Musc/Skel 231 final Saunders Evovle

The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding? 1. Temperature of 101.6° F orally 2. Complaints of discomfort during repositioning 3. Old bloody drainage outlined on the surgical dressing 4. Discomfort during coughing and deep-breathing exercises

1 The nursing assessment conducted after spinal surgery is similar to that done after other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101.6° F should be reported. Ignatavicius, Workman (2013), p. 964.

Client complains of pain and numbness in fingers when types on a computer keyboard. Which action helps nurse assess for Phalen's sign? 1-Having the client hold both hands above his head with his arms straight for 30 seconds 2-Having the client hold both wrist in acute flexion with the dorsal surfaces touching for 60 seconds 3-Tapping gently over the median nerve in the wrist 4-Having the client extend his wrists while the nurse provides resistance

2 Acute wrist flexion places pressure on inflamed median nerve, causing pain and numbness of carpal tunnel syndrome (Phalens sign). Holding hand above the head with arms straight for 30 seconds isn't an assessment technique. Tapping gently over the median nerve tests for Tinel's sign, another sign of carpal tunnel syndrome. Placing the wrists in extension against resistance tests strength.

The nurse is planning to teach proper use of a thoracolumbosacral orthosis (TLSO) to a client who has had spinal fusion with instrumentation. The nurse should include which teaching points in the discussion with the client? 1. The brace should be applied directly next to the skin. 2. The device is applied before getting out of bed in the morning. 3. The self-adhering closures should be fairly loose to avoid constriction. 4. Areas of skin redness at the edges of the brace indicate a good, snug fit.

2 Rationale: After spinal surgery, a brace or corset may be required temporarily to support the spine. Clients who have lumbar or thoracic spinal fusions wear a fiberglass brace, which resembles a shell. Initially, back braces or corsets may be worn constantly, whether the client is in or out of bed. If not required constantly, the brace is applied in the morning before getting out of bed. As the client's muscles strengthen, the use of braces or corsets is usually decreased. A back brace or TLSO is individually fitted to the client. A layer of clothing is worn between the orthosis and the skin. The closures should be secure, but not overly loose or tight. The brace should not irritate the skin with proper fitting. Always follow the health care provider's activity prescriptions.

A client who has had spinal fusion and insertion of hardware is extremely concerned with the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to prior employment. The nurse understands that the client's needs could best be addressed by referral to which member of the health care team? 1. The surgeon 2. A social worker 3. The physical therapist 4. The clinical nurse specialist

2 Rationale: After spinal surgery, concerns about finances and employment are best handled by referral to a social worker. This professional can provide the most helpful information about resources available to the client. The clinical nurse specialist and the surgeon do not have information related to financial resources. The physical therapist has the best knowledge of techniques for increasing mobility and endurance.

A client is being transferred to the nursing unit from the postanesthesia care unit after spinal fusion with rod insertion. The nurse should prepare to transfer the client from the stretcher to the bed by using which best method? 1. A bath blanket and the assistance of four people 2. A bath blanket and the assistance of three people 3. A transfer (slider) board and the assistance of two people 4. A transfer (slider) board and the assistance of four people

4 Rationale: After spinal fusion, with or without instrumentation, the client is transferred from the stretcher to the bed using a transfer (slider) board and the assistance of four people. This strategy permits optimal stabilization and support of the spine while allowing the client to be moved smoothly and gently. In addition, a nurse may also be positioned at the head of the client's bed to protect and support client's head and neck if the client is unable to assist.

A client is being discharged to home after spinal fusion with insertion of instrumentation (rod). The unit nurse should consult with the continuing care nurse regarding the need for modification of the home environment if the client makes which statement? 1. "The bathroom has hand railings in the shower." 2. "There are three steps to get up to the front door." 3. "My family has rented a commode for me to use." 4. "My bedroom and bathroom are on the second floor of my home."

4 Rationale: Stair climbing may be restricted or limited for several weeks after spinal fusion with instrumentation. If stairs need to be climbed to reach a bathroom, hand rails should be installed and the area should be kept free of clutter. The nurse ensures that resources are in place before discharge so that the client may sleep and perform all activities of daily living on a single living level. From the options provided, options 1, 2, and 3 do not indicate a need for modification of the environment.

A client is seen in the health care provider's office for complaints of wrist pain. A diagnosis of carpal tunnel syndrome is made. In explaining this disorder to the client, the nurse states that it is caused by compression of which nerve? 1. Median 2. Peroneal 3. Trigeminal 4. Spinal accessory

1 Rationale: Carpal tunnel syndrome is caused by excessive pressure on the median nerve as a result of injury, overuse, or disease. The peroneal nerve is in the leg. Trigeminal neuropathy results in facial pain, also known as tic douloureux. The spinal accessory nerve is a motor nerve impacting shoulder function. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Musculoskeletal Strategy(s): Subject Priority Concepts: Mobility, Pain Test-Taking Strategy: Focus on the subject, the pain associated with carpal tunnel syndrome. Knowledge regarding the pathophysiology of carpal tunnel syndrome and the anatomy of the arm is needed to answer this question. Remember that carpal tunnel syndrome is caused by excessive pressure on the median nerve. Review: Pain associated with carpal tunnel syndrome Reference(s): Ignatavicius, Workman (2013), p. 1170.

A nurse is caring for a client with acute back pain. Which are the most likely causes of this problem?Select all that apply. 1. Twisting of the spine 2. Curvature of the spine 3. Hyperflexion of the spine 4. Sciatic nerve inflammation 5. Degeneration of the facet joints 6. Herniation of an intervertebral disk

1,3,6 Rationale: Acute back pain is sudden in onset and is usually precipitated by injury to the lower back, such as with hyperflexion, twisting, or disk herniation. Degenerative vertebral changes, sciatica, and scoliosis are more likely to cause chronic back pain, which can be more insidious in onset and may also be accompanied by degeneration of the intervertebral disk. Test-Taking Strategy: The strategic words in the question are most likely. Also focus on the subject, acute back pain. Use knowledge of the vertebral spine structures and mechanisms of injury to make your selection. You could also choose correctly by recalling that the term acute is often associated with a problem that is sudden in onset. Review: Causes of acute back pain

A client who has been taking high doses of acetylsalicylic acid (ASA, or aspirin) to relieve pain from osteoarthritis now has more generalized joint pain and an elevated temperature. The nurse should assess for which complication to determine whether the client has other signs of aspirin toxicity? 1. Diarrhea 2. Constipation 3. Double vision 4. Ringing in the ears

4 Rationale: Mild intoxication with acetylsalicylic acid, called salicylism, commonly occurs when the daily dosage is more than 4 g. Tinnitus (ringing in the ears) is the most frequent effect noted with intoxication. Hyperventilation also may occur because a salicylate stimulates the respiratory center. Fever may result because a salicylate interferes with the metabolic pathways coupling oxygen consumption and heat production. Options 1, 2, and 3 are not signs of aspirin toxicity.

3. A checkout clerk in a grocery store has muscle and tendon tears that have become inflamed, causing pain and weakness in the left hand and elbow. The nurse identifies these symptoms as related to a. muscle spasms. b. meniscus injury. c. repetitive strain injury. d. carpal tunnel syndrome.

Correct Answer: C Rationale: The patient's occupation and the inflammation, pain, and weakness in the elbow and hand suggest a repetitive strain injury. Muscle spasms would be characterized by a palpable, firm muscle mass during the spasm. Meniscus injury would affect the knee. Carpal tunnel syndrome is characterized by weakness and numbness of the hand.

4. When working with a patient whose job involves many hours of word processing, the nurse will teach the patient about the need to a. do stretching and warm-up exercises before starting work. b. wrap the wrists with a compression bandage every morning. c. use acetaminophen (Tylenol) instead of NSAIDs for wrist pain. d. obtain a keyboard pad to support the wrist while word processing.

Correct Answer: D Rationale: Repetitive strain injuries caused by prolonged times working at a keyboard can be prevented by the use of a pad that will keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to use to decrease swelling. Cognitive Level: Application Text Reference: p. 1633 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance