Unit 16

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds knowing that which would most likely result from this improper crutch measurement? 1. A fall and further injury 2. Injury to the brachial plexus nerves 3. Skin breakdown in the area of the axilla 4. Impaired ROM while the client ambulates

2. Injury to the brachial plexus nerves

The nurse is administering an IV dose of methocarbamol to a client with a muscle skeletal injury. For which adverse effect should the nurse monitor? 1. Tachycardia 2. Rapid pulse 3. Bradycardia 4. Hypertension

3. Bradycardia

The nurse is caring for a client with a diagnosis of gout. Which lab value would the nurse expect to note in the client? 1. calcium of 9 2. uric acid of 9 3. potassium of 4.1 4. phosphorus of 3.1

2. uric acid of 9

A client with a hip fracture asks the nurse about Buck's extension traction that is being applied before surgery and what is involved. The nurse should provide which information to the client? 1. Allows bony healing to begin before surgery and involves pins and screws 2. Provides rigid immobilization of the fracture site and involves pulleys and wheels 3. Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws 4. Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels

4. Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels

A client with DM has had a right below the knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery? 1. Hemorrhage 2. Edema of the residual limb 3. Slight redness of the incision 4. Separation of the wound edges

4. Separation of the wound edges

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this problem? 1. a 25 year old woman who runs 2. a 36 year old man who as asthma 3. a 70 year old man who consumes excessive alcohol 4. a sedentary 65 year old woman who smokes cigarettes

4. a sedentary 65 year old woman who smokes cigarettes

The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and has a plaster cast applied. Which position would be best for the casted leg? 1. elevated for 3 hours, then flat for 1 hour 2. flat for 3 hours, then elevated for 1 hour 3. flat for 12 hours, then elevated for 12 hours 4. elevated on pillows continuously for 24-48 hours

4. elevated on pillows continuously for 24-48 hours

The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take? 1. try to reduce the fracture manually. 2. assist the victim to get up and walk to the sidewalk. 3. leave the victim for a few moments to call an ambulance. 4. stay with the victim and encourage him or her to remain still.

4. stay with the victim and encourage him or her to remain still.

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? 1. Clear mentation 2. Minimal dyspnea 3. O2 sat of 85% 4. Arterial oxygen level of 78

1. Clear mentation

Allopurinol is prescribed for a client and the nurse provides medication instructions to the client. Which instruction should the nurse provide? 1. Drink 3L of fluid a day 2. Take the med on an empty stomach 3. The effect of the med will occur immediately 4. Any swelling of the lips is a normal expected response

1. Drink 3L of fluid a day

Cyclobenzaprine is prescribed for a client for muscle spasms, and the nurse is reviewing the client's record. Which disorder, if noted in the record, would indicate a need to contact the PHCP about the administration of this med? 1. Glaucoma 2. Emphysema 3. Hypothyroidism 4. DM

1. Glaucoma

A client is being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper care of the cast? 1. I need to avoid getting the cast wet 2. I need to cover the casted leg with warm blankets 3. I need to use my fingertips to lift and move my leg 4. I need to use something like a padded coat hanger end to scratch under the cast if it itches

1. I need to avoid getting the cast wet

The nurse has given the client instructions about crutch safety. Which statements indicate that the client understands the instructions? Select all that apply. 1. I should not use someone else's crutches. 2. I need to remove any scatter rugs at home. 3. I can use crutch tips even when they are wet. 4. I need to have spare crutches and tips available 5. When I'm using the crutches, my arms need to be completely straight

1. I should not use someone else's crutches. 2. I need to remove any scatter rugs at home. 4. I need to have spare crutches and tips available

In monitoring a client's response to disease-modifying antirheumatic drugs (DMARDs), which findings would the nurse interpret as acceptable responses? Select all that apply. 1. Symptom control during periods of emotional stress 2. Normal white blood cell counts, platelet, and neutrophil counts 3. Radiological findings that show nonprogression of joint degeneration 4. An increased range of motion in the affected joints 3 months into therapy 5. Inflammation and irritation at the injection site 3 days after injection is given 6. A low-grade temperature upon rising in the morning that remains throughout the day

1. Symptom control during periods of emotional stress 2. Normal white blood cell counts, platelet, and neutrophil counts 3. Radiological findings that show no progression of joint degeneration 4. An increased range of motion in the affected joints 3 months into therapy

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. Temp of 101.6 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. Temp of 101.6 orally

Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. 1. keep the cast clean and dry. 2. allow the cast 24 to 72 hours to dry. 3. keep the cast and extremity elevated. 4. expect tingling and numbness in the extremity. 5. use a hair dryer set on a warm to hot setting to dry the cast. 6. use a soft, padded object that will fit under the cast to scratch the skin under the cast.

1. keep the cast clean and dry. 2. allow the cast 24 to 72 hours to dry. 3. keep the cast and extremity elevated.

The nurse is preparing discharge instructions for a client who sustained a skeletal muscle injury and is receiving baclofen. Which instruction should be included in the teaching plan? 1. Restrict fluid intake 2. Avoid the use of alcohol 3. Stop the med if diarrhea occurs 4. Notify the PHCP if fatigue occurs

2. Avoid the use of alcohol

Colchicine is prescribed for a client with a diagnosis of gout. The nurse reviews the client's record, knowing that this medication would be used with caution in which disorder? 1. Myxedema 2. Kidney disease 3. Hypothyroidism 4. Diabetes mellitus

2. Kidney disease

The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome? 1. Cold, bluish-colored fingers 2. Numbness and tingling in the fingers 3. Pain that increases when the arm is dependent 4. Pain that is out of proportion to the severity of the fracture

2. Numbness and tingling in the fingers

A client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept, which is most important for the nurse to asses? 1. The injection site for itching and edema 2. The WBC counts and platelet counts 3. Whether the client is experiencing fatigue and joint pain 4. Whether the client is experiencing a metallic taste in the mouth and a loss of appetite

2. The WBC counts and platelet counts

A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor? 1. Bed rest 2. Ibuprofen 3. Bending or lifting 4. Application of heat

3. Bending or lifting

The nurse is analyzing the lab studies on a client receiving dantrolene to treat muscle spasms from an injury. Which lab test would identify an adverse effect associated with the administration of this medication? 1. Platelet count 2. Creatinine level 3. Liver function tests 4. BUN level

3. Liver function tests

The nurse is assessing the casted extremity of a client. Which sign is indicative of infection? 1. Dependent edema 2. Diminished distal pulse 3. Presence of a "hot spot" on the cast 4. Coolness and pallor of the extremity

3. Presence of a "hot spot" on the cast

The nurse is caring for a client who had an above knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take? 1. Apply ice to the site 2. Call the PHCP 3. Rewrap the residual limb with an elastic compression bandage 4. Apply a dry, sterile dressing and elevate the residual limb on 1 pillow

3. Rewrap the residual limb with an elastic compression bandage

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding?1. Redness around the pin sites 2. Pain on palpation 3. Thick, yellow drainage from the pin sites 4. Clear, watery drainage from the pin sites

3. Thick, yellow drainage from the pin sites

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by: 1. infection under the cast 2. the anxiety of the client 3. impaired tissue perfusion 4. the recent occurrence of the fracture

3. impaired tissue perfusion

The nurse has given instruction to a client returning home after a knee arthroscopy. Which statement by the client indicates that the instructions are understood? 1. I can resume regular exercise tomorrow 2. I can't eat food for the remainder of the day 3. I need to say off the leg entirely for the rest of the day 4. I need to report a fever or swelling to my health care provider

4. I need to report a fever or swelling to my health care provider

Alendronate is prescribed for a client with osteoporosis and the nurse is providing instructions on administration of the medication. Which instructions should the nurse provide? 1. Take the med at bedtime 2. Take the med in the morning with breakfast 3. Lie down for 30 mins after taking the med 4. Take the med with a full glass of water after rising in the morning

4. Take the med with a full glass of water after rising in the morning