Muscoloskeletal

A client has had a brace prescribed to facilitate recovery from a knee injury. What are the potential therapeutic benefits of a brace? Select all that apply. Preventing additional injury Immobilizing prior to surgery Providing support Controlling movement Promoting bone remodeling

Controlling movement Preventing additional injury Providing support

When completing a Neurovascular check, we look for the 6 "P"s. What are they?

pain poikilothermia pallor pulselessness paresthesia paralysis

The nurse is assessing a client for dietary factors that may influence her risk for osteoporosis. The nurse should question the client about her intake of what nutrients? Select all that apply. Calcium Simple carbohydrates Vitamin D Proteiin Soluble fiber

Calcium Vitamin D A client's risk for osteoporosis is strongly influenced by vitamin D and calcium intake. Carbohydrate, protein, and fiber intake do not have direct effect on the development of osteoporosis.

A client is reporting pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the client states the pain is unrelieved. The nurse should identify the warning signs of what complication? Subcutaneous emphysema Skin breakdown Compartment syndrome Disuse syndrome

Compartment syndrome Compartment syndrome may manifest as unrelenting, uncontrollable pain. This presentation of pain is not suggestive of disuse syndrome or skin breakdown. Subcutaneous emphysema is not a complication of casting.

A nurse is caring for a client who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the client's statements would indicate to the nurse that the client requires further teaching? "I'll need to keep several pillows between my legs at night." "I need to remember not to cross my legs. It's such a habit." "The occupational therapist is showing me how to use a 'sock puller' to help me get dressed." "I will need my husband to assist me in getting off the low toilet seat at home."

"I will need my husband to assist me in getting off the low toilet seat at home." To prevent hip dislocation after a total hip replacement, the client must avoid bending the hips beyond 90 degrees. Assistive devices, such as a raised toilet seat, should be used to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Likewise, teaching the client to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a client get dressed without flexing the hips beyond 90 degrees.

A client has returned to the postsurgical unit from the PACU after an above-the-knee amputation of the right leg. Results of the nurse's initial postsurgical assessment were unremarkable but the client has called out. The nurse enters the room and observes copious quantities of blood at the surgical site. What should be the nurse's initial action? Apply a tourniquet Elevate the residual limb Apply sterile gauze Call the surgeon

Apply a tourniquet The nurse should apply a tourniquet in the event of postsurgical hemorrhage. Elevating the limb and applying sterile gauze are likely insufficient to stop the hemorrhage. The nurse should attempt to control the immediate bleeding before contacting the surgeon.

The nursing care plan for a client in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)? Increased warmth of the calf Decreased circumference of the calf Loss of sensation to the calf Pale-appearing calf

Increased warmth of the calf Signs of DVT include increased warmth, redness, swelling, and calf tenderness. These findings are promptly reported to the physician for definitive evaluation and therapy. Signs and symptoms of a DVT do not include a decreased circumference of the calf, a loss of sensation in the calf, or a pale-appearing calf.

A client with a fractured femur is in balanced suspension traction. The client needs to be repositioned toward the head of the bed. During repositioning, what should the nurse do? a.Place slight additional tension on the traction cords b.Release the weights and replace them immediately after positioning c.Reposition the bed instead of repositioning the client d.Maintain consistent traction tension while repositioning

Maintain consistent traction tension while repositioning Traction is used to reduce the fracture and must be maintained at all times, including during repositioning. It would be inappropriate to add tension or release the weights. Moving the bed instead of the client is not feasible.

The child has a newly applied fiberglass hip-spica cast. Which interventions should the nurse implement? Select all that apply. Use a hairdryer on a high heat setting to help dry the cast. Place on a Bradford frame for elevation off the bed/ Place pillows to support the child's lower extremities Turn the child every 2 hours and monitor the CMS Petal the perineal area and other edges of the cast

Place pillows to support the child's lower extremities Turn the child every 2 hours and monitor the CMS Petal the perineal area and other edges of the cast

A 9-year-old is in a spica cast and complains of pain 1 hour after receiving intravenous opioid analgesia. What should the nurse do first? Give more pain mediction. Preform a neuromuscular assessment. Call the surgeon for orders. Change the child's position.

Preform a neuromuscular assessment. The nurse looks for the source of the pain by performing a neuromuscular assessment first.

A 6-year-old involved in a bicycle crash has a spleen injury and right tibia/fibia fracture that has been casted. Which is an early sign of compartment syndrome in this child? Edema Numbness Severe pain Weak pulse Anular rash

Severe pain Edema Edema and pain are early signs of compartment syndrome. 2,4,5- incorrect numbness and tingling are late signs, weak pulse is late sign, there is no rash with early compartment syndrome

Six weeks after an above-the-knee amputation (AKA), a client returns to the outpatient office for a routine postoperative checkup. During the nurse's assessment, the client reports symptoms of phantom pain. What should the nurse tell the client to do to reduce the discomfort of the phantom pain? Apply intermittent hot compresses to the area of the amputation Avoid activity until the pain subsides Take opioid analgesics as prescribed Elevate the level of the amputation site

Take opioid analgesics as prescribed Opioid analgesics may be effective in relieving phantom pain. Heat, immobility, and elevation are not noted to relieve this form of pain.

While assessing a 3-year-old child with a recent injury to the right leg that is refusing to walk, the nurse notices swelling in the right thigh. What should the nurse do first? Obtain vital signs Administer pain medictation Assess the neurovascular status of the toes on the right foot. Notify HCP provider immediately

Assess the neurovascular status of the toes on the right foot. When extremity injury has occurred you need to assess for neurological damage with the injury. You will do the other items but first you assess the child.

A client with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, the client reports a new onset of pain at the surgical site. What is the nurse's best action? Administer pain medication as prescribed Assess the surgical site and the affected extremity Reassure the client that pain is a direct result of increased activity Assess the client for signs and symptoms of systemic infection

Assess the surgical site and the affected extremity Worsening pain after a total hip replacement may indicate dislocation of the prosthesis. Assessment of pain should include evaluation of the wound and the affected extremity. Assuming he's anxious about discharge and administering pain medication do not address the cause of the pain. Sudden severe pain is not considered normal after hip replacement. Sudden pain is rarely indicative of a systemic infection.

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this client? Select all that apply. Systemic infection Complex regional pain syndrome Compartment syndrome Deep vein thrombosis Fat embolism

Compartment syndrome Deep vein thrombosis Fat embolism

The nurse is preparing to teach a child who has Cerebral Palsy (CP). What is the most important factor for the nurse to consider when teaching the child? Current age Type of cerebral palsy Prior illness experience Developmental level

Developmental level Developmental level is the most important to consider when preparing to teach the child with CP. Many children with CP have some degree of cognitive impairment.

A nurse is performing a shift assessment on an elderly client who is recovering after surgery for a hip fracture. The client reports chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the client is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this client is likely demonstrating symptoms of what complication? Avascular necrosis of bone Fat embolism syndrome Compartment syndrome Complex regional pain syndrome

Fat embolism syndrome Fat embolism syndrome occurs most frequently in young adults and elderly clients who experience fractures of the proximal femur (i.e., hip fracture). Presenting features of fat embolism syndrome include hypoxia, tachypnea, tachycardia, and pyrexia. The respiratory distress response includes tachypnea, dyspnea, wheezes, precordial chest pain, cough, large amounts of thick, white sputum, and tachycardia. Avascular necrosis (AVN) occurs when the bone loses its blood supply and dies. This does not cause coughing. Complex regional pain syndrome does not have cardiopulmonary involvement.

Which would the nurse teach an adolescent is a complication of corticosteroids used in the treatment of juvenile idiopathic arthritis (JIA)? Fat loss Adrenal stimulation Immune suppression Hypoglycemia

Immune suppression Steroids cause immune suppression; which is the reason behind its use in IJA; it reduces the body's attack on itself. Incorrect- 1- causes fat deposit- back, face, trunk, primary areas 2-adrenal suppression with steroid use because the exogenous steroid causes the body to lower production of its own steroid 4- steroids cause hyperglycemia

The nurse's comprehensive assessment of an older adult involves the assessment of the client's gait. How should the nurse best perform this assessment? nstruct the client to walk heel to toe for 15 to 20 steps Instruct the client to walk away from the nurse for a short distance and then toward the nurse Instruct the client to walk in a straight line while not looking at the floor Instruct the client to balance on one foot for as long as possible and then walk in a circle around the room

Instruct the client to walk away from the nurse for a short distance and then toward the nurse Gait is assessed by having the client walk away from the examiner for a short distance. The examiner observes the client's gait for smoothness and rhythm. Looking at the floor is not disallowed and gait is not assessed by observing balance on one leg. Heel-to-toe walking ability is not gauged during an assessment of normal gait.

The nurse is caring for a 13-year-old boy in traction prior to surgery for slipped capital femoral epiphysis. He has been in an acute care setting for 2 weeks and will require an additional 10 days in the hospital. He is complaining that he feels isolated and is resisting further treatment. Which response by the nurse would be most appropriate? I know it is boring, but you must remain immobile for 2 more weeks. If there are no complications, you only have 2 more weeks here. Let's come up with things to do like books, movies, games, and friends to visit. If you resist your treatment, your condition will only get worse.

Let's come up with things to do like books, movies, games, and friends to visit. After 2 weeks in traction, a teenager can become easily bored and isolated from usual peer interaction. The most helpful intervention would be to engage the help of the child to develop a list of books, games, movies, and other activities that he would enjoy. The nurse should also encourage visitation and phone calls from friends. Telling the adolescent that he needs to remain immobile or telling him that he has only 2 more weeks do not address the adolescent's issue. Telling the adolescent that his condition will worsen if he resists is threatening and inappropriate.

A client was fitted with an arm cast after fracturing her humerus. Twelve hours after the application of the cast, the client tells the nurse that her arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action? Prepare the client for opening or bivalving of the cast Obtain a prescription for a different analgesic Encourage the client to wiggle and move the fingers Petal the edges of the client's cast

Prepare the client for opening or bivalving of the cast

A nurse is assessing the neurovascular status of a client who has had a leg cast recently applied. The nurse is unable to palpate the client's dorsalis pedis or posterior tibial pulse and the client's foot is pale. What is the nurse's most appropriate action? Warm the client's foot and determine whether circulation improves Reposition the client with the affected foot dependent Reassess the client's neurovascular status in 15 minutes Promptly inform the primary provider

Promptly inform the primary provider Signs of neurovascular dysfunction warrant immediate medical follow-up. It would be unsafe to delay. Warming the foot or repositioning the client may be of some benefit, but the care provider should be informed first.

A nurse is providing discharge education to a client who is going home with a cast on his leg. What topic should the nurse emphasize in the teaching session? Using crutches efficiently Exercising joints above and below the cast, as prescribed Removing the cast correctly at the end of the treatment period Reporting signs of impaired circulation

Reporting signs of impaired circulation Reporting signs of impaired circulation is critical; signs of impaired circulation must be reported to the physician immediately to prevent permanent damage. For this reason, this education is a priority over exercise and crutch use. The client does not independently remove the cast.

An 18-month-old was brought to the emergency department by her mother, who states, I think she broke her arm. The child is sent for a radiograph to confirm the fracture. Additional assessment of the child leads the nurse to suspect possible child abuse. Which type of fracture would the radiograph most likely reveal? Plastic deformity Buckle fracture Spiral fracture Greenstick fracture

Spiral fracture A spiral fracture is very rare in children. A spiral femoral or humeral fracture, particularly in a child younger than 2 years of age, should always be thoroughly investigated to rule out the possibility of child abuse. Plastic, buckle, and greenstick fractures are common in children and do not usually suggest child abuse.

The child with hip pain for several months was diagnosed with Legg-Calve-Perthes disease. What should the nurse emphasize when preparing to teach the child and family about the treatment? Once treatment starts, it will likely continue for about 6 months. The treatment goal is a pain-free joint with full range of motion. Activities requiring hip adduction are encouraged for joint placement. Most of the treatments will be completed while the child is hospitalized.

The treatment goal is a pain-free joint with full range of motion. 2- Legg-Calve-Perthes disease is avascular necrosis of the proximal femoral epiphysis occurring in association with incomplete clotting factors. The treatment goal is a pain-free joint with full ROM Incorrect- 1- Treatment will likely last as long as 2 years 3-activites require abduction not adduction to promote proper joint placement 4-Most treatment will occur in the community-based settings rather than during hospitalization

A client has just had an arthroscopy performed to assess a knee injury. What nursing intervention should the nurse perform following this procedure? Wrap the joint in a compression dressing Perform passive range of motion Maintain the knee in flexion for up to 30 minutes Apply heat to the knee

Wrap the joint in a compression dressing Interventions to perform following an arthroscopy include wrapping the joint in a compression dressing, extending and elevating the joint, and applying ice or cold packs. Passive ROM exercises, static flexion, and heat are not indicated.

A client was brought to the emergency department after a fall. The client is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize? "Make sure you don't bring your knees close together." "Try to lie as still as possible for the first few days." "Try to avoid bending your knees until next week." "Keep your legs higher than your chest whenever you can."

"Make sure you don't bring your knees close together." After receiving a hip prosthesis, the affected leg should be kept abducted. Mobility should be encouraged within safe limits. There is no need to avoid knee flexion and the client's legs do not need to be higher than the level of the chest.

The nurse is teaching the parents about how to care for their infant with osteogenesis imperfecta (OI). Which statement should the nurse include in the instructions? "Check the color of your infant's nailbeds and mucus membranes for signs of circulatory impairment." "If you note signs of infection, bring your infant to the clinic because the infant has a significant immune dysfunction." "Protect your infant from injury and handle your baby carefully because your infant's bones can break very easily." "Notify your physician if your infant does not respond to sound because the infant's CNS fails to develop completely."

"Protect your infant from injury and handle your baby carefully because your infant's bones can break very easily." 3-With OI, also known as brittle bone disease, the infant should be handled carefully and protected from injury. The nurse should include this statement when teaching the parents. OI does not result in immune dysfunction, OI is not a disease affecting the circulatory system, OI is not a disease of the CNS

A nurse is assessing a client who is experiencing peripheral neurovascular dysfunction. What assessment findings are most consistent with this diagnosis? Hot skin with a capillary refill of 1 to 2 seconds Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin Pain, diaphoresis, and erythema Jaundiced skin, weakness, and capillary refill of 3 seconds

Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin Indicators of peripheral neurovascular dysfunction include pale, cyanotic, or mottled skin with a cool temperature; capillary refill greater than 3 seconds; weakness or paralysis with motion; and paresthesia, unrelenting pain, pain on passive stretch, or absence of feeling. Jaundice, diaphoresis, and warmth are inconsistent with peripheral neurovascular dysfunction.

The HCP is adducting the newborn's hip while pushing the thigh forward to detect developmental dysplasia of the hip (DDH). The nurse should identify this screening test as which maneuver? Barlow maneuver Pavlik maneuver Gowers maneuver Allis maneuver

Barlow maneuver - The barlow maneuver is performed by adducting the hip while pushing the thigh posterior. If the hip goes out of the socket, it is called "dislocatable" and is positive for DDH Incorrect- No pavlik maneuver= there is pavlik brace Gowers maneuver is used by children with MD to stand Allis maneuver is used with children who can respond to positional instruction

An elderly female with osteoporosis has been hospitalized. Prior to discharge, when teaching the client, the nurse should include information about which major complication of osteoporosis? Bone fracture Loss of estrogen Negative calcium balance Dowager hum

Bone fracture Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increases the fragility of bones. Estrogen deficiencies result from menopause, not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, but a negative calcium balance is not a complication of osteoporosis. Dowager hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature.

The nurse is teaching parents of a child with juvenile arthritis. How should the nurse explain the purpose of methotrexate in treating their child? Improves functional ability Controls the febrile seizures Minimizes the effects of uveitis Decreases the inflammatory response

Decreases the inflammatory response Methotrexate (Trexall) is an immunosuppressant that decreases the inflammatory response. It is categorized as a disease-modifying drug. Incorrect- 1- while decreasing the inflammation may improve fuctional ability, it is not the action of the drug 2- fever may be a sign of methotrexate toxicity 3- uveitis is a nonspecific term for any intraocular inflammatory disorder and is thought to be an autoimmune phenomenon; corticosteroids are prescribed for treating vuvetitis not methotrexate.

The school nurse assesses that the 6-year-old child who is crying and in pain sustained a twisting injury of the right arm. What interventions should the nurse implement? Select all that apply. Elevate the arm and apply ice at the site of the child's injury Wrap the child's arm with an elastic bandage. Telephone the child's parent to discuss the injury. Meet with the student who caused the injury Call the health care provider identified by the child

Elevate the arm and apply ice at the site of the child's injury Wrap the child's arm with an elastic bandage. Telephone the child's parent to discuss the injury.

A nurse is caring for a client who is 12 hours postoperative following foot surgery. The nurse assesses the presence of edema in the foot. What nursing measure should the nurse implement to control the edema? Elevate the foot on several pillows Apply warm compresses intermittently to the surgical area Administer a loop diuretic as prescribed Increase circulation through frequent ambulation

Elevate the foot on several pillows To control the edema in the foot of a client who experienced foot surgery, the nurse will elevate the foot on several pillows when the client is sitting or lying. Diuretic therapy is not an appropriate intervention for edema related to inflammation. Intermittent ice packs should be applied to the surgical area during the first 24 to 48 hours after surgery to control edema and provide some pain relief. Ambulation will gradually be resumed based on the guidelines provided by the surgeon.

A nurse is caring for a client who has a leg cast. The nurse observes that the client uses a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation? Allow the client to continue to scratch inside the cast with a pencil but encourage him to be cautious Give the client a sterile tongue depressor to use for scratching instead of the pencil Encourage the client to avoid scratching, and obtain a prescription for an antihistamine if severe itching persists Obtain a prescription for a sedative, such as lorazepam , to prevent the client from scratching

Encourage the client to avoid scratching, and obtain a prescription for an antihistamine if severe itching persists Scratching should be discouraged because of the risk for skin breakdown or damage to the cast. Most clients can be discouraged from scratching if given a mild antihistamine, such as diphenhydramine, to relieve itching. Benzodiazepines would not be given for this purpose.

The nurse is developing a plan of care for a child recently diagnosed with cerebral palsy (CP). Which should be the nurse's priority goal? Ensure the ingestion of sufficient calories for growth Decrease intracranial pressure Teach appropriate parenting strategies for a special-needs child. Ensure that the child reaches full potentia

Ensure that the child reaches full potential. 4-A child with CP needs a health-care team that can aid the family in helping them grow and develop to their full potential. The priority for all children is to develop to their full potential. Incorrect Choices- 1-adequate calories is appropriate but not the priority. 2- Children with CP do not have increased ICP 3-Teaching appropriate parenting strategies for a special-needs child is important and is done so that the child can maximize their personal skills and minimize their limitations.

A nurse is caring for a client who has suffered a hip fracture and who will require an extended hospital stay. The nurse should ensure that the client does what action to prevent common complications associated with a hip fracture? Avoid requesting analgesia unless pain becomes unbearable Use supplementary oxygen when transferring or mobilizing Increase fluid intake and perform prescribed foot exercises Remain on bed rest for 14 days or until instructed by the orthopedic surgeon

Increase fluid intake and perform prescribed foot exercises Deep vein thrombosis (DVT) is among the most common complications related to a hip fracture. To prevent DVT, the nurse encourages intake of fluids and ankle and foot exercises. The client should not be told to endure pain; a proactive approach to pain control should be adopted. While respiratory complications commonly include atelectasis and pneumonia, the use of deep-breathing exercises, changes in position at least every 2 hours, and the use of incentive spirometry help prevent the respiratory complications more than using supplementary oxygen. Bed rest may be indicated in the short term, but is not normally required for 14 days.

An older adult client sought care for the treatment of a swollen, painful knee joint. Diagnostic imaging and culturing of synovial fluid resulted in a diagnosis of septic arthritis. The nurse should prioritize what aspect of care? Administration of oral and IV corticosteroids as prescribed Prevention of falls and pathologic fractures Maintenance of adequate serum levels of vitamin D Intravenous administration of antibiotics

Intravenous administration of antibiotics IV antibiotics are the major treatment modality for septic arthritis; the nurse must ensure timely administration of these drugs. Corticosteroids are not used to treat septic arthritis and vitamin D levels are not necessarily affected. Falls prevention is important, but septic arthritis does not constitute the same fracture risk as diseases with decreased bone density.

A newborn is diagnosed with metatarsus adductus. The parents ask the nurse how this occurred. Which response by the nurse would be most appropriate? This condition is due to a genetic defect in the bones. It's most likely from how the baby was positioned in utero. They really don't know what causes this condition. There is probably an underlying deformity of the baby's hip.

It's most likely from how the baby was positioned in utero. Metatarsus adductus is a medial deviation of the forefoot that occurs as a result of in utero positioning. Osteogenesis imperfecta is a genetic bone disorder. The underlying cause of congenital clubfoot is not known. Developmental dysplasia of the hip involves a deformity of the newborn's hip.

The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply. Keep small toys and sharp objects away from the cast. Use a padded ruler or another padded object to scratch the skin under the cast if it itches. Elevate the extremity on pillows for the first 24-48 hours after casting to prevent swelling. Contact the HCP if the child complains of numbness or tingling in the extremity.

Keep small toys and sharp objects away from the cast. Elevate the extremity on pillows for the first 24-48 hours after casting to prevent swelling. Contact the HCP if the child complains of numbness or tingling in the extremity. sharp and small objects are kept away from cast elevation is to decrease swelling notify the HCP immediately if signs of neurological impairment. Incorrect- 1- use palm not finger tips 3-no objects are to be placed inside the cast, even padded

A nurse is caring for a client who is postoperative day 1 right hip replacement. How should the nurse position the client? Keep the client's hips in abduction at all times Keep hips flexed at no less than 90 degrees Elevate the head of the bed to high Fowler's Seat the client in a low chair as soon as possible

Keep the client's hips in abduction at all times The hips should be kept in abduction by an abductor pillow. Hips should not be flexed more than 90 degrees, and the head of bed should not be elevated more than 60 degrees. The client's hips should be higher than the knees; as such, high seat chairs should be used.

The nurse is educating the family whose child is newly diagnosed with scoliosis. What is the goal of therapy as explained by the nurse? Limit or stop progression of the curvature of the spine. Prepare the child for surgical correction at a later date. Minimize the complications of prolonged immobilization. Develop a pain management plan to minimize complications.

Limit or stop progression of the curvature of the spine. 1-The goal of therapy for scoliosis is to limit the progression of the spinal curvature, obviating the need for more aggressive interventions. Incorrect- 2-Not all children with scoliosis need surgery. 3-Most children with scoliosis do not require prolonged immobilization. 4-Most children with scoliosis do not require aggressive pain management.

The results of a nurse's musculoskeletal examination show an increase in the lumbar curvature of the spine. The nurse should recognize the presence of what health problem? Osteoporosis Kyphosis Lordosis Scoliosis

Lordosis he nurse documents the spinal abnormality as lordosis. Lordosis is an increase in lumbar curvature of the spine. Kyphosis is an increase in the convex curvature of the spine. Scoliosis is a lateral curvature of the spine. Osteoporosis is the significant loss of bone mass and strength with an increased risk for fracture.

The nurse is assessing the 4-year-old with Duchenne muscular dystrophy (DMD). Which observation indicates that the child has a Gowers sign? Rises from the floor to stand by walking the hands up the legs Unable to initiate an effective cough or expectorate secretions Has difficulty lifting the head and supporting it in an upright position Tests at a high IQ and is advanced for the child's developmental age

Rises from the floor to stand by walking the hands up the legs The progressive muscular weakness and wasting that occur with Duchenne MD make it difficult for the child to rise from the floor normally. The child will use the hands to walk up the legs.

While assessing a client who has had knee replacement surgery, the nurse notes that the client has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this client? Risk for Infection Risk for Ineffective Peripheral Tissue Perfusion Unilateral Neglect Related to Hematoma Disturbed Kinesthetic Sensory Perception

Risk for Ineffective Peripheral Tissue Perfusion The hematoma may cause an interruption of tissue perfusion. There is also an associated risk for infection because of the hematoma, but impaired perfusion is a more acute threat. Unilateral neglect and impaired sensation are lower priorities than tissue perfusion.

The nurse is caring for an infant with myelomeningocele who is going to surgery later today for closure of the sac. Which would be the priority nursing diagnosis before surgery? Alteration in parent-infant bonding. Altered growth and development. Risk of infection. Risk for weight loss.

Risk of infection. The unrepaired myelomeningocele is often times a thin membrane that covers the neural contents of the spine. A normal saline dressing is placed over the sac to prevent tearing. The tearing would allow CSF ti escape and microorganisms to enter. The infant is at high risk for spinal cord infections. The priority nursing diagnosis is risk of infection.

A nurse's assessment of a teenage girl reveals that her shoulders are not level and that she has one prominent scapula that is accentuated by bending forward. The nurse should expect to read about what health problem in the client's electronic health record? Lordosis Kyphosis Scoliosis Muscular Dystrophy

Scoliosis Scoliosis is evidenced by an abnormal lateral curve in the spine, shoulders that are not level, an asymmetric waistline, and a prominent scapula, accentuated by bending forward. Lordosis is the curvature in the lower back; kyphosis is an exaggerated curvature of the upper back. This finding is not suggestive of muscular dystrophy.

The nurse is developing a discharge teaching plan for a child who is to have his cast removed. What instruction would the nurse most likely include? Applying petroleum jelly to the dry skin Rubbing the skin vigorously to remove the dead skin Soaking the area in warm water every day Washing the skin with dilute peroxide and water

Soaking the area in warm water every day After a cast is removed, the child and family should be instructed to soak the area in warm water every day to help soften and remove the dry flaky skin. Moisturizing lotion, not petroleum jelly, should be applied to the skin. Vigorous rubbing would traumatize the skin and should be avoided. Warm soapy water, not dilute peroxide and water, should be used to wash the area.

A rehabilitation nurse is working with a client who has had a below-the-knee amputation. In order to determine the client's ability to be an active participant in self-care, the nurse should prioritize assessment of what variable? The client's learning style The client's attitude The client's nutritional status The client's presurgical level of function

The client's attitude Amputation of an extremity affects the client's ability to provide adequate self-care. The client is encouraged to be an active participant in self-care. The client and the nurse need to maintain positive attitudes and to minimize fatigue and frustration during the learning process. Balanced nutrition and the client's learning style are important variables in the rehabilitation process but the client's attitude is among the most salient variables. The client's presurgical level of function may or may not affect participation in rehabilitation.

An older adult client has come to the clinic for a regular check-up. The nurse's initial inspection reveals an increased thoracic curvature of the client's spine. The nurse should document the presence of: scoliosis epiphyses lordosis kyphosis

kyphosis Kyphosis is the increase in thoracic curvature of the spine. Scoliosis is a deviation in the lateral curvature of the spine. Epiphyses are the ends of the long bones. Lordosis is the exaggerated curvature of the lumbar spine.

A nurse is assessing a child who has a diagnosis of muscular dystrophy. Assessment reveals that the child's muscles have greater-than-normal tone. The nurse should document the presence of: tonus flaccidity atony spasticity

spasticity A muscle with greater-than-normal tone is described as spastic. Soft and flabby muscle tone is defined as atony. A muscle that is limp and without tone is described as being flaccid. The state of readiness known as muscle tone (tonus) is produced by the maintenance of some of the muscle fibers in a contracted state.