exam 5 musculoskeletal integumentary

Which zone of burn injury sustains the most damage?

inner

While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at her daughter's home with six other people. During her visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:

"all family members need to be treated"

A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction?

"apply ice oacks for the first 24hrs, then apply heat packs"

A client with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the client's cast care?

"keep your right leg elevated above heart level"

The nurse is planning discharge instructions for the client with osteomyelitis. What instructions should the nurse include in the discharge teaching?

"you will receive IV antibiotics for 3 to 6 weeks"

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?

27%

A nurse is performing the initial assessment of a client who has a recent diagnosis of systemic lupus erythematosus (SLE). What skin manifestation would the nurse expect to observe on inspection?

butterfly rash

The nurse assesses a patient with silvery-white, thick scales on the scalp, elbows, and hand that bleed when picked off. What does the nurse suspect that this patient may have?

psoriasis

The nurse knows that a patient who presents with the symptom of "blanching of fingers on exposure to cold" would be assessed for what rheumatic disease?

raynaud's phenomenon

The nurse is providing education to the client with multiple burns and lists the options for skin grafting and application techniques. Which is the primary benefit for using an autograft slit graft versus other types of grafts?

rejection is unlikely

Which nursing diagnosis takes highest priority for a client with a compound fracture?

risk for infection related to effects of trauma

A client calls the clinic and tells the nurse that he was bitten by a tick and is afraid he has Lyme disease. How long does the nurse understand that the tick must be attached to have Lyme disease?

36 to 48 hrs

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?

36%

An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?

36%

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?

a urine output consistently above 40 ml/ hour

While reading a client's chart, the nurse notices that the client is documented to have paresthesia. The nurse plans care for a client with...

abnormal sensations

A patient is scheduled for a procedure that will allow the physician to visualize the knee joint in order to diagnose the patient's pain. What procedure will the nurse prepare the patient for?

arthroscopy

The nurse is preparing a client for a surgical procedure that will allow visualization of the extent of joint damage of the knee for a client with rheumatoid arthritis and also obtain a sample of synovial fluid. What procedure will the nurse prepare the client for?

arthroscopy

A client has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action?

assess the clients peripheral pulses distal to the dressing

A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock?

decreased blood pressure

The nurse is assessing the client following orthopedic surgery for a deep vein thrombosis. When performing this assessment, the nurse is most correct to perform which movement?

dorsiflexion

A young student is brought to the school nurse after falling off a swing. The nurse is documenting that the child has bruising on the lateral aspect of the right arm. What term will the nurse use to describe bruising on the skin in documentation?

ecchymoses

The nurse is reviewing the diagnostic test findings of a client with rheumatoid arthritis. What would the nurse expect to find?

elevated erythrocyte sedimentation rate

A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the:

epidermis and portion of deeper dermis

Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area?

fluid resuscitation

A client is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the client's arm?

full thickness

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following?

full-thickness

Which of the following conditions is the cause of thickening of the nail?

fungal infection

A nurse is teaching a client about preventing osteoporosis. Which teaching point is correct?

the recommended daily allowance of calcium may be found in a wide variety of foods

A 91-year-old client is slated for orthopedic surgery and the nurse is integrated gerontologic considerations into the client's plan of care. What intervention is most justified in the care of this client?

use of a pressure-relieving mattress

How long does it take for the bone to regain its former structural strength after a break?

1 year

The nurse teaches the client that the presence of crystals in the synovial fluid obtained from arthrocentesis confirms which disease process?

Gout

A nurse is caring for a client with an undiagnosed bone disease. When instructing on the normal process to maintain bone tissue, which process transforms osteoblasts into mature bone cells?

Ossification and calcification

The purpose of melanin is to:

determin skin color

Dry, rough, scaly skin with the presence of itching is best described as:

pruritus

A client in the emergency department is being treated for a wrist fracture. The client asks why a splint is being applied instead of a cast. What is the best response by the nurse?

"a splint is applied when more swelling is expected at the site of injury"

When performing a skin assessment, the nurse notes a localized skin infection of a single hair follicle. The nurse documents the presence of

a furuncle

A patient is evaluated for a diagnosis of Paget's disease. Which of the following is a diagnostic finding for this disease?

alkaline phosphate of 165 IU/L

A nurse is reviewing the pathophysiology that may underlie a client's decreased bone density. What hormone should the nurse identify as inhibiting bone resorption and promoting bone formation?

calcitonin

The nurse intervenes to assist the client with fibromyalgia to cope with which symptoms?

chronic fatigue, generalized muscle aching, and stiffness

Which term describes the transfer of heat from the body to a cooler object in contact with it?

conduction

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

hoarness of the voice

The nurse observes an African-American patient with a large hypertrophied area of scar tissue on the left ear lobe. What does the nurse document this finding as?

keloid

a client experiences a musculoskeletal injury that involves the structure that connects a muscle to the bone. the nurse understands that this injury involves which structure?

tendon

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior?

the client has experienced extensive full-thickness burns

Which device is designed specifically to support and immobilize a body part in a desired position?

splint

A client who has undergone a lower limb amputation is preparing to be discharged home. What outcome is necessary prior to discharge?

client can demonstrate safe use of assistive devices

Which would be contraindicated as a component of self-care activities for the client with a cast?

cover the cast with plastic to insulate it

Which term refers to an injury to ligaments and other soft tissues surrounding a joint?

sprain

A client has a burn on the leg related to an engine fire. When the burn area was assessed, it was determined that the client felt no pain in the area and that it appeared charred. What depth of burn injury does the client have?

fullthickness (third degree)

The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply.

hourly urine output skin turgor daily weights

Production of melanin is controlled by a hormone secreted by which gland?

hypothalamus

A patient with a history of chronic respiratory illness exhibits nail clubbing. The nurse interprets this finding as indicating which of the following?

hypoxia

Which of the following is the analgesic of choice for burn pain?

morphine sulfate

Each bone is comprised of cells, protein matrix, and mineral deposits. Which type of bone cell is not only a mature bone cell, but is also involved in maintaining bone tissue.

osteocytes

An elderly client's hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse's priority assessment?

signs of neurovascular compromise

The health care team is caring for a client with osteomalacia. It has been determined that the osteomalacia is caused by malabsorption. What treatment should the nurse anticipate?

supplemental calcium and increased doses of vitamin D

A nurse is performing the health history and physical assessment of a client who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA?

joint stiffness, especially in the morning

A nurse is preparing to discharge a client from the emergency department after receiving treatment for an ankle sprain. While providing discharge education, the nurse should encourage what action?

keep an elastic compression bandage on the ankle

A nurse is caring for a patient who is postoperative day 1 right hip replacement. How should the nurse position the patient?

keep the clients hip in abduction at all times

A client's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid?

lactated ringers

The human body has 206 bones, which are classified into four categories. Which types of bones are located in the forearm?

long bones

While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects:

melanoma

The nurse is discussing the new medication that a client will be taking for treatment of rheumatoid arthritis. Which disease-modifying antirheumatic drug (DMARD) will the nurse educate the client about?

methotrexate(rheumatrex)

The nurse is caring for a client with questionable lice infestation. The nurse is using a bright light focused on an area of the head to confirm the presence of lice. In which manner is it easiest to differentiate nits from dandruff?

nitts are difficult to move from hair shafts

A nurse is caring for a client who is recovering in the hospital following orthopedic surgery. The nurse is performing frequent assessments for signs and symptoms of infection in the knowledge that the client faces a high risk of what infectious complication?

osteomyelitis

Which instruction is the most important to give a client who has recently had a skin graft?

protect the graft from direct sunlight

A 19-year-old patient presents to the emergency room with an injury to her left ankle that occurred during a high school basketball game. She complains of limited motion and pain on walking, which increased over the last 2 hours. The nurse knows that her diagnosis is most likely which of the following?

second-degree sprain

A client has had surgical repair of a hip injury after joint manipulation was unsuccessful. After surgery, the nurse implements measures to prevent complications. Which complications is the nurse seeking to prevent? Select all that apply.

skin breakdown wound infection pneumonia

Which findings from a nail assessment are considered abnormal? Select all that apply.

spooning clubbing

Radiographic evaluation of a client's fracture reveals that a bone fragment has been driven into another bone fragment. The nurse identifies this as which type of fracture?

impacted

A nurse suspects that a client with a recent fracture has compartment syndrome. Assessment findings may include:

inability to perform active movement and pain with passive movement.

A client's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response?

inform the primary care provider promptly because the graft may need to be removed

Pressure sores are categorized into one of four stages depending on the extent of injury. Which phase is described as "the pressure sore is red and accompanied by blistering or a shallow break in the skin, sometimes described as a skin tear. Impairment of the skin leads to microbial colonization and infection of the wound"?

stage II

A client has undergone arthroscopy. After the procedure, the site where the arthroscope was inserted is covered with a bulky dressing. The client's entire leg is also elevated without flexing the knee. What is the appropriate nursing intervention required in caring for a client who has undergone arthroscopy?

apply cold pack at the insertion site