Mobility for musculoskeletal
10. in planning the postoperative care for a client with a cast, the nurse would select which of the following as an appropriate nursing diagnosis? 1. risk for deficient fluid volume related to excess fluid loss 2. total urinary incontinence: related to aging process 3. constipation related to decreased mobility 4. imbalanced nutrition: less than body requirements related to lack of knowledge of appropriate food choices
10. 3. constipation related to decreased mobility is an appropriate nursing diagnosis for a client with a cast.
9. A nurse places a patient with a sacral pressure ulcer in the left Sims position. How should the nurse position the patient's right arm? 1. On a pillow 2. Behind the back 3. With the palm up 4. In internal rotation
1. In the left Sims position the patient's right arm and leg are supported on pillows to prevent internal
17. the nurse assesses which of the following clinical manifestations in a client with osteomyelitis? select all that apply: [ ] 1. night sweats [ ] 2. cool extremities [ ] 3. petechiae [ ] 4. Fever [ ] 5. nausea [ ] 6. restlessness
17. 1. 4. 5. 6. osteomyelitis is an infection of the bone characterized by both local and systemic manifestations. systemic manifestations include fever, chills, night sweats, nausea, malaise, and restlessness.
1. A nurse is repositioning a patient to the left lateral position. What action should the nurse implement when positioning this patient? 1. Rest the right leg on top of the left leg 2. Maintain knee flexion at ninety degrees 3. Place the ankles in plantar flexion 4. Left shoulder protracted
1. 1. The right leg should be supported on a pillow in front of the left leg. 2. This excessive flexion can result in contractures of the hip and knee if permitted to remain in this position extensively. 3. The ankles should be maintained at 90 degrees. 4. In the left lateral (side-lying) position, the left arm is positioned in front of the body with the shoulder pulled forward (protracted). This reduces the pressure on the joint in the shoulder and the acromial process.
the nurse is caring for a client who just returned from surgery with a long leg cast. which of the following interventions is the priority in the first 24 hours? 1. position the client supine to facilitate drying of the cast 2. dangle the client on the side of the bed in the evening 3. elevate the leg on a pillow above heart level 4. assess the cast for rough edges and smoothness
1. 3. the priority nursing intervention for a client with a long leg cast in the first 24 hours is to elevate the extremity above the level of the heart by placing the leg on several pillows to prevent edema. the edges of the cast may be checked for smoothness or roughness.
1. the nurse explains to the client that which of the following drugs is the drug of choice in raynaud's phenomenon? 1. nonsteroidal anti-inflammatories 2. corticosteroids 3. aspirin 4. calcium-channel blockers
1. 4. the drugs of choice to treat raynaud's phenomenon are calcium-channel blockers, such as diltiazem (cardizem) and nifedipine (procardia). they are particularly useful in treating acute episodes, but are also used in chronic episodes. they relieve vasospastic attacks by relaxing the smooth muscles of the arterioles.
11. When the first class of drugs prescribed for rheumatoid arthritis fails, the nurse anticipates which category of drugs will be prescribed? 1. nonsteroidal anti-inflammatory 2. Disease-modifying antirheumatic 3. salicylates 4. biologic response modulators
11. 4. Disease-modifying antirheumatic drugs (DMarDs) are the first drugs used to try to reduce joint clinical manifestations in rheumatoid arthritis. biologic response modulators have a 66% success rate after failure with DMarDs.
29. A nurse must transfer a patient from a bed to a chair using a mechanical lift. What should the nurse do? 1. Ensure that there is a practitioner's order to move the patient using this device 2. Hook the longer straps on the end of the sling closest to the patient's feet 3. Place a sheepskin inside the sling so that it is under
2. The longer straps/chains go in the holes for the seat support, which keep the legs and pelvis below the upper body. Appropriate placement of the
21. A nurse is planning to help move a patient up in bed. What can the nurse do to reduce the risk of self-strain when performing this action? 1. Move the patient up against gravity 2. Use the large muscles of the legs 3. Bend the body from the waist 4. Keep the knees locked
2. To exert an upward lift the gluteal and leg muscles should be used, rather than the sacrospinal muscles of the back. These larger muscles fatigue less quickly, and their use protects the intervertebral disks.
22. the nurse is caring for a client with an open fracture. which of the following would be the priority to include in this client's treatment plan? 1. a high-protein diet 2. insertion of a Foley catheter 3. tetanus toxoid 4. passive range-of-motion exercises
22. 3. the priority nursing intervention for an open fracture in which the skin integrity is broken is to administer a tetanus toxoid. a high-protein diet would be important but not the priority.
26. a client with a fractured pelvis has a nursing diagnosis of impaired mobility related to bed rest, weakness, and traction. the nurse should inform the client that the rationale for maintaining good body alignment in the bed is to 1. decrease protein catabolism. 2. minimize the workload on the heart. 3. increase body strength and muscle mass. 4. reduce musculoskeletal strain and enhance lung expansion.
26. 4. Fractures cause damage to the affected bone, placing additional strain on the surrounding tissues, ligaments, and joints. traction places the affected bone in proper alignment to reduce the strain on the surrounding parts. a client who has bed rest ordered may have a rapid deconditioning resulting in decreased lung capacity and orthostatic hypotension. proper body alignment reduces the strain and increases lung expansion.
26. the nurse is preparing to delegate clinical assignments to a licensed practical nurse. Which of the following assignments may the nurse delegate? 1. instruct a client taking an opioid analgesic on the effects of sedation on reactive time 2. Monitor the white blood count and platelets in a client receiving interleukin-1 anakinra (kineret) 3. evaluate a client with rheumatoid arthritis on compliance with drug therapy 4. administer prednisolone (prelone) with food to a client with rheumatoid arthritis
26. 4. it is within the job description of a licensed practical nurse to administer prednisolone (prelone) with food. instructing a client taking an opioid analgesic on the effects of sedation, monitoring the white blood count and platelets of a client receiving interleukin-1 anakinra (kineret), and evaluating compliance with drug therapy are all clinical assignments that requ
27. a nurse is developing a care plan for a client with an open fracture of the femur. which of the following nursing diagnoses would the nurse choose as the priority nursing diagnosis? 1. risk for constipation related to immobilization 2. activity intolerance related to prolonged immobility 3. risk for impaired skin integrity related to immobility 4. impaired neurovascular status related to compression of nerves
27. 4. compression of the nerves is the most serious complication from an open fracture and is caused by edema or bone displacement. compression of nerves can cause cell death. risk for constipation, activity intolerance, and risk for impaired skin integrity are all important nursing diagnoses, but they are not the priority.
32. which of the following is a priority for the nurse to include in the preoperative teaching plan for a client scheduled for a total hip arthroplasty? 1. signs of prosthetic dislocation 2. Methods to prevent dehydration 3. exercises to promote hip flexion 4. Measures to prevent malnutrition
32. 1. when a hip is replaced, dislocation is a real problem; it is very important to teach the signs of dislocation to the client both preoperatively and postoperatively. dehydration and malnutrition are not usual manifestations of hip arthroplasty, and hip flexion is not a desired outcome. hip flexion can cause dislocation of the arthroplasty.
36. a client with systemic lupus erythematosus (sle) is admitted to a nursing unit. which of the following would indicate to the nurse that the client's condition is deteriorating? 1. a serum sodium of 145 meq/l 2. a serum potassium of 5.5 meq/l 3. large amounts of glucose in the urine 4. large amounts of protein in the urine
36. 4. protein in the urine indicates renal failure, and lupus nephritis is the number one cause of death in sle. serum sodium and potassium and glucose in the urine are not indicative of complications resulting from sle. a serum sodium level of 145 meq/l and a serum potassium level of 5.5 meq/l are normal.
19. A nurse in a community center is conversing with a group of older adults who voiced fears about falling. What is the most common consequence associated with older adults' fear of falling that the nurse should discuss with them? 1. Impaired skin integrity 2. Occurrence of panic attacks 3. Self-imposed social isolation 4. Decreased physical conditioning
4. Most falls occur when ambulating. Fear of falling results in the conscious choice not to place oneself in a position where a fall can occur. Disuse and muscle wasting cause a reduction of muscle strength at the rate of 5% to 10% per week so that within 2 months of immobility more than 50% of a muscle's strength can be lost. In addition, there is a decreased cardiac reserve. These responses result in decreased physical conditioning.
22. A patient with an order for bed rest has diaphoresis. What should the nurse use to best limit the negative effects of perspiration on dependent skin surfaces of this patient? 1. Ventilated heel protectors 2. Air-filled rings 3. Air mattress 4. Sheepskin
4. The soft tuffs of sheepskin allow air to circulate, thereby promoting the evaporation of moisture that can precipitate skin breakdown.
14. A patient is diagnosed with a stage IV pressure ulcer with eschar. Which medical treatment should the nurse anticipate the physician will order for this patient? 1. Heat lamp treatment three times a day 2. Application of a topical antibiotic 3. Cleansing irrigations twice daily 4. Débridement of the wound
4. Thick, leather-like, necrotic devitalized tissue (eschar) must be removed surgically or enzymatically before wound healing can occur.
25. Which nursing action is most effective in relation to the concept Immobility can lead to occlusion of blood vessels in areas where bony prominences rest on a mattress? 1. Encouraging the patient to breathe deeply 10 times per hour 2. Performing range-of-motion exercises twice a day 3. Placing a sheepskin pad under the sacrum 4. Repositioning the patient every 2 hours
4. Turning a patient relieves pressure on the capillary beds of the dependent areas of the body, particularly the skin
6. before a client has skin traction applied, which of the following should the nurse include in the instructions given to the client? 1. skin traction may be used for long periods of time 2. skin traction is applied until surgery can be performed 3. a pin will be put in the bone 4. weights up to 45 pounds will be applied
6. 2. the purpose of skin traction such as buck's, bryant's, russell, a pelvic belt, or a sling is simply to stabilize the affected part and maintain alignment until surgery or skeletal traction can be performed. skin traction is only a short-term treatment and generally for no longer than 48 to 72 hours. generally the weight for skin traction does not exceed 7 to 10 pounds.
7. in planning the post-op care for a client with a hip spica cast, the nurse should know that the best method of positioning this client would be to 1. maintain the client in a prone position. 2. use the support bar between the thighs to turn the client. 3. turn the client side to side and support with pillows. 4. allow the client to turn into any position that offers comfort.
7. 3. a client with a hip spica cast should be turned from side to side and supported with pillows. the prone position and turning the client by using the support bar are contraindicated because they can cause the cast to break.
12. Which of the following would be the best indicators to the nurse that a client receiving naprosyn for rheumatoid arthritis is experiencing adverse reactions from this drug? select all that apply: [ ] 1. tinnitus [ ] 2. blurred vision [ ] 3. confusion [ ] 4. headache [ ] 5. vasoconstriction [ ] 6. hypokalemia
12. 1. 2. 3. 4. naprosyn is a nonsteroidal antiinflammatory drug used in the treatment of musculoskeletal and soft tissue inflammatory disorders, such as rheumatoid arthritis. adverse reactions include headache, dizziness, blurred vision, confusion, tinnitus, and gastrointestinal upset. naprosyn results in vasodilation and hyperkalemia.
12. which of the following interventions would be appropriate for the nurse to include in the treatment plan of a client with a stump? 1. expose the stump to air for 20 minutes 2. generously apply lotion to the stump 3. administer skin care by rubbing with alcohol 4. scrub the stump daily to prevent infection
12. 1. Following an amputation, the stump is exposed to air for 20 minutes daily after washing to promote adequate drying. lotion and alcohol are contraindicated unless specifically prescribed by the physician. scrubbing a stump is strictly contraindicated. the stump should be gently cleansed.
13. a client who had an osteoarthritic knee replacement has been receiving ibuprofen (Motrin) and experiencing excellent pain relief with this drug. recently the client has been experiencing amblyopia, heartburn, nausea, and diarrhea. Which of the following would be the best nursing action for the nurse to include in this client's plan of care? 1. administer the Motrin with milk 2. give the Motrin 2 hours before meals 3. administer the Motrin with prescribed misoprostol (cytotec) 4. give the Motrin with aspirin 2 hours after meals
13. 3. the most appropriate nursing action for a client who verbalizes effective pain relief from a nonsteroidal anti-inflammatory (nsaiD) medication such as ibuprofen (Motrin) for osteoarthritis but is now complaining of gastrointestinal upset is to administer misoprostol (cytotec) in conjunction with the Motrin. cytotec is frequently given in conjunction with an nsaiD drug that is causing gastrointestinal upset. cytotec inhibits gastric acid secretion, has mucosal protective properties, and does not interfere with the efficacy of the Motrin. it is given for the duration that the nsaiD drug is taken. amblyopia (blurred vision) has no impact on the gastrointestinal upset. if a client experiences heartburn, nausea, and diarrhea, the nsaiD may be administered with food and milk. if no gastrointestinal upset is experienced, the nsaiD is given on an empty stomach.
13. the nurse is assisting a client to walk with a crutch for the first time after an amputation. which of the following indicates the nurse correctly understands the principles of crutch walking after an amputation? 1. instruct the client to remove the compression dressing before crutch walking 2. encourage the client to place the weight of the body on the axilla 3. administer an analgesic 30 minutes prior to crutch walking 4. assist the client to crutch walk for no more than 5 minutes
13. 4. initially following an amputation, crutch walking is limited to 5 minutes to avoid dependent edema. a client should never place weight on the axilla. this can compromise the nerve passing through the axilla. a compression dressing would not be removed prior to ambulation. administration of an analgesic 30 minutes prior to ambulation could cause sedation and predispose a client to a fall.
14. a client with rheumatoid arthritis is being treated with etanercept (enbrel). Which of the following statements by the nurse indicates the nurse understands the proper handling of this medication? 1. "i will mix the drug by injecting liquid into the vial of powder, swirl it, and inject the drug into the client's upper arm." 2. "i will take the prefilled syringe and warm it before injecting it into the client's upper arm." 3. "i will infuse the drug through a peripheral iv over a period of 2 hours." 4. "i will shake the prefilled syringe and inject it into the client's thigh."
14. 1. etanercept (enbrel) is an immunomodulator used in the treatment of moderate to severe rheumatoid arthritis for clients who have been unsuccessfully treated with one or more antirheumatic drugs. it comes in a vial as a powder. it must be liquefied by adding liquid and swirling to mix. it should not be shaken. it is injected into the upper arm, abdomen, or thigh.
14. because a client has bursitis, plans for nursing interventions should include 1. aggressive antibiotic therapy. 2. rest. 3. range-of-motion activities. 4. a high-protein diet.
14. 2. bursitis is inflammation of the bursa (small sacs of the connective tissues lined with synovial fluid). bursitis is generally the result of some kind of mechanical injury and is most successfully treated by rest.
15. The nurse raises a patient's arm over the head during range-of-motion exercises. What word should the nurse use when documenting exactly what was done during range-of-motion exercises? 1. Flexion 2. Supination 3. Opposition 4. Hyperextension
15. 1. The shoulder, a ball-and-socket joint, flexes by raising the arm from a position by the side of the body forward and upward to a position beside the head.
15. the nurse is admitting a client with rheumatoid arthritis. which of the following laboratory test results would the nurse evaluate as being elevated and used to monitor disease activity? 1. serum uric acid 2. erythrocyte sedimentation rate 3. bence jones protein 4. white blood cell count
15. 2. although no single laboratory test is used for rheumatoid arthritis, the erythrocyte sedimentation rate (ers) is elevated in over 80% of clients and is used to monitor disease activity and the response to treatment.
16. the nurse is caring for a client with gout. which of the following dietary selections should the nurse include in the dietary instructions? select all that apply: [ ] 1. salmon [ ] 2. Macaroni [ ] 3. sardines [ ] 4. cheese [ ] 5. spinach [ ] 6. venison
16. 2. 4. Foods high in purine are limited for a client with gout. gout is repeat arthritic episodes associated with high levels of serum uric acid. uric acid is the end product of purine catabolism. liver, salmon, sardines, venison, and sweetbreads are high in purine content. Macaroni and cheese are lower-purine food choices.
18. the nurse assists a client with osteoporosis to make which of the following menu selections? 1. scrambled eggs and a banana 2. bagel with cream cheese and half a grapefruit 3. 3 oz grilled chicken and a baked potato 4. sardines and cooked broccoli
18. 4. osteoporosis is characterized by a deterioration of bone and increased bone fragility. an adequate intake of calcium is essential in both the prevention and treatment of osteoporosis. Foods high in calcium include milk and milk products, sardines, salmon, and certain green leafy vegetables such as broccoli. eggs, fruits, poultry, and potatoes are poor calcium food choices.
19. the nurse expects to find which of the characteristic clinical manifestations in a client with osteoarthritis? 1. loss of function from bouchard's and heberden's nodes 2. joint pain that is relieved by rest 3. joint stiffness that is worse with activity 4. pain and stiffness that improve with humidity and low barometric pressure
19. 2. joint pain that is relieved by rest is characteristic of osteoarthritis. pain and stiffness are made worse with increased humidity and a low barometric pressure. heberden's nodes are bony overgrowths at the distal interphalangeal joints. bouchard's nodes involve the proximal interphalangeal joints. although these nodes are generally red, swollen, and tender, they do not cause a significant loss of function.
2. A nurse turns a patient's ankle so that the sole of the foot moves medially toward the midline. What word should the nurse use when documenting exactly what was done during range-of-motion exercises? 1. Inversion 2. Adduction 3. Plantar flexion 4. Internal rotation
2. 1. Inversion, a gliding movement of the foot, occurs by turning the sole of the foot medially toward the midline of the body. 2. Adduction occurs when an arm or leg moves toward and/or beyond the midline of the body. 3. Plantar flexion occurs when the joint of the ankle is in extension by pointing the toes of the foot downward and away from the anterior portion of the lower leg. 4. Internal rotation of a leg occurs by turning the foot and leg inward so that the toes point toward the other leg.
2. allopurinol (zyloprim) and colchicine have been prescribed for a client with gout and diabetes mellitus. Which of the following instructions should be given to this client? 1. blood glucose tests may not be valid 2. urine sugar tests may not be valid 3. protein restrictions can cause diabetic ketoacidosis 4. protein cannot be restricted so increased dosing of allopurinol may be required
2. 2. urine sugar tests may indicate false positives when taking gout medications. blood glucose testing is still accurate. protein restrictions do not cause diabetic ketoacidosis, and protein is not restricted for diabetic clients.
2. immediately after application of a plaster of paris cast, the client asks the nurse when weight bearing may begin. the most appropriate response by the nurse is which of the following? 1. "i do not know. i will ask your physician." 2. "it is all individualized based on how you feel." 3. "within 8 hours, you will be standing next to the bed." 4. "generally after 24 to 48 hours
2. 4. generally for 24 to 48 hours after direct cast application, direct weight bearing is contraindicated. after the 24- to 48-hour time frame, a walking heel will be applied to the cast.
31. A patient has been experiencing prolonged immobility because of a brain attack resulting in a coma. For which local response should the nurse monitor the patient? 1. Renal calculi 2. Contractures 3. Thrombophlebitis 4. Pathological fracture
2. A contracture is a localized response to immobility. When muscle fibers are not able to shorten or lengthen, eventually a permanent shortening of the muscles, tendons, and ligaments occurs.
5. A patient has hemiplegia as a result of a brain attack (cerebrovascular accident). Which complication of immobility is of most concern to the nurse? 1. Dehydration 2. Contractures 3. Incontinence 4. Hypertension
2. Contractures result from permanent shortening of muscles, tendons, and ligaments. Routine range-of-motion exercises and maintaining the body in functional alignment can prevent contractures.
34. A nurse identifies that a patient's pressure ulcer has just partial-thickness skin loss involving the epidermis and dermis. What stage pressure ulcer should the nurse document based on this assessment? 1. Stage I 2. Stage II 3. Stage III 4. Stage IV
2. In a stage II pressure ulcer the partial-thickness skin loss presents clinically as an abrasion, blister, or shallow crater.
30. An emaciated patient is at risk for developing a pressure ulcer. In which position should the nurse avoid placing the patient? 1. Low-Fowler 2. Side-lying 3. Supine 4. Prone
2. In the side-lying position the majority of the body weight is borne by the greater trochanter. The bone is close to the surface of the skin, with minimal overlying protective tissue.
33. A nurse is making an occupied bed. What should the nurse do to prevent plantar flexion? 1. Tuck in the top linens on just the sides of the bed 2. Place a toe pleat in the top linens over the feet 3. Let the top linens hang off the end of the bed 4. Use trochanter rolls to position the feet
2. Making a vertical or horizontal toe pleat at the foot of the bed over the patient's feet leaves room for the feet to move freely and avoids exerting pressure on the upper surface of the feet, thus minimizing plantar flexion.
18. A nurse is caring for a variety of patients, each experiencing one of the following problems. Which health problem places a patient at the greatest risk for complications associated with immobility? 1. Incontinence 2. Quadriplegia 3. Hemiparesis 4. Confusion
2. Quadriplegia, paralysis of all four extremities, places the patient at greatest risk for pressure ulcers because the patient has no ability to shift the body weight off of bony prominences or change position without total assistance.
7. A patient has a cast from the hand to above the elbow because of a fractured ulna and radius. After the cast is removed, the nurse teaches the patient active range-of-motion exercises. Which patient action indicates that further teaching is necessary? 1. Moves the elbow to the point of resistance 2. Keeps the elbow flexed after the procedure 3. Assesses the elbow's response after the procedure 4. Puts the elbow through its full range at least three times
2. This is undesirable because it contributes to a flexion contracture. Functional alignment is preferred because it minimizes stress and strain on muscles tendons, ligaments, and joints.
20. A nurse is evaluating an ambulating patient's balance. What factor about the patient is most important for the nurse assess? 1. Posture 2. Strength 3. Energy level 4. Respiratory rate
20. 1. Assessing posture will identify whether the patient's center of gravity is in the midline from the middle of the forehead to a midpoint between the feet and, therefore, balanced within the patient's base of support.
20. the nurse should include which of the following in the plan of care for a client who has rheumatoid arthritis for which methotrexate (rheumatrex) has been prescribed? 1. instruct the client to avoid sunlight 2. instruct the client to avoid engaging in strenuous exercise 3. Monitor the client for respiratory depression 4. restrict the client's fluid intake
20. 1. Methotrexate (rheumatrex) is a diseasemodifying antirheumatic drug (DMarD). exposure to the sunlight makes the skin more susceptible to adverse reactions of the sun, such as damage to the eye and sunburn, so the client should be advised to avoid sunlight and wear sunscreen and sunglasses. there are no indications that aerobic exercise causes any adverse events to occur with DMarD therapy. respiratory depression is not an adverse reaction to DMarDs. fluids should be encouraged to at least 2000 ml daily to ensure adequate hydration and prevent nephrotoxicity.
20. the nurse is admitting a client for possible systemic lupus erythematosus (sle). when assessing this client, the nurse understands that the most significant clinical manifestation present in sle is 1. petechiae on the abdomen. 2. low-grade afternoon fever. 3. discoid rash over the face and upper chest. 4. multiple ecchymoses over the body.
20. 3. a discoid (coinlike) rash is the classic dermatologic manifestation of systemic lupus erythematosus. it characteristically takes on a butterfly appearance.
21. When providing care to a client who is on dexamethasone (Decadron), the nurse should monitor the client for which of the following adverse reactions? select all that apply: [ ] 1. hyperglycemia [ ] 2. acne [ ] 3. hypotension [ ] 4. Dehydration [ ] 5. Menstrual irregularities [ ] 6. Depression
21. 1. 2. 5. adverse reactions to corticosteroids, such as dexamethasone (Decadron), include hyperglycemia, acne, menstrual irregularities, hypertension, edema, and euphoria.
21. the nurse evaluates a serum potassium of 4.0 meq/l to be in the normal range of .
21. 3.5-5.4 meq/l a normal serum potassium level is 3.5-5.4 meq/l.
22. Which of the following interventions should the nurse include in the plan of care for a client taking denosumab (prolia)? select all that apply: [ ] 1. administer subcutaneously in the upper arm, upper thigh, or abdomen every 6 months [ ] 2. administer 1000 mg calcium a day [ ] 3. instruct the client to take with food [ ] 4. instruct the client to avoid lying down for 30 minutes after receiving drug [ ] 5. administer 400 units of vitamin D every day [ ] 6. instruct the client to report chest pain, dizziness, and weakness of the arms or legs
22. 1. 2. 5. nursing interventions for denosumab (prolia) include administering it subcutaneously in the upper arm, upper thigh, or abdomen; administering 1000 mg of calcium daily; and administering 400 units of vitamin D daily. instructing the client to take the drug with food is an intervention for estrogen. avoiding lie down after administration of the drug for 30 minutes is an intervention for a bisphosphate. instructing the client to report leg pain, chest pain, dizziness, and weakness of the arms and legs is an intervention for estrogen.
23. A nurse is teaching a class to nursing assistants about how to care for patients who are immobile. What should the nurse include about why immobilized people develop contractures? 1. Muscles that flex, adduct, and internally rotate are stronger than weaker opposing muscles 2. Muscular contractures occur because of excessive muscle flaccidity 3. Muscle mass and strength decline at a progressive rate weekly 4. Muscle catabolism exceeds muscle anabolism
23. 1. The state of balance between muscles that serve to contract in opposite
23. the nurse should instruct a client that which of the following concepts are necessary to achieve good body mechanics and prevent pain and injury in a client at risk for falls and back pain? select all that apply [ ] 1. stamina [ ] 2. body alignment [ ] 3. nutrition [ ] 4. balance [ ] 5. coordinated movement [ ] 6. hydration
23. 2. 4. 5 body alignment, balance, and coordinated movement—sensors in muscles and joints tell the cerebellum and other parts of the brain where and how the arm or leg is moving and what position it is in (feedback results in balance with smooth, coordinated motion).
23. the nurse is caring for a client with a history of chronic gout. the nurse should understand that the client is to receive probenecid (benemid) for which of the following purposes? 1. slows uric acid production 2. Decreases inflammation 3. increases uric acid excretion 4. reduces pain
23. 3. probenecid (benemid) is an antigout drug that acts by inhibiting renal tubular reabsorption of uric acid, promoting uric acid excretion, and decreasing serum urate levels. allopurinol (zyloprim) slows uric acid production. colchicine acts by reducing the pain and inflammation.
24. a client is scheduled for an open reduction internal fixation (oriF) of a fracture. the nurse is explaining to the client why this procedure is necessary. which of the following is the primary reason for the nurse to give a client that best describes the purpose of the oriF? 1. "it is used when the client is in too much pain to do a closed reduction." 2. "it is completed whenever a client cannot maintain long-term immobility." 3. "it is necessary when no other realignment method can be completed." 4. "it is necessary when a cast would be too large to provide adequate mobility."
24. 3. when no other method, such as long-term immobility, can accomplish realignment for a fracture, open reduction internal fixation (oriF) will be completed. pain is evident in a fracture; however, with the medications available today, pain can usually be controlled enough to complete a closed reduction either under iv conscious sedation or with general anesthesia.
25. which of the following neurovascular complications should the nurse assess for after a fracture? select all that apply: [ ] 1. petechiae over all extremities [ ] 2. pallor [ ] 3. exaggerated extremity movement [ ] 4. decreased sensation distal to the fracture site [ ] 5. purulent drainage at the site of an open fracture [ ] 6. pulselessness
25. 2. 4. 6. neurovascular complications are assessed by a neurovascular check. clinical manifestations of a possible neurovascular problem include pain with passive motion, pallor, pulselessness, paresthesia, pressure, and paralysis. loss of sensation is an indication of paresthesia.
25. the nurse is discharging a client with osteoporosis who is to begin on alendronate (fosamax). Which of the following should the nurse include in the medication instructions? 1. take with food or within 30 minutes of eating 2. notify the physician if urinary retention develops 3. avoid taking within 2 hours of eating calcium-rich foods 4. avoid driving while taking the medication
25. 3. alendronate (fosamax) should not be taken with food or within 2 hours of calcium-rich foods. it is best if it is taken 30 minutes before food. urinary retention and sedation are not adverse reactions to fosamax.
26. A patient sits for excessive lengths of time in a wheelchair. Which sites should the nurse assess for skin breakdown in this patient? 1. Ischial tuberosities 2. Bilateral scapulae 3. Trochanters 4. Malleoli
26. 1. When in the sitting position, the hips and knees are flexed at 90 degrees and the body's weight is borne by the pelvis, particularly the ischial tuberosities, which are bony protuberances of the lower portion of the ischium. Using a wheelchair results in prolonged sitting unless interventions are implemented to promote local circulation.
28. Which is the earliest nursing assessment that indicates permanent damage to tissues because of compression of soft tissue between a bony prominence and a mattress? 1. Nonblanchable erythema 2. Circumoral cyanosis 3. Tissue necrosis 4. Skin abrasion
28. 1. Nonblanchable erythema refers to redness of intact skin that persists when finger pressure is applied. This is the classic sign of a stage I pressure ulcer.
28. the nurse has given discharge instructions to a client with an above-the-knee amputation who will be fitted with a prosthesis when healing is complete. which of the following statements by the client would indicate that the client has understood the instructions? 1. "i should lie on my abdomen for 30 minutes three or four times a day." 2. "i should change the limb sock when it becomes soiled or stretched out." 3. "i should use lotion on the stump to prevent drying and cracking of the skin." 4. "i should elevate the residual limb on a pillow several times a day to decrease edema."
28. 1. lying on the abdomen will help to make a wellrounded stump and prevent hip contractures. the limb sock should always be changed daily. lotion is never used on a stump. elevation is not a treatment of amputation. pressure on the stump and hip contractures are to be avoided.
29. the nurse assesses that a client has lower-extremity weakness on the left. what should the nurse observe the client doing to evaluate the client's ability to use a walker? 1. Moving both the walker and the left leg forward 6 inches, then moving the right leg while the body weight is supported by the arms and the left leg 2. Moving both the walker and the right leg forward 6 inches, then moving the left leg while the body weight is supported by the arms and the right leg 3. Moving the walker forward 12 inches, bearing the body weight on the arms and extremities, then walking up to the walker 4. Moving both the walker and the left leg forward 12 inches, then moving the right leg while the body weight is supported by the arms and the left leg
29. 1. a walker is a mechanical aid used for walking assistance by clients who need more support than a cane. instructions for use of a walker are to move the walker and affected leg ahead 6 inches, then move the stronger leg ahead, and repeat. arms bear the weight in the second step after the affected leg is moved forward 6 inches.
3. A nurse is transferring a patient from a bed to a wheelchair. What should the nurse do to quickly assess this patient's tolerance to the change in position? 1. Obtain a blood pressure 2. Monitor for bradycardia 3. Determine if the patient feels dizzy 4. Allow the patient time to adjust to the change in position
3. 1. Although a blood pressure reading may indicate the presence of hypotension, the blood pressure should be obtained before and after a transfer to allow a comparison to conclude that the hypotension is orthostatic hypotension.
3. the nurse should administer which of the following prescribed drugs to a client with rheumatoid arthritis who has severe joint involvement and a positive rheumatoid factor? 1. Methotrexate 2. naproxen (naprosyn) 3. acetylsalicylic acid (aspirin) 4. hydroxychloroquine sulfate (plaquenil)
3. 1. because of the serious adverse reactions, such as hepatotoxicity and bone marrow depression, methotrexate is reserved for severe rheumatoid arthritis with severe systemic involvement and a positive rheumatoid factor. laboratory monitoring must be obtained periodically throughout treatment. Methotrexate acts by facilitating a rapid anti-inflammatory response within days to weeks.
3. the client asks the nurse after a total hip replacement with a cemented prosthesis when ambulation and weight bearing may begin. the nurse bases the answer on the knowledge that weight bearing and ambulation 1. are permitted after 4 weeks. 2. are individualized and difficult to predict. 3. may begin with a walker the first postoperative day. 4. occur within 3 to 5 months.
3. 3. weight bearing and ambulation following a total hip replacement with a cemented prosthesis may begin with a walker the first postoperative day
17. A nurse plans to teach a patient with hemiparesis to use a cane. What should the nurse teach the patient to do? 1. Move forward 1 step with the weak leg first followed by the strong leg and cane 2. Adjust the cane height 12 inches lower than the waist 3. Hold the cane in the strong hand when walking 4. Look at the feet when walking
3. A cane is a hand-gripped assistive device; therefore, the hand opposite the hemiparesis should hold the cane. Exercises can strengthen the flexor and extensor muscles of the arms and the muscles that dorsiflex the wrist.
27. A nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? 1. Under the small of the back 2. Behind the knees when supine 3. Alongside the ilium to mid-thigh 4. In the palm of the hand with the fingers flexed
3. A trochanter roll is a rolled wedge, pillow, or sandbag placed by the lateral aspect of the leg between the iliac crest and knees to prevent external hip rotation.
37. An immobilized bed-bound patient is placed on a 2-hour turning and positioning program. What should the nurse explain to the patient as to why this program is important? 1. Support comfort 2. Promote elimination 3. Maintain skin integrity 4. Facilitate respiratory function
3. Compression of soft tissue greater than 32 mm Hg prevents capillary circulation and compromises tissue oxygenation in the compressed area. Turning the patient relieves the compression of tissue in dependent areas, particularly those tissues overlying bony prominences.
39. Nurses should monitor for which systemic responses in immobilized patients? Select all that apply. 1. _____ Plantar flexion contracture 2. _____ Hypostatic pneumonia 3. _____ Dependent edema 4. _____ Muscle atrophy 5. _____ Pressure ulcer
3. Decreased calf muscle activity and pressure of the bed on the legs allow blood to accumulate in the distal veins. The resulting increased hydrostatic pressure moves fluid out of the intravascular compartment into the interstitial compartment, causing edema. 4. Atrophy is a decrease in the size of a tissue or an organ as a result of inactivity or decreased function. After 24 to 36 hours of inactivity, muscles begin to lose their contractile strength and begin the process of atrophy.
12. A nurse is performing passive range-of-motion exercises for a patient who is in the supine position. Which motion occurs when the nurse bends the patient's ankle so that the toes are pointed toward the ceiling? 1. Supination 2. Adduction 3. Dorsal flexion 4. Plantar extension
3. Dorsal flexion (dorsiflexion) of the joint of the ankle occurs when the toes of the foot point upward and backward toward the anterior portion of the lower leg.
35. Which is the most important nursing action when assisting a patient to move from a bed to a wheelchair? 1. Lowering the bed to 2 inches below the height of the patient's wheelchair 2. Applying pressure under the patient's axillae areas when standing up 3. Letting the patient help as much as possible when permitted 4. Keeping the patient's feet within 6 inches of each other
3. Encouraging the patient to be as selfsufficient as possible ensures that the transfer is conducted at the patient's pace, promotes self-esteem, and decreases the physical effort expended by the nurse.
16. A patient with a history of thrombophlebitis should not have pressure exerted on the popliteal space. In what position should the nurse avoid placing this patient? 1. Prone 2. Supine 3. Contour 4. Trendelenburg
3. In the contour position the head of the bed and the knee gatch are slightly elevated. The elevated knee gatch puts pressure on the popliteal spaces. 4. In the Trendelenburg position the hips and knees are extended, which does not
11. A nurse concludes that a patient has the potential for impaired mobility. Which assessment reflects a risk factor that may have precipitated this conclusion? 1. Exertional fatigue 2. Sedentary lifestyle 3. Limited range of motion 4. Increased respiratory rate
3. Limited range of motion is associated with contracture formation and impaired mobility.
8. Which word is most closely associated with nursing care strategies to maintain functional alignment when patients are bed bound? 1. Endurance 2. Strength 3. Support 4. Balance
3. The line of gravity passes through the center of gravity when the body is correctly aligned; this results in the least amount of stress on the muscles, joints, and soft tissues. Bed-bound patients often need assistive devices such as pillows, sandbags, bed cradles, wedges, rolls, and splints to support and maintain the vertebral column and extremities in functional alignment.
10. A patient with impaired mobility is to be discharged within a week from the hospital. Which is the best example of a discharge goal for this patient? The patient will: 1. Understand range-of-motion exercises 2. Be taught range-of-motion exercises 3. Transfer independently to a chair 4. Be kept clean and dry
3. This is a patient-centered goal and measurable.
30. a client has been admitted to the hospital with a diagnosis of osteoporosis resulting in a compression fracture of the spine. the physician has ordered complete bed rest and has ordered a dietician consultation. which of the following is the priority for the dietician to include in the nutritional counseling? 1. protein intake should be increased to 50% of the calorie intake daily 2. vitamin d should be taken in the diet as food, not as an oral medication 3. calcium intake should be 1500 mg daily 4. calorie and fat intake should not exceed 1500 calories daily
30. 3. calorie, protein, and fat intake if adequate for sustaining health are not a concern in osteoporosis. it is true that getting vitamins in the food is best; however, if additional vitamin d is required, a supplement is good if the client gets at least 15 minutes of sunlight per day. calcium intake for women before menopause should be at least 1000 mg/day and after menopause should increase to at least 1500 mg/ day. in a client with osteoporosis at any age, adequate calcium intake is at least 1500 mg/day.
31. a student nurse asks the nurse what the normal serum sodium level is. the most appropriate response by the nurse is
31. 135-147 meq/l. a normal serum range is between 135 and 147 meq/l.
32. A patient prefers to remain in the low-Fowler position the majority of the time. What is the greatest potential problem associated with the low-Fowler position? 1. Pressure on the ischial tuberosities of the pelvis 2. Dorsiflexion contractures of the feet 3. External rotation of the hips 4. Adduction of the legs
32. 1. In the low-Fowler position, the majority of the body's weight is borne by portions of the pelvis: bony protuberances of the lower portion of the ischium (ischial tuberosities) and the
33. which of the following would be the priority nursing action after being unable to palpate the client's pedal pulse after an open reduction of a tibia fracture? 1. notify the physician of the inability to detect the pedal pulse 2. check the lower extremity for pallor 3. use a doppler to check for the pedal pulse 4. Measure both extremities for comparison
33. 3. to ensure that the circulation is intact when the pulse is not palpable, the nurse should use a doppler. it is inappropriate to notify the physician without collecting all the appropriate data. although checking the lower extremity pallor and measuring circumference will provide data of circulation, it does not ensure that a pedal pulse is present.
34. a client has received teaching on the use of a cane to assist with ambulation. which of the following statements by the client would indicate to the nurse that further teaching is needed? 1. "My elbows should be slightly bent when i use the cane." 2. "i should hold the cane on my unaffected side." 3. "a walker would be more difficult to use than a cane." 4. "while walking, i should have shoes and socks on at all times."
34. 3. the client should use the cane on the unaffected side. the elbow is held slightly flexed. there are different reasons to use a walker versus a cane; however, neither one is "better." shoes must be worn. never use socks alone. socks may be optional to wear with the shoes.
35. during an exercise session, the nurse assists the client to dorsiflex and plantarflex the foot. the client asks what kind of exercise this is. which of the following is the appropriate response by the nurse? 1. active range of motion 2. passive range of motion 3. isometric 4. isotonic
35. 2. passive range-of-motion is exercise conducted with the assistance of another individual. active range of motion is done by the client alone. isometric exercise involves resistance, and isotonic exercise does not use resistance.
36. A nurse places a patient in the orthopneic position. What is the primary reason for the use of this position? 1. Facilitate respirations 2. Support hip extension 3. Prevent pressure ulcers 4. Promote urinary elimination
36. 1. Sitting in the high-Fowler position and leaning forward allows the abdominal organs to drop by gravity, which promotes contraction of the diaphragm. The arms resting on an over-bed table increases thoracic excursion.
37. the registered nurse delegates which of the following nursing tasks to unlicensed assistive personnel? 1. perform active range-of-motion activities on a client who had a hip arthroplasty 2. reinforce the instruction given on how to perform a two-point crutch walk 3. instruct a client on how to use a walker 4. walk a client who has an ankle sprain to the bathroom
37. 4. unlicensed assistive personnel cannot reinforce instruction or provide instruction. performing active range-of-motion exercises on a client who had a hip arthroplasty is not an appropriate job assignment for unlicensed assistive personnel, and active range of motion is likely to dislocate the hip (particularly adduction). unlicensed assistive personnel may walk a client who has an ankle sprain to the bathroom.
38. which of the following crutch gaits should the nurse instruct the client to use who has bilateral paralysis of the hips and legs? 1. swing-to gait 2. Four-point gait 3. three-point gait 4. two-point gait
38. 1. a swing-to gait is a crutch gait that is used by clients who have paralysis of the hips and legs or wear bilateral braces on the legs. a fourpoint gait may be used by arthritic clients. a three-point gait may be used by a client with a broken leg or sprained ankle. a two-point gait requires more weight bearing on each foot. it is a faster crutch gait than a four-point gait.
39. which of the following should the nurse include when instructing a client with crutches on the two-point gait? 1. Move the right crutch followed by the left foot, then move the left crutch forward followed by the right foot 2. Move both crutches forward together and bring the legs through beyond the crutches 3. Move the left crutch and right foot forward together, followed by moving the right crutch and the left foot forward together 4. Move both crutches and the weaker leg forward, followed by moving the stronger leg forward
39. 3. when using the two-point gait, the left crutch and right foot are moved forward together, followed by moving the right crutch and left foot forward together. the crutch walk requires some weight bearing on each foot. during the four-point gait, the right crutch is moved forward followed by the left foot, then the left crutch is moved forward followed by the right foot. this is the most stable of all crutch walks. it provides the most support while requiring weight bearing on both legs. this gait may be used for some types of paralysis, such as in children with cerebral palsy. in the three-point gait, both crutches are moved forward with the weaker leg, followed by moving the stronger leg forward. in this gait, the client is required to bear all weight on the unaffected leg. in the swing-to gait, both crutches are moved forward together followed by bringing the legs through beyond the crutches. this gait is used by clients who have a paralysis of their lower extremities.
4. the nurse is caring for a client who has a compression dressing in place after an amputation. the nurse appropriately removes the dressing 1. for bathing and physical therapy. 2. when getting the client into a chair. 3. for 2 hours once a shift. 4. when the pain has stopped.
4. 1. the compression dressing that is applied immediately following surgery is only removed for bathing and physical therapy. the purpose of the compression dressing is to support the soft tissues while reducing edema and promoting limb shrinkage to ensure a good prosthetic fit at a later date
6. Which stage pressure ulcer requires the nurse to measure the extent of undermining? 1. Stage 0 2. Stage I 3. Stage II 4. Stage III
4. In a stage III pressure ulcer there is fullthickness skin loss involving damage to subcutaneous tissue that may extend to the fascia and there may or may not be undermining, which is tissue destruction underneath intact skin along wound margins.
38. What do nurses sometimes do that increase their risk for injury when moving patients? 1. Use the longer, rather than the shorter, muscles when moving patients 2. Place their feet wide apart when transferring patients 3. Pull rather than push when turning patients 4. Misalign their backs when moving patients
4. Misaligning the back when moving patients occurs most often when not facing the direction of the move. Twisting (rotation) of the thoracolumbar spine and flexion of the back place the line of gravity outside the base of support, which can cause
24. The nurse turns the palm of a patient's hand downward when performing range-ofmotion exercises. What word should the nurse use when documenting exactly what was done? 1. External rotation 2. Circumduction 3. Lateral flexion 4. Pronation
4. Pronation of the hand occurs by rotating the hand and arm so that the palm of the hand is facing down toward the floor.
4. A nurse is transferring a patient from the bed to a wheelchair using a mechanical lift. Which is a basic nursing intervention associated with this procedure? 1. Lock the base lever in the open position when moving the mechanical lift 2. Raise the mechanical lift so that the patient is six inches off the mattress 3. Keep the wheels of the mechanical lift locked throughout the procedure 4. Ensure the patient's feet are protected when on the mechanical lift
4. The legs dangle from the sling and therefore may drag across the linens or hit other objects if not protected.
40. the nurse should include which of the following in the teaching plan for a client who has a cane prescribed? 1. Move the cane forward 2 feet to ensure that the body weight is supported on both legs 2. hold the cane with the hand on the weaker side of the body 3. position the arm holding the cane so the elbow is completely straight to ensure maximum support 4. position the cane 6 inches to the side and 6 inches to the front of the foot of the strongest leg
40. 4. to provide a wide base of support, the cane should be positioned both 6 inches to the side and 6 inches to the front of the foot of the strongest leg. the cane should be held on the stronger side of the body. the elbow is bent to correctly use a cane. a cane is not an appropriate assistive device for someone with bilateral leg weakness.
5. the nurse is discharging a client with rheumatoid arthritis who complains of morning stiffness. which of the following measures should the nurse include in the discharge instructions? 1. encourage the client to sleep with pillows under the knees 2. instruct the client to apply ice packs to the joints before getting out of bed 3. instruct the client to take a warm shower in the morning when getting up 4. teach the client to perform all of the household chores at one time
5. 3. Morning stiffness is a common complaint of clients with rheumatoid arthritis because of the limited joint movements. a warm shower upon arising is recommended to increase mobility and decrease discomfort associated with the limited mobility. cold packs may be used during exacerbations of the disease, but heat is most effective to relieve stiffness. the work of cleaning the house should be spread out throughout the week and not done at one time.
8. which of the following dietary guidelines should the nurse provide to a client with a fracture? 1. three large, high-calorie meals 2. high-fiber foods and 2000 to 3000 ml of fluids daily 3. low-protein and low-fat foods 4. limit milk and milk products to two servings daily
8. 2. although three well-balanced meals are encouraged following a fracture, an excessive calorie intake is to be avoided because of the limited mobility that predisposes the client to weight gain. a high-fiber diet and increased fluid intake are necessary to prevent constipation. adequate protein and calcium intake must be maintained to ensure adequate healing.
9. which of the following changes in a client's neurovascular assessment should be reported as a critical sign of arterial insufficiency? 1. pale extremity that is cool to touch 2. hypersensation below the injury 3. pain unrelieved by analgesic 4. reduced motion in affected extremity
9. 1. a pale and cool extremity following a musculoskeletal injury is the classic indication of arterial insufficiency and must be immediately reported. hypersensation below the injury as well as other abnormal sensations may be experienced, but they are not the priority finding. an evaluation of a potential problem including a comparison of the affected and unaffected extremity will prove beneficial. pain unrelieved by analgesics is indicative of compartment syndrome. reduced movement in the affected extremity should be investigated as potential damage to the motor component of the affected nerves.