. For which clinical indicator unique to a fat embolus should the nurse assess the client?

Petechiae

A 7-year-old child was recently found to have juvenile idiopathic arthritis. The parents are concerned about the lifelong effects of the disorder and are investigating other therapies to use with the medications. What referral should the nurse recommend?

Physical therapy

A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the rationale for a high-protein diet is to:

A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the rationale for a high-protein diet is to:

An infant has developmental dysplasia of the hip. What clinical finding should the nurse expect to note during an assessment?

Apparent shortening of one leg

A client who had an above-the-knee amputation has an elastic bandage around the residual limb. The prescriptions include bathing the residual limb daily and rewrapping the elastic bandage as needed. What should the nurse do when wrapping the bandage on the client's residual limb?

Apply it smoothly without wrinkles or creases.

The nurse is caring for a client with a spinal cord injury who has paraplegia. The nurse can expect which major problem early in the recovery period?

Bladder control

A client is placed into a whirlpool tub for range-of-motion exercises. The nurse should explain that rehabilitating exercises carried out underwater use the water's:

Buoyant force

A nurse expects a client with a herniated intervertebral disk to report a sudden increase in pain with which activities? Select all that apply

Coughing or sneezing Straining when having a bowel movement

A cast is applied to the involved extremity of an infant with talipes equinovarus (clubfoot). The nurse tells the parents that they will have to bring their baby back to the clinic for a cast change:

Each week

A client has a below-the-knee amputation and asks why the prosthesis is applied immediately after surgery. The nurse informs the client that the primary reason is to:

Encourage a normal walking pattern

A client is admitted to the hospital after falling and fracturing a hip. The health care provider applies a Buck's boot with traction until surgery to replace the head of the femur with a prosthesis can be performed. What action can the nurse take to ensure that the Buck's traction is being applied correctly?

Hang the weight to apply traction, but limit it to eight pounds

A nurse is administering gold salts to a client with the diagnosis of rheumatoid arthritis. For which adverse effect of this drug should the client be monitored?

Kidney damage

A client who had an open reduction and internal fixation of a fractured ankle is being discharged. Which behavior indicates the need for further instruction about the use of crutches?

Leaning axillae on the crutches to support the body's weight

A client had a right above-the-knee amputation secondary to trauma sustained in a motor vehicle accident. Six days after surgery, the client falls while attempting to transfer to a chair unassisted. The nurse concludes that this fall is most likely the result of:

Loss of balance

A client had a total knee replacement several days ago and has been receiving warfarin sodium (Coumadin) therapy. An international normalized ratio (INR) is performed each afternoon, and the evening warfarin sodium dose is prescribed by the health care provider on a daily basis. The nurse identifies that the afternoon INR is 4.6. The next action the nurse should take is to:

Maintain the client on bed rest until the health care provider reviews the laboratory results.

A client is scheduled for a lumbar puncture. What nursing care should be implemented after the procedure?

Maintaining the client in the supine position for several hours

The plan of care for a client with osteoporosis includes active and passive exercises, calcium supplements, and daily vitamins. How does a nurse determine that the desired effect of therapy has been achieved?

Mobility increases

A client has a total hip replacement for long-standing degenerative bone disease of the hip. When assessing this client postoperatively, the nurse considers that the most common complication of hip surgery is:

Pulmonary embolism

A nurse is assessing an infant with talipes equinovarus (clubfoot) who has had a corrective boot cast applied. Which peripheral vascular assessment cannot be performed while the cast is in place?

Pulse

A client has a shoulder immobilizer after surgical repair of a fractured humerus. What should be included in the nurse's instruction to the client about the appropriate use of the immobilizer?

Release the wristband to exercise the forearm and hand routinely.

The health care provider prescribes one unit of packed red blood cells to be administered to the client who suffered a hip fracture. Several minutes after the start of the infusion, the client complains of itching. Upon further assessment, the nurse observes hives on the client's chest. Which action should the nurse take next?

Stop the transfusion immediately.

A client who has an above-the-knee amputation is fitted for a prosthesis. Two days after using the prosthesis, a small blister develops on the residual limb near the healed incision. The nurse anticipates that the client will be advised to:

Stop using the prosthesis until the blister heals

A client sustains a back injury after falling 20 feet. The nurse should place the client in what position?

Supine position while not allowing the spine to flex

Following an injury to the spinal cord, a client experiences severe headache, paroxysmal hypertension, diaphoresis, nausea, and bradycardia that characterize episodes of autonomic hyperreflexia (autonomic dysreflexia). The nurse recognizes that the episodes occur if the spinal injury is at or above a specific level of the spinal cord. Using the illustration, fill in the specific level of the spinal cord in the blank

T6 level

An x-ray film of a client's arm reveals a comminuted fracture of the radial bone. When determining an appropriate plan of care, the nurse recalls that with a comminuted fracture:

The bone has broken into several fragments and the skin is intact

After an above-the-knee amputation of a right leg, a client reports pain in the right foot. The nurse should inform the client that phantom limb pain is the result of:

Nerve endings in the limb that are still intact and react to stimuli.

Which clinical indicator does the nurse expect to identify when assessing a client admitted with a herniated lumbar disk?

Pain radiating to the hip and leg 2 Stiffness in shoulders

The left foot of a client with a history of intermittent claudication becomes increasingly cyanotic and numb. Gangrene of the left foot is diagnosed, and because of the high level of arterial insufficiency, an above-the-knee amputation (AKA) is scheduled. The response that demonstrates emotional readiness for the surgery is when the client:

Participates in learning perioperative care

A client's tibia is fractured in a motor vehicle accident, and a cast is applied. The nurse should assess for which manifestation indicating damage to major blood vessels caused by the fractured tibia?

Prolonged reperfusion of the toes after blanching