Musculoskeletal

The nurse is admitting a client with a fractured tibia. Which area should the nurse assess first? opposite extremity for baseline comparison actual fracture site area distal to the fracture area proximal to the fracture

area distal to the fracture Explanation: The nursing assessment is first focused on the region distal to the fracture for neurovascular injury or compromise. When a nerve or blood vessel is severed or obstructed at the actual fracture site, innervation to the nerve or blood flow to the vessel is disrupted below the site; therefore, the area distal to the fracture site is the area of compromised neurologic input or vascular flow and return, not the area above the fracture site or the fracture site itself. The nurse may assess the opposite extremity at the area proximal to the fracture site for a baseline comparison of pulse quality, color, temperature, size, and so on, but the comparison would be made after the initial neurovascular assessment.

A nurse is teaching a female client about preventing osteoporosis. Which teaching point is correct? To prevent fractures, the client should avoid strenuous exercise. Obtaining the recommended daily allowance of calcium requires taking a calcium supplement. The recommended daily allowance of calcium may be found in a wide variety of foods. Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss.

The recommended daily allowance of calcium may be found in a wide variety of foods. Explanation: Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. Clients usually can get the recommended daily requirement of calcium by eating a varied diet. Osteoporosis doesn't show up on ordinary X-rays until 30% of bone has been lost. Bone densitometry, however, can detect bone loss of 3% or less. This test is sometimes recommended routinely for women older than 35 who are at risk for osteoporosis. Strenuous exercise won't cause fractures. Although supplements are available, they aren't always necessary.

A nurse is caring for a client who's experiencing septic arthritis. This client has a history of immunosuppressive therapy and the client's immune system is currently depressed. Which assignment is the most appropriate for the nurse caring for this client? The nurse caring for this client is also caring for four other immunosuppressed clients on the medical floor. The nurse is caring for this client on the intensive care unit. The nurse caring for this client is also caring for two other immunosuppressed clients on the medical intensive care unit. The nurse caring for this client is also caring for four clients receiving chemotherapy for cancer treatment on the oncology floor.

The nurse is caring for this client on the intensive care unit. Explanation: This client is critically ill; the client's diagnosis and immunosuppression place them at a high risk for infection. The most appropriate place for this client is in an intensive care unit, where the nurse can focus exclusively on health promotion. This client shouldn't be on the oncology floor. This client requires close monitoring. The nurse caring for this client shouldn't also be caring for other clients who may require frequent interventions.

A client suspected of having systemic lupus erythematosus (SLE) is being scheduled for testing. The client asks which of the tests ordered will determine if the client is positive for the disorder. Which statement by the nurse is most accurate? "The diagnosis won't be based on the findings of a single test but by combining all data found." "SLE is a very serious systemic disorder." "Tell me more about your concerns about this potential diagnosis." "You should discuss that matter with your physician."

"The diagnosis won't be based on the findings of a single test but by combining all data found." Explanation: There is no single test available to diagnose SLE. Therefore, the nurse should inform the client that diagnosis is based on combining the findings from the physical assessment and the laboratory tests results. Advising the client to speak with the physician, stating that SLE is a serious systemic disorder, and asking the client to express their feelings about the potential diagnosis don't answer the client's question.

A client with osteoarthritis tells the nurse they are concerned that the disease will prevent them from doing their chores. Which suggestion should the nurse offer? "Do all your chores in the evening, when pain and stiffness are least pronounced." "Do all your chores after performing morning exercises to loosen up." "Do all your chores in the morning, when pain and stiffness are least pronounced." "Pace yourself and rest frequently, especially after activities."

"Pace yourself and rest frequently, especially after activities." Explanation: A client with osteoarthritis must adapt to this chronic and disabling disease, which causes deterioration of the joint cartilage. The most common symptom of the disease is deep, aching joint pain, particularly in the morning and after exercise and weight-bearing activities. Because rest usually relieves the pain, the nurse should instruct the client to rest frequently, especially after activities, and to pace themself during daily activities. Telling the client to do the chores in the morning is incorrect because the pain and stiffness of osteoarthritis are most pronounced in the morning. Telling the client to do all chores after performing morning exercises or in the evening is incorrect because the client should pace themself and take frequent rests rather than doing all chores at once.

The nurse is assisting a client who has had a spinal fusion apply a back brace. In which order of priority from first to last should the nurse assist the client applying the brace? All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Ask the client to stand with their arms held away from their body. 2Have the client in a side-lying position. 3Assist the client to log roll and rise to a sitting position. 4Verify the prescriptions for the settings for the brace.

Verify the prescriptions for the settings for the brace. Have the client in a side-lying position. Assist the client to log roll and rise to a sitting position. Ask the client to stand with their arms held away from their body. Explanation: The nurse should first verify the settings for the brace and activity prescriptions. Next, the client should be in a side-lying position; explain that the spine should be kept aligned and in a neutral position, and the client should not pull on objects with arms. For getting out of bed, log roll the client to the side, splint back, and rise to a sitting position by pushing against the mattress while swinging the legs over the side of the bed. Finally, the client should stand with the arms outstretched so the nurse can apply the brace.

In preparation for total knee surgery, a 200-lb (90.7-kg) client with osteoarthritis must lose weight. Which exercise should the nurse recommend as best if the client has no contraindications? tai chi exercise aquatic exercise walking weight lifting

aquatic exercise Explanation: When combined with a weight loss program, aquatic exercise would be best because it cushions the joints and allows the client to burn off calories. Aquatic exercise promotes circulation, muscle toning, and lung expansion, which promote healthy preoperative conditioning. Weight lifting and walking are too stressful to the joints, possibly exacerbating the client's osteoarthritis. Although tai chi exercise is designed for stretching and coordination, it would not be the best exercise for this client to help with weight loss.

The nurse is caring for a client who is 30 years of age with a fracture of the right femur and left tibia. Both legs have casts. The nurse assesses that the client's respiration rate is 30 breaths/min and respirations are rapid and shallow; there is the presence of a faint expiratory wheeze; and coughing produces thin pink sputum. The client is yelling at the nurse and wants to be released from the hospital; this is behavior unlike that previously reported. The last pain medication was administered 3 hours ago. What should the nurse do first? Cut slits in the top of the casts. Administer pain medication. Notify the health care provider (HCP). Obtain a chest x-ray.

Notify the health care provider (HCP). Explanation: The nurse's first action is to notify the HCP because the client is likely experiencing a fat embolus. Fat emboli are associated with embolization of marrow or tissue fat or platelets and free fatty acids to the pulmonary capillaries, producing rapid onset of symptoms. Multiple fractures and fractures of the long bones or pelvis increase a client's risk for developing a fat embolus; in addition, young adults between 20 and 30 years of age are at a higher risk for fat emboli with fractures. When fat emboli do occur, hypoxia results; therefore, it is most important for the nurse to assess changes in the client's level of consciousness and observe changes in behavior, such as restlessness and irritability. The nurse does not cut the cast; there is no indication that the casts are obstructing circulation. Arterial blood gas tests are used to confirm the diagnosis, not a chest x-ray. The client's behavior is a result of hypoxemia, not pain.

Unlicensed assistive personnel (UAP) are helping a client who had knee surgery 2 days ago get into bed. As the nurse makes rounds, which information requires the nurse to intervene? The side rails on the head and foot of the bed are in the up position. There is a clear path to the bathroom. The night light is dimmed, giving low-level lighting to the room. The call light is pinned to the head of the bed in the client's reach.

The side rails on the head and foot of the bed are in the up position. Explanation: Side rails are considered restraints and are not used at both the head and foot of the bed. Using side rails at the head of the bed will aid the client in sitting up and are safe, but using side rails at both the head and the foot of the bed presents risks for a client who might become wedged between the rail and the bed or attempt to climb over them. The nurse discusses side rail use with the UAP and lowers the side rail at the foot of the bed. The nurse assures the bed is placed in a low position. The accessible call light, dim lighting, and clear path to the bathroom are factors that contribute to fall prevention.

What are important nursing priorities on the first postoperative day for a client who has had an open reduction and internal fixation (ORIF) after a right hip fracture? assessing for skin integrity, enhancing nutritional status, and encouraging position changes while maintaining bed rest assessing the neurovascular status in the right leg, providing pain control, encouraging position changes, and early ambulation reorienting frequently to prevent confusion and disorientation, restricting analgesics, and encouraging pursed-lip breathing supporting the leg to maintain adduction, ensuring adequate pain control, and maintaining bed rest

assessing the neurovascular status in the right leg, providing pain control, encouraging position changes, and early ambulation Explanation: Assessing the neurovascular status, including circulation and innervation, is very important postoperatively. Control of pain is also a priority. Maintaining the integrity of the skin through frequent turns and ambulation will prevent pressure injuries. Correct postoperative positioning involves maintaining the leg in a neutral position and preventing adduction. Bed rest can result in immobility consequences. Assessing skin integrity and nutritional status is positive, but maintaining bed rest is incorrect. Reorienting frequently will not prevent disorientation, and the nurse would not restrict pain measures.

When assessing an older adult as a candidate for crutch walking, the nurse should take into account that for some elderly people, crutch walking is an impractical goal primarily because of decreased: motor coordination. visual acuity. reaction time. level of comprehension.

motor coordination. Explanation: Some elderly people are not good candidates for crutch walking because they are not strong enough to use crutches or are not coordinated enough to walk safely with crutches. Visual acuity, reaction time, and level of comprehension may influence the ability to learn crutch walking, but they are not as important as motor coordination. Some elderly people are not good candidates for crutch walking because they are not strong enough to use crutches or are not coordinated enough to walk safely with crutches. Visual acuity, reaction time, and level of comprehension may influence the ability to learn crutch walking, but they are not as important as motor coordination. Some elderly people are not good candidates for crutch walking because they are not strong enough to use crutches or are not coordinated enough to walk safely with crutches.Visual acuity, reaction time, and level of comprehension may influence the ability to learn crutch walking, but they are not as important as motor coordination.

A client who had a total hip replacement 4 days ago is worried about dislocation of the prosthesis. How should the nurse respond to the client's concern? "Don't worry. Your new hip is very strong." "Decreasing use of the abductor pillow will strengthen the muscles to prevent dislocation." "Using a cushioned toilet seat helps prevent dislocation." "Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid them."

"Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid them." Explanation: Dislocation precautions include avoiding extremes of internal rotation, adduction, and 90-degree flexion of the affected hip for at least 4 to 6 weeks after the procedure. Using an abduction pillow prevents adduction. Decreasing use of the abductor pillow does not strengthen the muscles to prevent dislocation. Informing a client to "not worry" is not therapeutic. A cushioned toilet seat does not prevent hip dislocation.

A client takes prednisone for an acute exacerbation of rheumatoid arthritis. The nurse determines the client understands how to take the prednisone when the client makes which statement? "I can stop taking the prednisone as soon as my joints feel better." "It's important for me to increase my sodium intake while I am taking this medication." "It's best if I take this medication with some food." "I shouldn't be concerned if I lose a little weight while I take the prednisone."

"It's best if I take this medication with some food." Explanation: Prednisone is a gastrointestinal irritant that is best taken with food. The client should not abruptly stop taking the prednisone when their joints feel better. Rather, the drug must be tapered slowly. Abrupt withdrawal can precipitate a return of the symptoms. Sodium intake should be reduced, not increased. The client will most likely retain fluids and demonstrate some weight gain.

The nurse is ensuring that all clients who are at risk for falls are wearing red slipper socks that identify clients who are at risk for falling. Which client(s) should receive red slipper socks? Select all that apply. a client who is 45 years of age, in hospice with terminal cancer, and receiving morphine every 2 hours a client who is 62 years of age, recovering from breast biopsy in outpatient surgery, and has a fear of falling a client who is 70 years of age, hospitalized for a lung biopsy, and receiving no medications a client who is 80 years of age and in a locked facility for clients with cognitive impairment a client who is 75 years of age and recovering at home from hip replacement surgery on the left hip

Clients who are at risk for falling include the client taking narcotics, the client with a known fear of falling, the client with cognitive impairment, and the client with gait problems. Age and setting are not necessarily risks for fallings. a client who is 45 years of age, in hospice with terminal cancer, and receiving morphine every 2 hours a client who is 62 years of age, recovering from breast biopsy in outpatient surgery, and has a fear of falling a client who is 80 years of age and in a locked facility for clients with cognitive impairment a client who is 75 years of age and recovering at home from hip replacement surgery on the left hip

The nurse is setting goals with a client with rheumatoid arthritis. Which is a priority goal for the client? Verbalize that recovery from rheumatoid arthritis will require several years of treatment. Demonstrate the use of adaptive equipment. Learn to limit activity so as to avoid joint pain. Minimize the frequency with which antiinflammatory drugs are used to control joint discomfort.

Demonstrate the use of adaptive equipment. Explanation: Depending on the degree of joint involvement, clients with rheumatoid arthritis may need to learn to function with adaptive equipment. Such equipment can help the client maintain independence. The consistent use of antiinflammatory drugs is considered important to minimize joint inflammation and damage. Periods of activity should be alternated with rest periods, but limiting activity to avoid joint pain is not a realistic or desirable outcome. The client needs to understand that rheumatoid arthritis cannot be cured.

When developing a care plan for a client newly diagnosed with scleroderma, which nursing diagnosis has the highest priority? Impaired skin integrity Impaired gas exchange Imbalanced nutrition: More than body requirements Risk for constipation

Impaired skin integrity Explanation: Impaired skin integrity is a concern for the client with scleroderma in its earlier stages. Meticulous skin care is required to prevent complications. Although Risk for constipation may also be appropriate, this nursing diagnosis isn't the priority. Clients with scleroderma are at risk for Imbalanced nutrition: Less than body requirements. The client with advanced scleroderma, not newly diagnosed scleroderma, is at increased risk for developing respiratory complications.

A client in balanced suspension traction is transported to surgery for closed reduction and internal fixation of a fractured femur. What should the nurse do when transporting the client to the operating room? Transfer the client to a cart with manually suspended traction. Remove the traction, and send the client on a cart. Call the surgeon to request a prescription to temporarily remove the traction. Send the client on the bed with extra help to stabilize the traction.

Send the client on the bed with extra help to stabilize the traction. Explanation: The nurse should send the client to the operating room on the bed with extra help to keep the traction from moving to maintain the femur in the proper alignment before surgery. Transferring the client to a cart with manually suspended traction is inappropriate because doing so places the client at risk for additional trauma to the surrounding neurovascular and soft tissues, as would removing the traction. The surgeon need not be called because the decision about transferring the client is an independent nursing action.

A client has had a cast applied to the arm. When discharging the client, what should the nurse tell the client to: do? Use powder on the skin around the cast. Use a padded ruler to reach inside and rub under the cast. Smell the cast for foul odors. Apply a heating pad to the arm for 24 hours after the injury.

Smell the cast for foul odors. Explanation: The client should be instructed to smell the cast to note foul odors, a sign of potential infection. Powder should not be used around the cast because it can get under the cast and become a potential medium for infection. Nothing should be inserted into the cast because a break in skin integrity can lead to an infection. A heating pad is not applied to a fracture; rather, the application of cold may be used to decrease edema and help decrease pain.

A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be? providing comprehensive client teaching including symptoms of the disorder, treatment options, and expected outcomes administering ordered analgesics and monitoring their effects supplying adaptive devices, such as a zipper-pull, easy-to-open beverage cartons, lightweight cups, and unpackaged silverware performing meticulous skin care

administering ordered analgesics and monitoring their effects Explanation: An acute exacerbation of rheumatoid arthritis can be very painful, and the nurse should make pain management the priority. Client teaching, skin care, and supplying adaptive devices are important, but these actions do not take priority over pain management.

After total hip replacement, a client is receiving epidural analgesia to relieve pain. Which action is a nursing priority for this client? assessing capillary refill time keeping the client flat in bed assessing for sensation in the legs changing the catheter site dressing every shift

assessing for sensation in the legs Explanation: For epidural analgesia, a catheter is placed outside the dura mater in the epidural space. Catheter displacement, which may cause spinal injury, is signaled by loss of motion and sensation in the legs. Therefore, the nurse should assess closely for sensation and ask about numbness of the legs. The nurse should change the catheter site dressing every day or every other day. Capillary refill time has no bearing on epidural analgesia. A client with an epidural catheter may ambulate and need not be confined to bed.

The nurse visits the home of a client with a newly applied leg cast. On which area should the nurse focus when assessing this client's neurovascular functioning? Select all that apply. muscle tone motion body temperature capillary refill sensation

capillary refill sensation motion The neurovascular assessment includes assessment of motion, sensation, and peripheral circulation. Muscle tone and body temperature are not a part of the neurovascular assessment after the application of an immobilization device such as a cast.

The nurse is teaching the client how to use crutches. The nurse should instruct the client to bear weight primarily on which part of the body? upper arms elbows axillae hands

hands Explanation: The proper use of crutches requires supporting the body weight primarily on the hands. Improper use of crutches can cause nerve damage from excess pressure on the axillary nerve, and undue weight bearing on the elbows and arms.

Which equipment should the nurse plan to use to help prevent external rotation of the client's right leg postoperatively? a rubber air ring a high footboard sandbags a metal bed cradle

sandbags Explanation: It is best to support the client's leg in its proper anatomic position and to prevent external rotation by supporting the leg with sandbags. A trochanter roll can also be used. Sandbags should be placed along the length of the thigh and lower leg.A footboard, rubber air ring, or metal frame will not help prevent external rotation of the leg.

A client with rheumatoid arthritis has been taking large doses of aspirin to relieve joint pain. Which finding is likely? dysuria tinnitus chest pain drowsiness

tinnitus Explanation: Tinnitus (ringing in the ears) is a common symptom of aspirin toxicity. Dysuria, chest pain, and drowsiness are not associated with aspirin toxicity.

During a routine physical examination on a 75-year-old female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, "How is that possible? I was always 5 feet and 1/2 inches (1.7 m) tall." Which statement is the best response by the nurse? "There may be some slight discrepancy between the measuring tools used." "The posture begins to stoop after middle age." "After age 40, height may show a gradual decrease as a result of spinal compression." "After menopause, the body's bone density declines, resulting in a gradual loss of height."

"After menopause, the body's bone density declines, resulting in a gradual loss of height." Explanation: The nurse should tell the client that after menopause, the loss of estrogen leads to a loss in bone density, resulting in a loss of height. This client's history doesn't indicate spinal compression. Telling the client that measuring tools used to obtain the client's height may have a discrepancy or that the posture begins to stoop after middle age doesn't address the client's question.

A client is brought to the emergency department with a painful swollen ankle. What is the nurse's most appropriate action? Apply a warm compress. Administer I.V. morphine sulfate as needed. Assess range of motion. Elevate the ankle.

Elevate the ankle. Explanation: Soft tissue injuries should be treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase the risk of further injury. Morphine is not the drug of choice for pain due to inflammation.

The nurse is instructing a client following right-knee replacement on how to use crutches. Which instructions are included? Select all that apply. Step forward first on your right leg. Pivot on your left leg. Have your elbows bent when holding the crutch handles. Swing your left leg forward. Place crutches 1 foot in front of you. Let your armpits support your weight.

Have your elbows bent when holding the crutch handles. Place crutches 1 foot in front of you. Pivot on your left leg. Swing your left leg forward. It is very important to instruct a client to safely use crutches. Additional damage to the injured knee may result with improper crutch use. When using crutches, instruct the client to "place the crutches about 1 foot (0.3 meters) in front of your feet, slightly wider apart than your body. Next, lean on the handles of your crutches (not armpit) and move your body forward. Use the crutches for support. Do not step forward on the weak leg. Finish the step by swinging your left leg forward. Repeat steps to move forward. Turn by pivoting on the strong left leg, not the right leg. The armpits should not support your body weight."

A nurse is managing the care of a client with osteoarthritis. Appropriate treatment strategies for osteoarthritis include administration of monthly intra-articular injections of corticosteroids. vigorous physical therapy for the joints. administration of opioids for pain control. administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program.

administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program. Explanation: NSAIDs are routinely used for anti-inflammatory and analgesic effects. NSAIDs reduce inflammation, which causes pain. Opioids aren't used for pain control in osteoarthritis. Intra-articular injection of corticosteroids is used cautiously for an immediate, short-term effect when a joint is acutely inflamed. Normal joint range of motion and exercise (not vigorous physical therapy) are encouraged to maintain mobility and reduce joint stiffness.

A client has a left tibial fracture that required casting. Approximately 5 hours later, the client has increasing pain distal to the fracture despite the morphine injection administered 30 minutes ago. Which area should be the nurse's next assessment? vital sign changes potential for drug tolerance distal pulses pain with a pain rating scale

distal pulses Explanation: The nurse should assess the client's ability to move the toes and for the presence of distal pulses, including a neurovascular assessment of the area below the cast. Increasing pain unrelieved by usual analgesics and occurring 4 to 12 hours after the onset of casting or trauma may be the first sign of compartment syndrome, which can lead to permanent damage to nerves and muscles. Although the nurse can use a pain rating scale or assess for changes in vital signs to objectively assess the client's pain, the client's comments suggest early and important signs of compartment syndrome requiring immediate intervention. The nurse should not confuse these signs with the potential for drug tolerance. This assessment might be appropriate once the suspicion of compartment syndrome has been ruled out.

The client is being discharged today after having an above-the-knee amputation a week ago. Which complications should the nurse include in the discharge directions? Select all that apply. worsening pain not controlled by medication skin around the stump or wound dark or turning black new openings in wound or skin around the wound pulling away temperature of 36.8° C pink, fleshy tissue

new openings in wound or skin around the wound pulling away worsening pain not controlled by medication skin around the stump or wound dark or turning black Explanation: Complications for above-the-knee amputation include new openings in wound or skin around the wound is pulling away; skin around the stump or wound is dark or is turning black; and pain is worse and is not controlled by medication. Other complications include swelling, new drainage or bleeding from the wound; temperature 38.6° C or higher, foul smell, red streaking up the extremity; if stump is redder, feels warmer, is bulging, or if it has gotten bigger. Pink, fleshy tissue and temperature of 36.8° C are normal findings.

A client is admitted to the hospital with a diagnosis of a right hip fracture. The client has right hip pain and cannot move the right leg. The nurse should further assess the right leg to determine if the leg is in which position? rotated internally shorter than the leg on the unaffected side adducted held in a flexed position

shorter than the leg on the unaffected side Explanation: After a hip fracture, the leg on the affected side is characteristically shorter than the unaffected leg.A fractured hip usually rotates externally.Holding the leg in a flexed position is seen in clients with a dislocated hip, not a fractured hip.Typically, the fractured hip is in an abducted position.

The nurse is caring for a client with a spinal cord injury. The client is experiencing blurred vision and has a blood pressure of 204/102 mm Hg. What should the nurse do first? Administer pain medications. Check the client's bladder for distention. Control the environment by turning the lights off and decreasing stimulation for the client. Position the client on the left side.

Check the client's bladder for distention. Explanation: The client is experiencing autonomic dysreflexia, which is a medical emergency. The nurse should immediately evaluate the client for bladder distention and be prepared to catheterize the client. Positioning the client on the left side, reducing environmental stimuli, and administering pain medications are not used to treat autonomic hyperreflexia.

After a person experiences a closure of the epiphyses, which statement is true? The bone increases in thickness and is remodeled. The bone grows in length but not thickness. Both bone length and thickness continue to increase. No further increase in bone length occurs.

No further increase in bone length occurs. Explanation: After closure of the epiphyses, no further increase in bone length can occur. The other options are inappropriate and not related to closure of the epiphyses.

Passive range-of-motion (ROM) exercises for the legs and assisted ROM exercises for the arms are part of the care regimen for a client with a spinal cord injury. Which observation by the nurse would indicate a successful outcome of this treatment? external rotation of the hips at rest absence of paralytic foot drop absence of tissue ischemia over bony prominences free, easy movement of the joints

free, easy movement of the joints Explanation: ROM exercises help preserve joint motion and stimulate circulation. Contractures develop rapidly in clients with spinal cord injuries, and the absence of this complication indicates treatment success. Range of motion will keep the ankle joints freely mobile. Foot drop, however, is prevented by proper positioning of the ankle and foot, which is usually accomplished with high-top sneakers or splints. External rotation of the hips is prevented by using trochanter rolls. Local ischemia over bony prominences is prevented by following a regular turning schedule.

The client sustained an open fracture of the femur from an automobile accident. The nurse should assess the client for which type of shock? cardiogenic neurogenic hypovolemic anaphylactic

hypovolemic Explanation: A fractured femur, especially an open fracture, can cause much soft tissue damage and lead to significant blood loss. Hypovolemic shock can develop. Cardiogenic shock occurs when cardiac output is decreased as a result of ineffective pumping. Neurogenic shock occurs as a result of an impaired autonomic nervous system function. Anaphylactic shock is the result of an allergic reaction.

A client recovering from lumbar surgery is fitted for a contour splint. What should the nurse explain to the client about this device? "The splint supports the spine while you are in traction." "The splint will not be removed for several weeks." "The splint immobilizes the body part in a functional position." "The splint permits free range of motion of the body area."

"The splint immobilizes the body part in a functional position." Explanation: Contoured splints are used for health issues to immobilize the area and support the body part in a functional position. Splints are easily removed and are not indicated for use in traction. The splint prevents, not permits, free range of motion of the body area.

A client who has just been diagnosed with mixed muscular dystrophy asks the nurse about the usual course of this disease. How should the nurse respond? "This form of muscular dystrophy is a relatively benign disease that progresses slowly." "You may experience progressive deterioration in all voluntary muscles." "The strength of your arms and pelvic muscles will decrease gradually, but this should cause only slight disability." "You should ask your physician about that."

"You may experience progressive deterioration in all voluntary muscles." Explanation: The nurse should tell the client that muscular dystrophy causes progressive, symmetrical wasting of skeletal muscles, without neural or sensory defects. The mixed form of the disease typically strikes between ages 30 and 50 and progresses rapidly, causing deterioration of all voluntary muscles. Because the client asked the nurse this question directly, the nurse should answer and not simply refer the client to the physician. Limb-girdle muscular dystrophy causes a gradual decrease in arm and pelvic muscle strength, resulting in slight disability. Facioscapulohumeral muscular dystrophy is a slowly progressive, relatively benign form of muscular dystrophy; it usually arises before age 10.

The nurse is teaching the client with rheumatoid arthritis to perform isometric exercises to strengthen the leg muscles after having a hip replacement. Which is the expected benefit of isometric exercise? involve clients in their own care and thus improves morale strengthens the muscles while keeping the joints stationary prevents joint stiffness does not require specialized equipment

strengthens the muscles while keeping the joints stationary Explanation: An exercise program is recommended to strengthen muscles after arthroplasty. Isometric (or muscle-setting) exercises strengthen muscles but keep the joint stationary during the healing process. Isometric exercises do not require specialized equipment, but this does not explain the benefits of the exercises. Isometric exercises may help improve a client's morale by promoting self-care, but this is not the reason for doing them. Because the joint is kept stationary, isometric exercise will not help prevent joint stiffness

After surgery to treat a hip fracture, a client returns from the postanesthesia care unit to the medical-surgical unit. Postoperatively, how should the nurse position the client? with the affected hip flexed acutely with the leg on the affected side abducted with the leg on the affected side adducted with the affected hip rotated externally

with the leg on the affected side abducted Explanation: The nurse must keep the leg on the affected side abducted at all times after hip surgery to prevent accidental dislodgment of the affected hip joint. Placing a pillow or an A-frame between the legs helps maintain abduction and reminds the client not to cross the legs. Because the leg on the affected side must be kept abducted, the nurse must avoid adducting that leg, such as by moving it toward the midline. The nurse should also avoid acutely flexing the client's affected hip (for example, by elevating the head of the bed excessively) or externally rotating the affected hip (such as by removing support along the outer side of the leg). All these positions may cause dislocation of the injured hip joint.

After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis? infection Volkmann's ischemic contracture compartment syndrome fat embolism

fat embolism Explanation: Fat embolism is a relatively rare but life-threatening complication of pelvis and long-bone fractures, arising 24 to 48 hours after the injury. It occurs when fat droplets released at the fracture site enter the circulation, become lodged in pulmonary capillaries, and break down into fatty acids. Because these acids are toxic to the lung parenchyma, capillary endothelium, and surfactant, the client may develop pulmonary hypertension. Signs and symptoms of fat embolism include an altered mental status, fever, tachypnea, tachycardia, hypoxemia, and petechiae. Compartment syndrome and infection may complicate any fracture and aren't specific to a pelvis fracture. Volkmann's ischemic contracture is a potential complication of a hand or forearm fracture.

An older adult is admitted with a fracture of the femur. What should the nurse assess first about this client? mechanism of injury type of pain ability to change positions extent of anxiety

mechanism of injury Explanation: The nurse first assesses the mechanism of injury to help determine related injuries, tests needed, and potential treatment options. The next step is to assess the location, type, quality, and intensity of the pain. Neurovascular stasis of the injured site is assessed after pain; therefore, the nurse checks for functional ability or changing positions. Although the nurse can also determine the extent of anxiety while assessing the injury and can use communication strategies to minimize anxiety, it is not the first priority for assessing this client.

A nurse is teaching a client who was recently diagnosed with carpal tunnel syndrome. Which statement should the nurse include? "This condition is associated with various sports." "Ergonomic changes can be incorporated into your workday to reduce stress on your wrist." "Surgery is the only sure way to manage this condition." "Using arm splints will prevent hyperflexion of the wrist."

"Ergonomic changes can be incorporated into your workday to reduce stress on your wrist." Explanation: Ergonomic changes, such as adjusting keyboard height, can help clients with carpal tunnel syndrome avoid hyperextension of the wrist. This condition is associated with repetitive tasks such as clerical work, not sports. The condition may be managed with medications, yoga, acupuncture, and wrist (not arm) splints.

The nurse is teaching a client about cast care. Which statement indicates the nurse should provide additional information to the client? "I will exercise my joints above and below the cast." "I will elevate the cast above my heart initially." "I can pull out cast padding to scratch inside the cast." "I will apply ice for 10 minutes to control edema for the first 24 hours."

"I can pull out cast padding to scratch inside the cast." Explanation: Clients should not pull out cast padding to scratch inside the cast because of the hazard of skin breakdown and subsequent potential for infection. Clients are encouraged to elevate the casted extremity above the level of the heart to reduce edema and to exercise or move the joints above and below the cast to promote and maintain flexibility and muscle strength. Applying ice for 10 minutes during the first 24 hours helps reduce edema.

A nurse is performing an admission assessment on a client admitted with a pelvic fracture. Which statement by the client requires the nurse to seek more information from a legal standpoint? "I'm afraid I'll lose my job because I'm going to miss so much work." "Sometimes my spouse gets so angry with me." "I'm going to need help at home after I'm discharged." "I'm so clumsy."

"Sometimes my spouse gets so angry with me." Explanation: Legally, the nurse must further investigate the client's statement concerning the spouse's anger. This statement suggests that the client's injury might be caused by domestic abuse. The other statements are common and don't require further investigation, from a legal standpoint, by the nurse.

A client with rheumatoid arthritis is taking high doses of nonsteroidal anti-inflammatory medications. What should the nurse teach the client about taking these medications? "Do not drive or use heavy machinery if dizziness occurs." "Do not stop taking the medication suddenly; the dose needs to be decreased gradually." "Take prescribed medication with food to lessen the likelihood of an upset stomach." "Use mouthwash to rinse the mouth after taking this medication."

"Take prescribed medication with food to lessen the likelihood of an upset stomach." Explanation: Gastric upset is a side effect of nonsteroidal antiinflammatory medications; taking medication with food minimizes this effect. Corticosteroids affect adrenal gland function and are discontinued by lowering the dose gradually, but this is not true of nonsteroidal antiinflammatory medications. It is not necessary to rinse the mouth, as stomatitis is not a usual side effect. Dizziness is not an effect of this drug.

The nurse is evaluating the outcome of therapy for a client with osteoarthritis. Which finding indicates the goals of therapy have been met? Joint range of motion has improved. The client is able to self-administer gold compound safely. The client feels better than on hospital admission. Joint degeneration has been arrested.

Joint range of motion has improved. Explanation: One outcome criterion for the client with osteoarthritis is improved joint mobility. It is probably not possible to arrest the disease. Gold compound is administered to clients with rheumatoid arthritis, not osteoarthritis. Outcome criteria should be specific; feeling better is too general to be useful.

A client is receiving nonsteroidal antiinflammatory drugs (NSAIDs) to manage the pain of rheumatoid arthritis. What information should the nurse give to the client about taking these medications? Take antacids 1 hour after taking NSAIDs. Take NSAIDs with food. Take NSAIDs only when experiencing pain. Perform joint exercises before taking the next dose of the medication.

Take NSAIDs with food. Explanation: NSAIDs irritate the gastric mucosa and should be taken with food. NSAIDs should be taken on a regular basis to maintain blood levels of the drug, not just when the client is experiencing pain. If the client's care plan involves doing joint exercises, the client should do them after taking the NSAID when the drug level has peaked. Antacids may interfere with the absorption of NSAIDs.

What is the most important assessment for the nurse to make when assessing peripheral pulses on a client who is post limb fracture? local temperature and visible pulsations amplitude and symmetry of both extremities strong contractility and rate of only the unaffected limb color of the skin and rhythm above the affected fracture site

amplitude and symmetry of both extremities Explanation: Assessment of any peripheral pulse should include the characteristics of the pulse (e.g., amplitude, rhythm, and rate). The presence or lack of symmetry in the peripheral pulses must also be assessed. The other answers are incorrect because they are not based on assessment of pulses distal to the fracture site.

A nurse is developing a teaching plan for a client diagnosed with osteoarthritis. To minimize injury to the osteoarthritic client, the nurse should instruct the client to get help when lifting objects. wear worn, comfortable shoes. install safety devices in the home. wear protective devices when exercising.

install safety devices in the home. Explanation: Most accidents occur in the home, and safety devices such as hand rails are the most important element in minimizing injury. Shoes should be supportive and not too worn. The client needs to use proper body mechanics when stooping or lifting objects. Protective devices aren't usually necessary when the client exercises.

Which findings best correlate with a diagnosis of osteoarthritis? joint stiffness that decreases with activity fever and malaise erythema and edema over the affected joint anorexia and weight loss

joint stiffness that decreases with activity Explanation: A characteristic feature of osteoarthritis (degenerative joint disease) is joint stiffness that decreases with activity and movement. Erythema and edema over the affected joint, anorexia, weight loss, and fever and malaise are associated with rheumatoid arthritis, a more severe and destructive form of arthritis.

A client seeks care for lower back pain of 2 weeks duration. Which assessment finding suggests a herniated intervertebral disk? back pain when the knees are flexed pain radiating down the posterior thigh atrophy of the lower leg muscles Homans' sign

pain radiating down the posterior thigh Explanation: A herniated intervertebral disk may compress the spinal nerve roots, causing sciatic nerve inflammation that results in pain radiating down the leg. Slight knee flexion should relieve, not precipitate, lower back pain. If nerve root compression remains untreated, weakness or paralysis of the innervated muscle group may result; lower leg atrophy may occur if muscles aren't used. Homans' sign is more typical of phlebothrombosis.

The second morning after surgery for a below-the-knee amputation of the left leg, the client says, "This sounds crazy, but I feel my left toes tingling." The nurse determines the client is experiencing which phenomenon? phantom-limb sensation denial reaction body image disturbance hallucination

phantom-limb sensation Explanation: Descriptions of sensations, painful and otherwise, in the amputated part are common and are known as phantom-limb sensations. The client should be reassured that these sensations are normal and are not a sign of a mental problem. Denial may be present after amputation; signs include refusal to look at or talk about the amputation. The client is not hallucinating. Body image disturbances can develop after amputation due to fear, grief, loss of locomotion, and decreased self-esteem related to the loss of the body part.

The nurse is preparing a primary prevention program to reduce the incidence of osteoporosis in a population. For which risk factors will the nurse screen to identify the subgroup of the population who is at greatest risk for developing osteoporosis? women who are diagnosed as hypothyroid postmenopausal women who are inactive older men and women who are active smokers postmenopausal women who are overweight

postmenopausal women who are inactive Explanation: In primary osteoporosis, the rate of bone resorption accelerates while bone formation slows. Although the cause of primary osteoporosis is unknown, an important contributing factor may be faulty protein metabolism resulting from estrogen deficiency and a sedentary lifestyle and is more common in underweight, rather than overweight women. Typically, primary osteoporosis would occur in females who are postmenopausal. Although smoking does increase the risk for primary osteoporosis, this is not as significant as being postmenopausal and decreased activity level. Hyperthyroidism increases the risk for secondary osteoporosis but hypothyroidism is not a significant risk factor unless it is overtreated.

The nurse is creating a plan of care for an older adult client with osteoarthritis. Which nursing diagnosis is most appropriate? risk for injury related to altered mobility self-care deficit related to immobility activity intolerance related to sedentary lifestyle imbalanced nutrition: Less than body requirements related to effects of aging

risk for injury related to altered mobility Explanation: Typically, a client with osteoarthritis has stiffness in large, weight-bearing joints, such as the hips. This joint stiffness alters functional ability and range of movement, placing the client at risk for falling and injury. Therefore, risk for injury is the most appropriate nursing diagnosis. Activity intolerance related to sedentary lifestyle assumes that the client with osteoarthritis is limited in physical activity. Self-care deficit related to immobility assumes that the client with osteoarthritis is unable to complete self-care activities. Imbalanced nutrition: Less than body requirements is incorrect because osteoarthritis does not affect nutrition.

A nurse is assessing a client who recently experienced a stroke. The client has a left facial droop, hemiparesis of the upper left extremity, and diplopia. Which nursing intervention is most appropriate for this client? Encourage the client to write rather than attempt to speak. Consistently place client care items in the same location. Assess the vagus nerve function before giving food or fluids. Match visual tasks with a verbal statement.

Consistently place client care items in the same location. Explanation: Clients with diplopia see two of the same object. Consistently placing items in the same location assists the client in locating the item. Based on the clinical presentation, the client most likely had a stroke located in the right middle cerebral artery. The speech center, Broca's area, is located in the left hemisphere of the brain and therefore the client may have some slurred speech due to the facial droop, but not experience aphasia. The vagus nerve, which controls swallowing, is located in the brainstem. The client has double vision, therefore writing or observing visual cues would be difficult.

A client is to have a below-the-knee amputation. Before the surgery, what should the circulating nurse in the operating room do? Start an intravenous (IV) infusion. Insert a Foley catheter. Initiate a time-out. Verify that the surgeon possesses the degree of expertise needed.

Initiate a time-out. Explanation: The Universal Protocol is used to prevent wrong-site, wrong-procedure, and wrong-person surgery. The actions included in the protocol are: conduct a preprocedure verification process; mark the procedure site; and perform a time-out. Exceptions to the Universal Protocol are routine or "minor" procedures, such as venipuncture, peripheral IV line placement, insertion of oral/nasal drainage or feeding tubes, or Foley catheter insertion. Prior to closure, the surgeon or circulating nurse will initiate a time-out to verbally confirm a review of informed consent and procedures completed; all specimens are identified, accounted for, and accurately labeled; and all foreign bodies have been removed. The chief of surgery and medical director are the ones who will verify the surgeons' levels of expertise.

The nurse has positioned a client in balanced skeletal traction. What should the nurse do to ensure the traction is effective? Remove the weights briefly as necessary to reposition the client in bed. Increase the traction weight gradually as the client's tolerance increases. Apply and remove the traction weights at regular intervals throughout the day. Observe that the traction weights hang freely from the bed at all times.

Observe that the traction weights hang freely from the bed at all times. Explanation: In balanced skeletal traction, the appropriate pressures and counter pressures are applied to the fracture site, with the traction weights hanging freely at all times. The amount of traction weight used is determined by radiography and the alignment of the fracture. These weights are in place continuously and should never be lifted, reduced, or eliminated.

The emergency room nurse is caring for a client who fell, breaking the tibia. The nurse determines that the client understands the risk of compartment syndrome when knowing to report which early symptom following treatment? heat swelling skin flushing paresthesia

paresthesia Explanation: Compartment syndrome is the compression of the nerves, blood vessels, and muscle inside a closed space. It may occur after trauma to an extremity. The earliest sign of compartment syndrome is paresthesia. This is one of the "5 Ps" of compartment syndrome. The others are pain out of proportion to the injury, pallor and delayed capillary refill, normal-to-absent pulses in distal extremity, and paralysis in the limb (a late sign). Flushing, swelling, and heat are not associated with compartment syndrome.

A home care nurse visits a client with muscular dystrophy. Which comment by the client indicates that more information about an advance directive is needed? "I'm going to the doctor to get a new brace next week." "I've documented that my younger brother will make decisions about my care for me if I am not able to." "I've got a sore on my heel where my wheelchair rubs." "I don't ever want a feeding tube when the time comes that I can't eat."

"I don't ever want a feeding tube when the time comes that I can't eat." Explanation: The client states a desire not to have a feeding tube but does not say that this wish is formally documented. There may be a need for teaching about advance directives. When the client says that a specific relative will make decisions and that this intent is documented, it is unlikely that further teaching is needed. Statements about a new brace or a sore relate to the client's condition and care plan and are not relevant to advance directives.

A client undergoes an arthroscopy at the outpatient clinic. After the procedure, the nurse provides discharge teaching. Which response by the client indicates the need for further teaching? "I should use my heating pad this evening to reduce some of the pain in my knee." "Elevating my leg will reduce swelling after the procedure." "I may notice some bruising or swelling in my knee." "My physician may prescribe pain pills after the procedure."

"I should use my heating pad this evening to reduce some of the pain in my knee." Explanation: The client requires additional teaching if he states that he'll use a heating pad to reduce pain the evening of the procedure. The client shouldn't use heat at the procedure site during the first 24 hours because doing so may increase localized swelling. Ice is indicated during this time. Elevating the extremity helps reduce swelling. The client may experience some discomfort after the procedure for which the physician may order medication. Bruising and swelling are common after an arthroscopy.

A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct? "OA affects joints on both sides of the body. RA is usually unilateral." "OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." "OA and RA are very similar. OA affects the smaller joints and RA affects the larger, weight-bearing joints." "OA is more common in women. RA is more common in men."

"OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." Explanation: OA is a degenerative arthritis, characterized by the loss of cartilage on the articular surfaces of weight-bearing joints with spur development. RA is characterized by inflammation of synovial membranes and surrounding structures. OA may occur in one hip or knee and not the other, whereas RA commonly affects the same joints bilaterally. RA is more common in women; OA affects both sexes equally.

To reduce the incidence of complications in a client in traction, which intervention should be included in the care plan? Reduce fluid intake. Increase fiber intake. Remove the weights during linen changes. Increase calorie intake.

Increase fiber intake. Explanation: Immobility increases the incidence of constipation. Increasing fiber intake will reduce GI complications. The weights in traction should never be removed. Inactivity results in fewer calories being burned. Increasing calories would be counterproductive. Reducing fluids will increase the likelihood of constipation.

The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which statement indicates that the client still has a knowledge deficit? "I can use heat and cold as often as I want." "Heat-producing liniments can be used with other heat devices." "With heat, I should apply it for no longer than 20 minutes at a time." "Ten to 15 minutes per application is the maximum time for cold applications."

"Heat-producing liniments can be used with other heat devices." Explanation: Heat-producing liniment can produce a burn if used with other heat devices that could intensify the response to the heat. Heat and cold can be used as often as the client desires. However, each application of heat should not exceed 20 minutes, and each application of cold should not exceed 10 to 15 minutes. Application for longer periods results in the opposite of the intended effect: vasoconstriction instead of vasodilation with heat and vasodilation instead of vasoconstriction with cold.

The nurse is providing teaching for a client being discharged after a fiberglass cast application for a fractured tibia. Which statement by the client indicates need for further teaching? "Pain at the fracture site and a small amount of swelling is to be expected." "I should be able to freely wiggle my toes while in the cast." "Hot, painful, areas on the cast are normal and can be treated with ice packs." "I can shower with the cast as long as I keep it well covered."

"Hot, painful, areas on the cast are normal and can be treated with ice packs." Explanation: Teaching should include recognition of important signs and symptoms that would indicate circulation impairment; these include pale skin and coolness of the extremity. Additionally, the nurse teaches the client that hot, painful areas can be a sign of infection and should be addressed. Pain from the fracture and a small amount of swelling is normal. The client should be able to wiggle toes and can shower but should avoid getting the cast wet or getting water inside the cast.

The client was recently diagnosed with a musculoskeletal disorder and ordered carisoprodol. The nurse completes teaching about the medication. Which statement by the client indicates a need for more teaching about carisoprodol? "I may take my medication with food or milk." "I'll have someone drive me to work for a few days." "I won't have wine with dinner anymore." "I will stop the medication as soon as the muscle spasticity goes away."

"I will stop the medication as soon as the muscle spasticity goes away." Explanation: The nurse must clarify that muscle spasticity will return if the medication is suspended. Also, abrupt cessation of carisoprodol may cause withdrawal effects. Carisoprodol may be taken with or without food; it should be taken with food or milk if GI upset occurs. This medication should not be used with alcohol, and activities such as driving should be avoided until the client is assured that the drug will not cause drowsiness or dizziness.

The nurse is providing information to the parents of a child newly diagnosed with juvenile arthritis. Which statements by the parents indicate understanding of the teaching? Select all that apply. "I help my child perform daily range-of-motion exercises." "I apply heat pads to the joints when my child is having pain." "I give my child NSAIDs three times a day." "I don't think my child should exercise to help the condition." "I encourage my child to stay home from school regularly."

"I help my child perform daily range-of-motion exercises." "I apply heat pads to the joints when my child is having pain." "I give my child NSAIDs three times a day." Explanation: NSAIDs are taken one to four times a day by children with juvenile arthritis and are given to control pain and inflammation as well as malaise and irritability. NSAIDs should be given even when the child is pain free because the anti-inflammatory properties of the drugs are key to preventing pain. Assisting the child to perform daily range-of-motion exercises and applying heat pads to joints when in pain are also correct interventions. The child should be encouraged to attend school regularly and to exercise.

A client with a history of osteoarthritis is admitted to the rehabilitation unit after hospitalization for a hip fracture. Which plan by the multidisciplinary team best optimizes client outcomes? Coordinating all activities in the afternoon so that the client is tired at bedtime. Alternating periods of activity with periods of rest to optimize client participation Coordinating activities in the morning so that the client can rest in the afternoon and evening Including the client in developing a care plan that works toward meeting discharge goals

Including the client in developing a care plan that works toward meeting discharge goals Explanation: Involving the client in the care plan development optimizes client outcomes; alternating periods of activity and rest helps optimize participation. Coordinating all activities in the morning or afternoon doesn't necessarily optimize client participation.

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician? a small amount of yellow drainage at the left pin insertion site a slight reddening of the skin surrounding the insertion site pain at the insertion site crust around the pin insertion site

a small amount of yellow drainage at the left pin insertion site Explanation: The nurse should report the presence of yellow drainage, which indicates the presence of infection, at the left pin insertion site. Crust formation around the pin site is a natural response to the trauma caused by the pin insertion. Redness at the insertion site may be an early sign of infection; the nurse should continue to monitor the area, but this finding doesn't need to be reported to the physician. The client may experience pain at the pin insertion sites; therefore, the nurse should administer pain medications as ordered. It's necessary to notify the physician only if the pain medication is ineffective.

A client in a double-hip spica cast is constipated. The surgeon cuts a window into the front of the cast. Which outcome is intended? The window in the cast will allow: relief from pressure due to abdominal distention. the surgeon to manipulate the fracture site. the nurse to reposition the client. the nurse to palpate the superior mesenteric artery.

relief from pressure due to abdominal distention. Explanation: The hip spica cast is used for the treatment of femoral fractures; it immobilizes the affected extremity and the trunk securely. A double-hip spica cast extends from above the nipple line to the base of the foot of both extremities. Constipation, possibly caused by lack of mobility, can cause abdominal distention or bloating. When the spica cast becomes too tight because of distention, the cast will compress the superior mesenteric artery against the duodenum. The compression produces abdominal pain, abdominal pressure, nausea, and vomiting. To relieve the compression, the surgeon can cut a "window" in the cast. The nurse should assess the abdomen for decreased bowel sounds, not the superior mesenteric artery. The surgeon cannot manipulate a fracture through a small window in a double-hip spica cast. The nurse cannot use the window to aid in repositioning because the window opening can break and negate the effect of the cast.

The nurse is caring for an older adult male client who had an open reduction internal fixation of the right hip 24 hours ago. The client is now experiencing shortness of breath and reports having "tightness in my chest." The nurse reviews the recent lab test results. The nurse should report which lab test result to the health care provider? serum glucose: 120 mg/dL (6.7 mmol/L) erythrocyte sedimentation rate (ESR): 22 mm per hour hematocrit: 40% (0.4 proportion of 1.0) troponin: 1.4 mcg/L (1.4 μg/L)

troponin: 1.4 mcg/L (1.4 μg/L) Explanation: Troponin is a cardiac biomarker and is normally almost undetectable in the blood. A level of 1.4 mcg/L (1.4 μg/L) means there has likely been some damage to the heart muscle. Although the serum glucose level (normal is 60 to 100 mg/dL [3.3 to 5.5 mmol/L]) and the ESR (normal is less than 20 mm per hour for men older than 50 years) are slightly elevated, this could be explained by normal stress and an inflammatory response to surgery. The hematocrit level is low (normal is 40% to 45% [0.4 to 0.5 proportion of 1.0] for men), but it is also not unexpected for a client following surgery.

A client undergoes a total hip replacement. Which statement made by the client indicates to the nurse that the client requires further teaching? "I'll need to keep several pillows between my legs at night." "The occupational therapist is showing me how to use a sock puller to help me get dressed." "I need to remember not to cross my legs. It's such a habit." "I don't know if I'll be able to get off that low toilet seat at home by myself."

"I don't know if I'll be able to get off that low toilet seat at home by myself." Explanation: The client requires additional teaching if they are concerned about using a low toilet seat. To prevent hip dislocation after a total hip replacement, the client must avoid bending the hips beyond 90 degrees. The nurse should instruct the client to use assistive devices, such as a raised toilet seat, 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. 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.

X-rays reveal a leg fracture in a client who was brought to the emergency department after falling on ice. After a cast is applied and allowed to dry, the nurse teaches the client how to use crutches. Which instruction should the nurse provide about climbing stairs? "Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together." "Place both crutches on the first step and swing both legs upward to this step." "Place the crutches and injured leg on the first step, followed by the unaffected leg." "Place the injured leg and the crutch on the unaffected side on the first step; the unaffected leg and crutch on the injured side follow."

"Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together." Explanation: When climbing stairs with crutches, the client should lead with the unaffected leg, followed by the crutches and injured leg moving together. Any other method is incorrect and could increase the client's risk of falling.

The day after a thoracotomy, a client experiencing intense incision pain has a temperature of 99° F (37.2° C); heart rate 96 beats/minute; blood pressure 136/86 mm Hg; and shallow respirations at 24 breaths/minute, with rhonchi at the bases and an oxygen saturation of 98%. Which nursing action is the priority? Turn and reposition the client every 2 hours when in bed. Administer analgesic medications as prescribed. Assist the client out of bed to sitting up in a chair. Provide antipyretics as prescribed to reduce the fever.

Administer analgesic medications as prescribed. Explanation: The priority is to relieve the pain and make the client comfortable. The vital signs are possible evidence of acute discomfort, although further assessment would be needed. Once the client is comfortable, assisting the client out of bed or turning and repositioning when in bed would be accomplished without adding to the discomfort. There is no evidence of acute respiratory complications; the oxygen saturation level is normal. Antipyretic medication would not be indicated for a client with this temperature.

On the evening of surgery for a total knee replacement, a client wants to get out of bed. What should the nurse do to safely assist the client? Ask the health care provider (HCP) to prescribe a walker for the client. Apply a knee immobilizer. Encourage the client to apply full weight bearing. Place a straight-backed chair at the foot of the bed.

Apply a knee immobilizer. Explanation: The knee is usually protected with a knee immobilizer (splint, cast, or brace) and is elevated when the client sits in a chair. Before and after surgery, the HCP prescribes weight-bearing limits and the use of assistive devices for progressive ambulation. Positioning a straight-backed chair at the foot of the bed is not an activity conducive to getting the client out of bed on the evening before surgery for a total knee replacement.

A client has a fiberglass cast on the right arm which was placed after internal fixation 1 week ago. The nurse notes a warm area on the cast. What priority action should the nurse take? Apply an ice pack to the warm area of the cast. Elevate the casted arm above the level of the heart. Assess client's temperature and interview about pain at the site. Ask the client if the cast has gotten wet recently.

Assess client's temperature and interview about pain at the site. Explanation: The nurse noting a warm area on the cast should alert to the possibility of infection. Internal fixation involves surgical intervention, and once the cast is applied, the surgical site is not readily visible. The warm area may indicate inflammation at the site. Additional signs of infection include fever and increased pain. A fiberglass cast can get wet, and being wet does not increase warmth. If swelling and pain is present, ice and elevation is recommended but is not the priority over assessing for signs of infection.

A client is admitted to undergo lumbar laminectomy for treatment of a herniated disk. Which action should the nurse take first to promote comfort preoperatively? Notify the physician of the client's pain. Administer hydrocodone as ordered. Help the client assume a more comfortable position. Provide teaching on nonpharmacologic measures to control pain.

Help the client assume a more comfortable position. Explanation: The nurse should first help the client assume a more comfortable position. After doing so, the nurse may administer pain medication as ordered. Next, the nurse should assess the client's knowledge of nonpharmacologic measures to relieve pain and provide teaching as necessary. If the client's pain isn't relieved after taking these actions, the nurse should notify the physician of the client's pain issues.

A client has a C7 spinal cord injury. Which would be the most important nursing intervention during the acute stage of the injury? Maintain proper alignment. Turn and reposition every 2 hours. Maintain a patent airway. Monitor vital signs.

Maintain a patent airway. Explanation: Initial care is focused on establishing and maintaining a patent airway and supporting ventilation. Innervation to the intercostal muscles is affected; if spinal edema extends to the C4 level, paralysis of the diaphragm usually occurs. The effects and extent of edema are unpredictable in the first hours, and respiratory status must be closely monitored. Suction equipment should be readily available. Monitoring vital signs, maintaining proper alignment, and turning and positioning are important, but the priority nursing intervention is maintaining a patent airway.

A client had a total hip replacement today. How should the nurse position the client when the client is transferred from the transport cart to the bed? Keep the lower extremities adducted by placing an immobilization device around both legs. Place weights alongside the affected extremity to keep the extremity from rotating. Elevate both feet on two pillows. Maintain the affected extremity in slight abduction by using an abduction splint or placing pillows between the thighs.

Maintain the affected extremity in slight abduction by using an abduction splint or placing pillows between the thighs. Explanation: After total hip replacement, proper positioning by the nurse prevents dislocation of the prosthesis. The nurse should place the client in a supine position and keep the affected extremity in slight abduction using an abduction splint or pillows or Buck's extension traction. The client must not abduct or flex the operated hip because this may produce dislocation.

A client is brought to the emergency department after injuring their right arm in a bicycle accident. The orthopedic surgeon tells the nurse that the client has a greenstick fracture of the arm. What does this mean? One side of the bone is broken and the other side is bent. Bone fragments are separated at the fracture line. The fracture line extends through the entire bone substance. The fracture results from an underlying bone disorder.

One side of the bone is broken and the other side is bent. Explanation: In a greenstick fracture, one side of the bone is broken and the other side is bent. A greenstick fracture also may refer to an incomplete fracture in which the fracture line extends only partially through the bone substance and doesn't disrupt bone continuity completely. (Other terms for greenstick fracture are willow fracture and hickory-stick fracture.) The fracture line extends through the entire bone substance in a complete fracture. A fracture that results from an underlying bone disorder, such as osteoporosis or a tumor, is a pathologic fracture, which typically occurs with minimal trauma. Bone fragments are separated at the fracture line in a displaced fracture.

A nurse is caring for a client who complains of lower back pain. Which instruction should the nurse give to the client to prevent back injury? "Push or pull an object using your arms." "Narrow the stance when lifting." "Stand close to the object you're lifting." "Bend over the object you're lifting."

"Stand close to the object you're lifting." Explanation: Standing close to an object when lifting moves the body's center of gravity closer to the object, allowing the legs, rather than the back, to bear the weight. No one should bend over an object when lifting; instead, the back should be straight, and bending should be at the hips and knees. When lifting, spreading the legs apart widens the base of support and lowers the center of gravity, providing better balance. Pushing or pulling an object using the weight of the body, rather than the arms or back, prevents back strain. Using a larger number of muscle groups distributes the workload.

A client being discharged after treatment for a compound fracture asks why antibiotics are needed for a broken bone. Which response by the nurse is most appropriate? "If your temperature is normal for 48 hours, you may discontinue the medication." "You may discuss your prescriptions with your healthcare provider at your follow-up appointment." "The antibiotics are prescribed to help the bone heal more quickly and more strongly." "This prophylactic antibiotic therapy is required because your bone broke through your skin."

"This prophylactic antibiotic therapy is required because your bone broke through your skin." Explanation: The client should be instructed that antibiotics are prescribed as a preventive measure after a compound fracture because such fractures expose the bone to the environment and possible infection. Directing the client to discuss prescribed medications with the healthcare provider at a follow-up appointment does not address the client's questions or immediate needs. The client needs this medication regardless of body temperature. Antibiotics are not used to enhance the healing of a bone fracture.

The nurse is planning care with an older adult who is at risk for falling because of postural hypotension. Which intervention will be most effective in preventing falls in this client? Instruct the client to sit, obtain balance, dangle their legs, and rise slowly. Attach a sensor to the client that will alarm when the client attempts to get up. Complete a fall diary. Encourage a family member to stay with the client.

Instruct the client to sit, obtain balance, dangle their legs, and rise slowly. Explanation: There are many risk factors for falls in older adults. Postural hypotension is a common risk. The nurse should instruct the client about postural hypotension and provide practical information regarding how to sit on the bed or chair, dangle the legs first and then rise slowly, supported by a walker if necessary.A diary of instances of an individual's falls may predict future falls by tracking the events and behaviors at the time of the fall, but it is not the most effective in preventing the fall.Asking a family member to be present at all times is not necessary or realistic for this client whose fall risk is attributed to the potential for postural hypotension.Attaching a sensor to the client or bed is reserved for clients who are at a serious risk for injury.

A client was undergoing conservative treatment for a herniated nucleus pulposus, at L5 - S1, which was diagnosed by magnetic resonance imaging. Because of increasing neurological symptoms, the client undergoes lumbar laminectomy. The nurse should take which step during the immediate postoperative period? Have the client sit up in a chair as much as possible. Discourage the client from doing any range-of-motion (ROM) exercises. Elevate the head of the bed to 90 degrees. Logroll the client from side to side.

Logroll the client from side to side. Explanation: Logrolling the client maintains alignment of the hips and shoulders and eliminates twisting in the operative area. The nurse should encourage ROM exercises to maintain muscle strength. Because of pressure on the operative area, having the client sit up in a chair or with the head of the bed elevated should be allowed only for short durations.

A male client underwent a lumbar spinal fusion yesterday. Which nursing assessment should alert the nurse to the development of a possible complication? use of the standing position to void clear yellowish fluid on the dressing nonproductive cough lateral rotation of the head and neck

clear yellowish fluid on the dressing Explanation: Clear yellowish fluid on the dressing may be cerebrospinal fluid (CSF). This fluid must be tested for glucose to determine whether it is CSF. If so, the client is at great risk for an infection of the central nervous system, which has a high mortality rate. The client should be able to laterally rotate the head and neck, which is above the surgical site in the spinal column. During the nursing postoperative neuromuscular-vascular assessment of movement of the head and neck, the nurse should find results consistent with the preoperative baseline status. Using the standing position to void is normal for a male client. Coughing is the body's defense mechanism to help clear the lungs of the anesthetic agents and to ventilate the lungs in response to a sustained deep inspiration for ventilation of the lower lobes of the lungs. A frequent cough could place a strain on the incision site and should be avoided. Also, a productive cough of thick, yellow sputum would indicate the complication of a respiratory infection.

A client is being discharged following an open reduction and internal fixation of the left ankle and is to wear a non-weight-bearing cast for 2 weeks. What should the nurse teach the client to do when using crutches? Use a four-point gait. Maintain balance by supporting the body's weight on the axillae. Keep the leg dependent when sitting. Maintain two to three finger widths between the axillary fold and underarm piece grip.

Maintain two to three finger widths between the axillary fold and underarm piece grip. Explanation: The nurse instructs the client to maintain two finger widths between the axillary fold and the underarm piece grip of the crutches to prevent pressure on the brachial plexus. The client is advised to use the three-point gait; in the four-point and two-point gait, there is partial weight bearing of both feet. The client is also advised to keep the affected leg elevated when sitting to prevent swelling and to use the arms, not the axillae, to maintain balance and support.

The nurse is caring for a client with a fractured fibula who has skeletal traction and skeletal pins. What would the nurse instruct the unlicensed assistive personnel (UAP) to report immediately? There is a small amount of clear fluid at the pin sites. The traction weights are resting on the floor. The client wants to change position. The client is reporting pain and muscle spasm.

The traction weights are resting on the floor. Explanation: The weights should always hang freely. When the weights are on this floor, they are not exerting pulling force to provide reduction and alignment or to prevent muscle spasm. Attending to the weights may reduce the client's pain and spasm. Skeletal pins usually have a small amount of clear fluid. It is most important to check the traction system after a client changes position, because position changes may alter the traction.

On a visit to the family physician, a client is diagnosed with a bunion on the lateral side of the great toe, at the metatarsophalangeal joint. Which statement should the nurse include in the teaching session? "Bunions are congenital and can't be prevented." "Bunions may result from wearing shoes that are too big, causing friction when the shoes slip back and forth." "Bunions are caused by a metabolic condition called gout." "Some bunions are congenital; others are caused by wearing shoes that are too short or narrow."

"Some bunions are congenital; others are caused by wearing shoes that are too short or narrow." Explanation: Bunions may be congenital or may be acquired by wearing shoes that are too short or narrow, which increases pressure on the bursa at the metatarsophalangeal joint. Acquired bunions can be prevented. Wearing shoes that are too big may cause other types of foot trauma but not bunions. Gout doesn't cause bunions. Although a client with gout may have pain in the big toe, such pain doesn't result from a bunion.