HCD Mobility and Tissue Integrity

a nurse is teaching a client about nutritional necessary to promote wound healing. which of the following nutrients should the nurse include in the teaching?

protein

a nurse is teaching a client about medications that prevent osteoporosis. the nurse should instruct the client that which of the following medications is prescribed to prevent osteoporosis?

raloxifene

a nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. the client is reporting pain from muscle spasms. which of the following actions should the nurse take first?

realign the clients position

a nurse is providing discharge teaching to a client who has a fracture of the right tibia and a fiberglass cast. which of the following instructions should the nurse Include in the teaching?

report any worsening or unrelieved pain

a nurse is assessing a client who has a lower left arm fracture. which of the following findings indicates impaired venous return in the clients affected arm?

increasing edema

a nurse is assessing a client who has a hip fracture. which of the following findings should the nurse expect?

muscle spasms

a nurse is assessing a client following the application of a leg cast for the treatment of a fracture. if the cast is too tight, which of the following findings should the nurse expect to observe first?

pallor of the toes

a nurse is teaching a client who is starting to take alendronate effervescent tablets to treat osteoporosis. which of the following information should the nurse include?

"sit upright or stand for at least 30 minutes after taking this medication"

a nurse is preparing to perform a wound irrigation on a client who has a puncture wound to the left leg. Identify the sequence of steps the nurse should take to perform the irrigation.

- place a waterproof pad under the client's leg - don clean gloves and remove the client's dressing - clean the wound using a circular motion - open a sterile dressing set and supplies - irrigate the wound until the solution becomes clear

a nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. the nurse should include which of the following information in the teaching?

Buck's extension traction will relieve muscle spasms

a nurse in a medical clinic is providing teaching to an older adult client who has osteoarthritis that is affecting her knees. which of the following client statements indicates an understanding of the teaching?

"I can use either heat or ice to help relieve the discomfort"

a nurse is caring for a client who has sustained a femur fracture in an automobile accident and is placed into skeletal traction. the nurse may remove the weights from the traction device if which of the following occurs?

the client develops a life threatening situation

a nurse is reviewing risk factors for osteoporosis with a group of nursing students. the nurse should include that which of the following types of medication therapy is a risk factor for osteoporosis?

thyroid hormones

a nurse is caring for an infant who has diaper dermatitis. which of the following actions should the nurse take?

use a moisturizer to wipe urine from the skin

a nurse is teaching a client about preventing osteoporosis. which of the following statements by the client indicates a need for further teaching?

"I will reduce my intake of vitamin K rich foods"

nurse in a clinic is talking with a client who has a new diagnosis of osteoarthritis. the nurse should anticipate that the client will require teaching about which of the following medicaitons?

acetaminophen

a nurse is planning care for an adolescent who has scoliosis and requires surgical intervention. which of the following behaviors by the adolescent should the nurse anticipate because it is most common reaction?

body image changes

a nurse is teaching a client at high risk for osteoporosis about dietary measures she can take to increase her calcium level. which of the following foods should the nurse advise the client to increase in her diet?

broccoli

a nurse is assessing a client who has a cast in place for a fractured tibia. which of the following actions should the nurse take first?

checking capillary refill

a nurse in a clinic is assessing a client. which of the following findings should the nurse identify as a risk factor for osteoporosis?

smokes 1 pack of cigarettes a day

a nurse teaching a client who has a new prescription for topical betamethasone to treat contact dermatitis. which of the following instructions should the nurse include?

"use the cream for a few days after the area has healed"

a nurse is teaching a client who is scheduled for dual energy x ray absorptiometry to screen for osteoporosis. which of the following instructions should the nurse include in the teaching?

"you will need to remove all jewelry before the test"

a nurse is talking with a young adult client who has a family history of osteoporosis. which health promotion activity should the nurse recommend as a possible preventive measure?

engage in weight bearing exercise regularly

a nurse is assessing an older client who has osteoporosis. which of the following spinal deformities should the nurse expect to find in this client?

kyphosis

a nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. after calling for help, which of the following actions should the nurse take first?

cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation

a nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. the nurse notes seperation of the wound edges with copious light brown serous drainage. which of the following actions should the nurse perform first?

cover the wound with a moist, sterile gauze dressing

a nurse is caring for a client who has a large lower leg ulcer. which of the following foods should the nurse suggest to the client to provide the most protein for wound healing?

grilled salmon

a nurse is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation. which of the following interventions should the nurse include in the plan of care?

initiate the use of a PCA pump for pain control

a nurse is teaching a group of clients about osteoarthritis. which of the following recommendations should the nurse include in the teaching?

maintain a recommended body weight

a nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. to assist in meeting this goal, which of the following nursing interventions is the highest priority?

maintain immobilization and alignment

a nurse is completing a physical assessment of client who has early osteoarthritis. which of the following manifestations should the nurse expect?

pain worsens with activity

a nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. which of the following actions is the most important for the nurse to complete in the postoperative period?

perform neurovascular checks of the extremities

a nurse working in a community health center is the preparing a flow sheet detailing essential screenings according to age group. at which developmental stage on the chart should the nurse add scoliosis screening?

pre adolescent/adolescent

a nurse is caring for a client who has contact dermatitis of the neck and upper chest. which of the following is an expected finding?

report of exposure to a skin irritant

a nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. which of the following actions is the nurse's priority?

schedule a follow up visit by a home health nurse for dressing changes

a nurse in a providers office is collecting a health history from a client who is at risk for primary osteoporosis. which of the following findings is a risk factor for the development of osteoporosis?

sedentary lifestyle

a nurse is assessing a clients wound dressing, and observes a watery red drainage. the nurse should document this drainage as which of the following?

serosanguineous

a nurse is providing teaching to a client who has osteoporosis and a new prescription for alendronate. which of the following adverse effects should the nurse instruct the client to report to the provider?

- jaw pain - blurred vision - dysphagia

a nurse is caring for a client who has a wound infection. which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?

cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen

a nurse is providing nutritional teaching to a client who has osteoporosis. which of the following foods should the nurse recommend as being the highest in calcium?

3 oz canned salmon

a nurse is teaching a client about risk factors for osteoarthritis. which of the following factors should the nurse include in the teaching?

- aging - obesity - smoking

a nurse is caring for a client who has a cast in place for a fractured tibia. which of the following nursing actions is the priority immediately after the provider has applied the cast?

checking capillary refill distal to the cast

a nurse is preparing a presentation at a community center about osteoarthritis. the nurse should plan to include which of the following information?

- affects weight bearing joints - crepitus can occur in affected joints - causes joint stiffness - causes joint pain

a nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. which of the following factors should the nurse include in the teaching?

- poor nutritional state - obesity - wound infection

a nurse is teaching a client about risk factors for osteoporosis. which of the following factors should the nurse include in the teaching?

- sedentary lifestyle - aging - caffeine intake - secondhand smoke

a nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. which of the following vitamins that promote healing should the nurse include in the teaching?

- vitamin A - vitamin B12 - vitamin C - vitamin K

a nurse is caring for a client who has an unrepaired femur fracture of the midshaft. which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?

instruct the client to wiggle his toes