Exam III Review
The nurse has given the client instructions about crutch safety. Which statement indicates 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, 2, 4 Rationale: The client should use only crutches measured for the client. When assessing for home safety, the nurse ensures that the client knows to remove any scatter rugs and does not walk on highly waxed floors. The tips should be inspected for wear, and spare crutches and tips should be available if needed. Crutch tips should remain dry. If crutch tips get wet, the client should dry them with a cloth or paper towel. When walking with crutches, both elbows need to be flexed not more than 30 degrees when the palms are on the handle.
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. Oxygen saturation of 85% 4. Arterial oxygen level of 78 mm Hg (10.3 kPa)
1. Clear mentation Rationale: An altered mental state is an early indication of fat emboli; therefore, clear mentation is a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80-100 mm Hg (10.6-13.33 kPa). Oxygen saturation should be higher than 95%.
The nurse is gathering subjective and objective data from a client with a diagnosis of suspected rheumatoid arthritis (RA). The nurse would expect to note which early signs and symptoms of RA? Select all that apply. 1. Fatigue 2. Weight gain 3. Restlessness 4. Morning stiffness 5. Pain with movement only
1. Fatigue 4. Morning stiffness Rationale: Early signs and symptoms of RA include fatigue, weight loss, fever, malaise, morning stiffness, pain at rest and with movement, and complaints of night pain. The involved joints appear edematous.
The nurse is caring for a client diagnosed with osteomyelitis. Which data noted in the client's record are supportive of this diagnosis? Select all that apply. 1. Pyrexia 2. Elevated potassium level 3. Elevated white blood cell count 4. Elevated erythrocyte sedimentation rate 5. Bone scan impression indicative of infection
1. Pyrexia 3. Elevated white blood cell count 4. Elevated erythrocyte sedimentation rate 5. Bone scan impression indicative of infection Rationale: Osteomyelitis is an infection of the bone, bone marrow, and surrounding tissue. Clinical data indicative of osteomyelitis include pyrexia, elevated white blood cell count, elevated erythrocyte sedimentation rate, and a bone scan, computed tomography scan, or magnetic resonance imaging scan indicative of infection. Elevated potassium level is not specifically associated with osteomyelitis.
The nurse is caring for a client with acute back pain. Which are the most likely causes of this problem? Select all that apply. 1. Twisting of the spine 2. Curvature of the spine 3. Hyperflexion of the spine 4. Sciatic nerve inflammation 5. Degeneration of the facet joints 6. Herniation of an intervertebral disk
1. Twisting of the spine 3. Hyperflexion of the spine 6. Herniation of an intervertebral disk Rationale: Acute back pain is sudden in onset and is usually precipitated by injury to the lower back, such as with hyperflexion, twisting, or disk herniation. Scoliosis (curvature), sciatica, and degenerative vertebral changes are more likely to cause chronic back pain, which can be more insidious in onset and may also be accompanied by degeneration of the intervertebral disk.
A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. Which are interventions to aid the client in relieving the spasm? Select all that apply. 1. Ice 2. Heat 3. Analgesics 4. Muscle relaxers 5. Intermittent traction
2. Heat 3. Analgesics 4. Muscle relaxers 5. Intermittent traction Heat, analgesics, muscle relaxers, and traction all may be used to relieve the pain of muscle spasm in the client with a vertebral fracture. Ice is applied to a painful site only for the first 48 to 72 hours (depending on the health care provider's preference) after an injury. Application of ice to the spine of a client could be uncomfortable and could result in feelings of being chilled.
A client has just undergone spinal fusion after experiencing herniation of a lumbar disk. The nurse should include which interventions to maintain client safety after this procedure? Select all that apply. 1. Use the overhead trapeze. 2. Keep the head of the bed flat. 3. Place pillows under the length of the legs. 4. Use logrolling technique for repositioning. 5. Assist the client with eating meals and drinking fluids.
2. Keep the head of the bed flat. 3. Place pillows under the length of the legs. 4. Use logrolling technique for repositioning. 5. Assist the client with eating meals and drinking fluids. After a client has spinal fusion, the head of bed generally is kept flat. Because the client is in the flat position, the nurse should assist the client with eating meals and drinking fluids. The client is logrolled from side to side as prescribed. Pillows may be placed under the entire length of the legs, in accordance with surgeon preference, to relieve tension on the lower back. The use of an overhead trapeze may decrease control of spinal movement and is contraindicated because its use could promote twisting of the spine after surgery.
The nurse has given activity guidelines to a client with chronic low back pain. The nurse determines that the client understands the instructions if the client states to do which activities? Select all that apply. 1. Lying prone 2. Sitting using a lumbar roll or pillow 3. Standing with one foot on a step or stool 4. Lying on the side, with knees and hips straight 5. Lift objects that need to be carried above elbow level. 6. Lean forward to reach objects, keeping the legs and knees straight.
2. Sitting using a lumbar roll or pillow 3. Standing with one foot on a step or stool Rationale: The client should avoid positions or activities that place strain on the lower back. The client should not sleep on the abdomen (prone) or on the side if the hips and knees are straight. It may be helpful for the client to stand with a foot elevated on a stool or to sit using a form of lumbar support. The client should not lean forward without bending the knees, stand in one position for long periods, or lift anything above elbow level.
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 Rationale: Low back pain that radiates into 1 leg (sciatica) is consistent with herniated lumbar disk. The nurse assesses the client to see whether the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, and coughing, or by lifting the leg straight up while supine (straight leg-raising test). Bed rest, heat (or sometimes ice), and nonsteroidal antiinflammatory drugs (NSAIDs) usually relieve back pain.
A client seeks treatment in the hospital emergency department for a lower leg injury. Deformity of the lower portion of the leg is evident, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this client has experienced which injury? 1. Strain 2. Sprain 3. Fracture 4. Contusion
3. Fracture Rationale: Typical signs and symptoms of fracture include pain, loss of function in the area, deformity, shortening of the extremity, crepitus, swelling, and ecchymosis. Not all fractures lead to the development of every sign or symptom. A strain results from a pulling force on the muscle, resulting in soreness and pain with muscle use. A sprain is an injury to a ligament caused by a wrenching or twisting motion and is manifested by pain, swelling, and inability to use the joint or bear weight normally. A contusion results from a blow to soft tissue and causes pain, swelling, and ecchymosis.
The nurse is caring for a client with osteoarthritis. The nurse performs an assessment knowing that which clinical manifestations are associated with the disorder? Select all that apply. 1. Elevated white blood cell count 2. A decreased sedimentation rate 3. Joint pain that diminishes after rest 4. Elevated antinuclear antibody levels 5. Joint pain that intensifies with activity
3. Joint pain that diminishes after rest 5. Joint pain that intensifies with activity Rationale: The stiffness and joint pain that occur in osteoarthritis diminish after rest and intensify with activity. No specific laboratory findings are useful in diagnosing osteoarthritis. The client may have a normal or slightly elevated sedimentation rate. Morning stiffness lasting longer than 30 minutes occurs in rheumatoid arthritis. Elevated white blood cell counts, platelet counts, and antinuclear antibody levels occur in rheumatoid arthritis.
The nurse is caring for a client admitted for a herniated intervertebral lumbar disk who is complaining about stabbing pain radiating to the lower back and the right buttock. The nurse determines that the client's signs/symptoms are most likely due to which condition? 1. Pressure on the spinal cord 2. Pressure on the spinal nerve root 3. Muscle spasm in the area of the herniated disk 4. Excess cerebrospinal fluid production in the area
3. Muscle spasm in the area of the herniated disk Rationale: Compression of a nerve results in inflammation, which then irritates adjacent muscles, putting them into spasm. The pain of muscle spasm is continuous, knife-like, and localized in the affected area. Pressure on the spinal cord itself could result in a variety of manifestations, depending on the area involved. Pressure on a spinal nerve root causes the symptoms of sciatica.
A hospitalized client has been diagnosed with osteomyelitis of the left tibia. The nurse determines that this condition is most likely a result of which event in the client's recent history? 1. Sprained left ankle 2. Decreased calcium intake 3. Open trauma to the left leg 4. Starting to smoke cigarettes
3. Open trauma to the left leg Rationale: Osteomyelitis is a bone infection and may be caused by direct contamination of bone through an open wound. Bacteria invade the bone tissue and produce inflammation. Ischemia and necrosis of the bone tissue may follow if not treated. The remaining options are unrelated to the cause of osteomyelitis.
A client has been placed in Buck's extension traction. The nurse can provide for countertraction to reduce shear and friction by performing which action? 1. Using a footboard 2. Providing an overhead trapeze 3. Slightly elevating the foot of the bed 4. Slightly elevating the head of the bed
3. Slightly elevating the foot of the bed Rationale: The part of the bed under an area in traction usually is elevated to aid in countertraction. For the client in Buck's extension traction (which is applied to a leg), the foot of the bed is elevated. The remaining options are incorrect.
The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder? 1. A 25-year-old woman who runs 2. A 36-year-old man who has asthma 3. A 70-year-old man who consumes excess alcohol 4. A sedentary 65-year-old woman who smokes cigarettes
4. A sedentary 65-year-old woman who smokes cigarettes Rationale: Risk factors for osteoporosis include female gender, being postmenopausal, advanced age, a low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids, anticonvulsants, and/or furosemide also increases the risk.
The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had 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 to 48 hours
4. Elevated on pillows continuously for 24 to 48 hours Rationale: A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and promote venous drainage. Options 1, 2, and 3 are incorrect.
The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest in Williams' position to minimize the pain. The nurse should put the bed in what position? 1. Flat with the knees raised 2. In high Fowler's position, with the foot of the bed flat 3. In semi Fowler's position, with the foot of the bed flat 4. In semi Fowler's position, with the knees slightly flexed
4. In semi Fowler's position, with the knees slightly flexed Rationale: Clients with low back pain often are more comfortable when placed in Williams' position. The bed is placed in semi Fowler's position with the knee gatch raised sufficiently to flex the knees. This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root. The remaining positions will not minimize the pain and may make the pain worse.
A client with myasthenia gravis has become increasingly weaker. The health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis? 1. No change in condition 2. complaints of muscle spasms 3. an improvement of the weakness 4. a temporary worsening of the condition
4. a temporary worsening of the condition Rationale: An edrophonium injection makes the client in cholinergic crisis temporarily worse. An improvement in the weakness indicates myasthenia crisis. Muscle spasms are not associated with this test.
