MEDSURG II: Saunders Musculoskeletal

The nurse is caring for a client diagnosed with osteomyelitis. Which mechanism of the disease process can result in necrosis of the bone? 1. Devascularization 2. Infection of the bone 3. Decreased bone mass 4. Decreased bone density

Answer: 1. Devascularization Rationale: Osteomyelitis is an infectious process affecting the bone, bone marrow, and surrounding soft tissue. A microorganism gains entry into the blood and grows, causing increased pressure on the bone, leading to ischemia and ultimately necrosis as a result of devascularization. Infection of the bone occurs but is not specifically related to necrosis of the bone. Decreased bone mass and decreased bone density are also not related to necrosis of the bone.

A client has been diagnosed with osteomalacia, or adult rickets. The nurse should anticipate that the health care provider will include a new prescription for which vitamin supplement? 1. A 2. D 3. E 4. K

Answer: 2. D Rationale: Osteomalacia technically refers to bone softening that results from demineralization of bone matrix and failure to calcify. A common cause is vitamin D deficiency in the diet. Other causes are inadequate exposure to sunlight (to synthesize vitamin D) and disorders that interfere with absorption and metabolism of vitamin D. Deficiencies of the vitamins noted in the remaining options are not associated with osteomalacia.

An older client is diagnosed with osteoporosis. The nurse teaches the client about self-care measures, knowing that the client is most at risk for which problem as a result of this disorder of the bones? 1. Anemia 2. Fractures 3. Infection 4. Muscle sprains

Answer: 2. Fractures Rationale: The client is most at risk for fractures as a result of osteoporosis. Although other complications can occur, fracture is the greatest concern. Anemia and infection can occur with bone marrow disorders, and muscle sprains are unrelated to osteoporosis.

A client is admitted to the emergency department with an open fracture of the right tibia. What intervention is most appropriate for this client? 1. Remove the client's shoes. 2. Place the client in a semi Fowler's position. 3. Check the neurovascular status of the area distal to the extremity. 4. Apply a tourniquet above the area of bleeding and loosen it every 15 minutes.

Answer: 3. Check the neurovascular status of the area distal to the extremity. Rationale: To prevent further damage, the neurovascular status must be assessed for temperature, color, sensation, movement, and capillary refill. Tourniquets are not used to control hemorrhage in extremities because of the risk of tissue ischemia. Direct pressure is applied at the site and over the proximal artery nearest the fracture if bleeding occurs. Clients need to be kept in a supine position to help prevent hypotension and shock. Shoes are not removed because this action may cause increased trauma.

The nurse determines that a client's skeletal traction needs correction if which observation is made? 1. Weights are not touching the floor. 2. Weights are hanging free of the bed. 3. Traction ropes rest against the footboard. 4. Traction ropes are aligned in each pulley.

Answer: 3. Traction ropes rest against the footboard. Rationale: Traction ropes must hang free of the bed. The remaining options are observations that indicate correct use of the traction setup.

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

Answer: 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.

A client has been diagnosed with gout, and the nurse provides dietary instructions. The nurse determines that the client needs additional teaching if the client states that it is acceptable to eat which food? 1. Carrots 2. Tapioca 3. Chocolate 4. Chicken liver

Answer: 4. Chicken liver Rationale: Liver and other organ meats should be omitted from the diet of a client who has gout because of their high purine content. Purines are a form of protein. The food items identified in the other options contain negligible amounts of purines and may be consumed freely by the client with gout.

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

Answers: 2. Heat 3. Analgesics 4. Muscle relaxers 5. Intermittent traction Rationale: 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.

The nurse is teaching a client who had a lumbar laminectomy how to perform activities of daily living without causing strain on the back. Which action performed by the client indicates a need for further instruction? 1. Bends over to tie shoes 2. Sits in a recliner with feet elevated 3. Squats to pick up an item from the floor 4. Sleeps in a side-lying position with knees and hips bent

Answer: 1. Bends over to tie shoes Rationale: To prevent strain on the lower back, it is important to use proper body mechanics. This includes bending at the knees, and not at the waist, when picking up things or lifting. Options 2, 3, and 4 are all appropriate ways to avoid lower back strain.

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)

Answer: 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 caring for a client who had surgery to repair a fractured left-sided hip using a posterior approach. In implementing hip precautions, which action should the nurse teach the client to avoid? 1. Crossing legs at the ankle 2. Using an elevated toilet seat 3. Placing a pillow between the legs 4. Keeping the legs abducted from the midline

Answer: 1. Crossing legs at the ankle Rationale: Following surgery to repair a fractured hip using a posterior approach, client education should include the following: avoiding crossing the legs at the ankle or the knee, using an elevated toilet seat, placing a pillow between the legs while lying down for the first 6 weeks, keeping the legs abducted from the midline, and keeping the hip in a neutral position at all times.

The nurse is receiving a client from the post-anesthesia care unit following left above-knee amputation. Which is the priority nursing action at this time? 1. Elevate the foot of the bed. 2. Position the residual limb flat on the bed. 3. Put the bed in a reverse Trendelenburg's position. 4. Keep the residual limb flat, with the client lying on his or her operative side.

Answer: 1. Elevate the foot of the bed. Rationale: Edema of the residual limb is controlled by elevating the foot of the bed for the first 24 hours after surgery. After the first 24 hours, the residual limb is placed flat on the bed to reduce hip contracture. Edema is also controlled by residual limb wrapping techniques.

The nurse provides instructions to a client diagnosed with osteoporosis. Education about prevention of which complication is the most important? 1. Fractures 2. Weight loss 3. Hypocalcemia 4. Muscle atrophy

Answer: 1. Fractures Rationale: Osteoporosis is a chronic, progressive metabolic bone disease characterized by low bone mass and structural deterioration of bone tissue, leading to increased bone fragility. The woman is most likely to suffer fractures as a result of this disorder. The remaining options are not directly related to this disorder.

The nurse is lecturing to a group of women who are at high risk for osteoporosis. The nurse should inform the women about which most important measure? 1. Limit caffeine intake. 2. Limit intake of vitamin D. 3. Limit participation in activities such as walking and swimming. 4. Limit protein in the diet because it contributes to the incidence of bone demineralization.

Answer: 1. Limit caffeine intake. Rationale: Excessive caffeine intake can increase calcium loss in the urine. Protein deficiency may contribute to the incidence of bone demineralization. Activities such as walking and swimming may be beneficial and are appropriate to reduce the risk of fracture. Adequate vitamin D intake is necessary for the metabolism of calcium.

A client is seen in the health care provider's office for complaints of wrist pain. A diagnosis of carpal tunnel syndrome is made. In explaining this disorder to the client, the nurse states that it is caused by compression of which nerve? 1. Median 2. Peroneal 3. Trigeminal 4. Spinal accessory

Answer: 1. Median Rationale: Carpal tunnel syndrome is caused by excessive pressure on the median nerve as a result of injury, overuse, or disease. The peroneal nerve is in the leg. Trigeminal neuropathy results in facial pain, also known as tic douloureux. The spinal accessory nerve is a motor nerve impacting shoulder function.

The nurse is reviewing the diagnostic tests performed in an adult with a connective tissue disorder. The erythrocyte sedimentation rate (ESR) is reported as 35 mm/hr (35 mm/hr). How should the nurse interpret this finding? 1. Normal 2. Indicating mild inflammation 3. Indicating severe inflammation 4. Indicating moderate inflammation

Answer: 2. Indicating mild inflammation Rationale: The ESR is a blood test that can confirm the presence of inflammation or infection in the body. The normal ESR range is less than or equal to 15 mm/hr in a male and less than or equal to 20 mm/hr in a female. Generally, an ESR value of 30 to 40 mm/hr indicates mild inflammation, 40 to 70 mm/hr indicates moderate inflammation, and 70 to 150 mm/hr indicates severe inflammation. {You do NOT have to know the normal values of ESR. Knowing that ESR increases with inflammation is enough}.

A client has Buck's extension traction applied to the right leg. Which intervention should the nurse plan to prevent complications of the device? 1. Give pin care once a shift. 2. Inspect the skin on the right leg. 3. Massage the skin of the right leg with lotion. 4. Release the weights on the right leg for daily range-of-motion exercises.

Answer: 2. Inspect the skin on the right leg. Rationale: Buck's extension traction is a type of skin traction. The nurse inspects the skin of the limb in traction at least once every 8 hours for irritation or inflammation. There are no pins to care for with skin traction. Massaging the skin with lotion is not indicated. The nurse never releases the weights of traction unless specifically prescribed by the health care provider.

The nurse is assigned to care for a client who is in Buck's traction. The nurse prepares a plan of care for the client and includes which nursing action in the plan? 1. Make sure that the knots are at the pulleys. 2. Inspect the skin under the boot at least every 8 hours. 3. Make sure the head of the bed is kept at a 45- to 90-degree angle. 4. Monitor the weights to be sure that they are resting on a firm surface.

Answer: 2. Inspect the skin under the boot at least every 8 hours. Rationale: When possible, remove the belt or boot that is used for skin traction every 8 hours to inspect under the device for skin irritation and breakdown. To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. Weights are not to be kept resting on a firm surface. The head of the bed is usually kept low to provide countertraction.

The nurse is caring for a client who sustained an open fracture and is diagnosed with acute osteomyelitis of the right lower extremity. Which intervention should the nurse plan to perform? 1. Apply ice to the affected area. 2. Perform sterile dressing changes. 3. Instruct the client on leg exercises. 4. Measure the leg circumference daily.

Answer: 2. Perform sterile dressing changes. Rationale: Osteomyelitis is a severe infection of the bone, bone marrow, and surrounding soft tissue. Clinical manifestations include constant bone pain unrelieved by rest that worsens with activity; swelling, tenderness, and warmth at the infection site; restricted movement of the affected part; fever, night sweats, chills, restlessness, nausea, and malaise. Option 2 is the correct option, as treatment of osteomyelitis often includes surgical debridement and requires sterile dressing changes. Option 1 is incorrect, as osteomyelitis is an infection and applying ice to the area will not help any swelling and may cause vasoconstriction. Option 3 is incorrect, as movement worsens the pain and some immobilization of the affected limb (e.g., splint, traction) is usually indicated. Option 4, measuring leg circumference daily, is not necessary.

The nurse is creating a plan of care for a client in skin traction. Which frequent assessment should the nurse include in the plan as a priority intervention? 1. Urinary incontinence 2. Signs of skin breakdown 3. The presence of bowel sounds 4. Signs of infection around the pin sites

Answer: 2. Signs of skin breakdown Rationale: Skin traction is achieved by Ace wraps, boots, and slings that apply a direct force on the client's skin. Skin traction is usually removed and reapplied once a day. Traction is maintained with 5 to 8 lb (2.3 to 3.6 kg) of weight, and this type of traction can cause skin breakdown. Urinary incontinence is not related to the use of skin traction. Although constipation can result from immobility, and although monitoring bowel sounds may be a component of the assessment, this intervention is not the priority assessment. There are no pin sites with skin traction.

The nurse is caring for a client with a swollen left ankle who has difficulty bearing weight on this leg and states that he twisted his ankle. Based on these findings, which condition does the nurse determine the client has most likely experienced? 1. Strain 2. Sprain 3. Fracture 4. Contusion

Answer: 2. Sprain Rationale: A sprain is an injury to a ligament caused by a wrenching or twisting motion. Signs and symptoms include pain, swelling, and inability to use the joint or bear weight normally. A strain results from a pulling force on a muscle. Manifestations include soreness and pain with muscle use. Typical signs and symptoms of fracture are variable but include pain, loss of function in the affected area, deformity, shortening of the extremity, crepitus, swelling, and ecchymosis. A contusion results from a blow to soft tissue and causes pain, swelling, and ecchymosis.

The nurse is preparing instructions for a client who is diagnosed with osteomalacia. Which information should the nurse include in the teaching? 1. "Avoid exposure to sunlight." 2. "Avoid weight-bearing exercise." 3. "Ensure adequate intake of vitamin D fortified foods." 4. "Osteomalacia and osteoporosis are interchangeable terms."

Answer: 3. "Ensure adequate intake of vitamin D fortified foods." Rationale: A common cause of osteomalacia is vitamin D deficiency, so the client should include adequate dietary intake of vitamin D-fortified foods. Other causes include inadequate exposure to sunlight (to synthesize vitamin D) and disorders that interfere with the absorption and metabolism of vitamin D. Osteomalacia technically refers to bone softening, which results from demineralization of bone matrix and its failure to calcify. This is different from osteoporosis, which is a metabolic bone disease characterized by low bone mass and structural deterioration of bone tissue, leading to increased bone fragility and pathologic fractures. Weight-bearing exercises are appropriate.

The nurse is caring for a client with a hip fracture who has just been placed in Buck's traction. What intervention is most important for the nurse to perform? 1. Ensure that the weight used as a pulling force is at least 20 lb (9 kg). 2. Ensure that the weights rest on the floor and are not freely hanging. 3. Inspect the skin at least every 8 hours for signs of irritation or inflammation. 4. Remove the weights for at least 5 minutes every hour to give the client a rest.

Answer: 3. Inspect the skin at least every 8 hours for signs of irritation or inflammation. Rationale: It is important for the skin to be assessed at least every 8 hours. Weights should be no more than 5 to 10 lb (2.3 to 4.5 kg) to prevent injury to the skin and should always be freely hanging. Additionally, the amount of weight is prescribed by the health care provider. Once traction is applied, a correct balance is maintained at all times. Weights are not removed on a scheduled basis and are never removed without a prescription to do so.

A client was admitted to the hospital 2 hours ago following multiple fractures to the pelvis and soft tissue injury to the abdomen. Diagnostic studies have ruled out perforation of abdominal organs. The nurse places highest priority on monitoring this client for which changes in vital signs? 1. Fever, bradycardia 2. Fever, hypertension 3. Tachycardia, hypotension 4. Bradycardia, hypertension

Answer: 3. Tachycardia, hypotension Rationale: Clients who experience fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and, in the case of a fractured femur, into the thigh. This can occur with closed fractures as well as open fractures. Signs of hypovolemic shock include tachycardia and hypotension.

The nurse has developed a plan of care for a client in traction and documents a problem of inability to perform self-care independently. The nurse evaluates the plan of care and determines that which observation indicates a successful outcome? 1. The client refuses care. 2. The client allows the family to assist in the care. 3. The client assists in self-care as much as possible. 4. The client allows the nurse to complete the care on a daily basis.

Answer: 3. The client assists in self-care as much as possible. Rationale: A successful outcome for the problem of self-care is for the client to do as much of the self-care as possible. The nurse should promote independence in the client and allow the client to perform as much self-care as is optimal, considering the client's condition. The nurse would determine that the outcome is unsuccessful if the client refused care or allowed others to do the care.

A client with a short-leg plaster cast complains of an intense itching under the cast. The nurse provides instructions to the client regarding relief measures for the itching. Which client statement indicates an understanding of appropriate measures to relieve the itching? 1. "I can use the blunt part of a ruler to scratch the area." 2. "I can trickle small amounts of water down inside the cast." 3. "I need to obtain assistance when placing an object into the cast for the itching." 4. "I can use a hair dryer on the low setting and allow the cool air to blow into the cast."

Answer: 4. "I can use a hair dryer on the low setting and allow the cool air to blow into the cast." Rationale: Itching is a common complaint of clients with casts. Objects should not be put inside a cast because of the risk of scratching the skin, thereby providing a point of entry for bacteria. A plaster cast can break down when wet. Therefore, the best way to relieve itching is with a forceful injection of air inside the cast.

An erythrocyte sedimentation rate (ESR) determination is prescribed for a client with a connective tissue disorder. The client asks the nurse about the purpose of the test. What should the nurse tell the client about the purpose of the test? 1. Determines the presence of antigens 2. Identifies which additional tests need to be performed 3. Confirms the diagnosis of a connective tissue disorder 4. Confirms the presence of inflammation or infection in the body

Answer: 4. Confirms the presence of inflammation or infection in the body Rationale: The ESR is a blood test that can confirm the presence of inflammation or infection in the body. It is particularly useful for the management of connective tissue disease because the rate measured directly correlates with the degree of inflammation and later with the severity of the disease. The other options are incorrect.

The nurse has taught a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that further teaching is needed if the client states the need to take which action? 1. Bend at the knees to pick up objects. 2. Increase fiber and fluid intake in the diet. 3. Strengthen the back muscles by swimming or walking. 4. Get out of bed by sitting straight up and swinging the legs over the side of the bed.

Answer: 4. Get out of bed by sitting straight up and swinging the legs over the side of the bed. Rationale: The client is taught to get out of bed by sliding near the edge of the mattress. The client then rolls onto 1 side and pushes up from the bed using 1 or both arms. The client keeps the back straight and swings the legs over the side. Proper body mechanics includes bending at the knees, not the waist, to lift objects. Increasing fluid intake and dietary fiber helps prevent straining at stool, thereby preventing increases in intraspinal pressure. Walking and swimming are excellent exercises for strengthening lower back muscles.

Which tests can be used to diagnose gout? Select all that apply. 1. Renal ultrasound 2. Serum uric acid level 3. Bone marrow biopsy 4. Urinalysis with culture 5. Synovial fluid aspiration 6. 24-hour urine uric acid level

Answers: 2. Serum uric acid level 5. Synovial fluid aspiration 6. 24-hour urine uric acid level Rationale: Diagnostic tests for gout include serum uric acid level and 24-hour urine uric acid level, as well as synovial fluid aspiration and x-ray of the affected areas. Renal ultrasound, bone marrow biopsy, and urinalysis with culture are not specifically associated with gout; they test for a variety of other conditions.

A rheumatoid factor assay is performed in a client with a suspected diagnosis of rheumatoid arthritis (RA). Which laboratory result should the nurse anticipate? 1. The presence of inflammation 2. The presence of infection in the body 3. The presence of antigens of immunoglobulin A (IgA) 4. The presence of unusual antibodies of the IgG and IgM types

Answer: 4. The presence of unusual antibodies of the IgG and IgM types Rationale: Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. The rheumatoid factor assay tests for the presence of unusual antibodies of the IgG and IgM types, which develop in a number of connective tissue diseases. The test result in a person without RA would be negative or <60 units/mL by nephelometric method of laboratory testing. The other options are incorrect.

The nurse is providing care for a client admitted 3 days ago with a severe left ankle contusion. The nurse determines that heat application to the area has been effective if which has occurred? 1. Signs of infection are absent. 2. The muscles are beginning to relax. 3. Abscess formation has not occurred. 4. There is reabsorption of blood noted at the injured site.

Answer: 4. There is reabsorption of blood noted at the injured site. Rationale: The primary benefit from applying heat to a contusion is to speed up the rate of absorption of blood that has hemorrhaged into the affected soft tissue. Although heat also promotes muscle relaxation, this is not the intended benefit of this therapy in treating a contusion. Heat is not applied to prevent infection or abscess formation.

A test for the presence of rheumatoid factor is performed in a client with a diagnosis of rheumatoid arthritis (RA). What result should the nurse anticipate in the presence of this disease? 1. Neutropenia 2. Hyperglycemia 3. Antigens of immunoglobulin A (IgA) 4. Unusual antibodies of the IgG and IgM type

Answer: 4. Unusual antibodies of the IgG and IgM type Rationale: Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. The test for rheumatoid factor detects the presence of unusual antibodies of the IgG and IgM type, which develop in a number of connective tissue diseases. The other options are incorrect.

The nurse is creating a plan of care for a client scheduled for a left total hip arthroplasty. Which interventions should the nurse include in the plan to prevent complications of the surgery? Select all that apply. 1. Keep the leg slightly abducted. 2. Teach leg exercises to the client. 3. Use aseptic technique for wound care. 4. Prevent hip flexion beyond 90 degrees. 5. Keep the client's knees flexed whenever the client is in bed. 6. Massage the legs daily to increase circulation and venous return.

Answers: 1. Keep the leg slightly abducted. 2. Teach leg exercises to the client. 3. Use aseptic technique for wound care. 4. Prevent hip flexion beyond 90 degrees. Rationale: A total hip arthroplasty (THA) is also known as a total hip replacement (THR). Postoperative complications can include dislocation, infection, venous thromboembolism, hypotension, bleeding, and infection. To prevent dislocation, the nurse needs to position the client correctly with the leg slightly abducted and prevent hip flexion beyond 90 degrees. Signs of dislocation such as acute pain, rotation, and extremity shortening needs to be reported immediately to the surgeon. To prevent infection the nurse needs to perform thorough handwashing and use aseptic technique for wound care and emptying of drains. To prevent venous thromboembolism, the client would wear elastic stockings and/or a sequential compression device per agency policy and surgeon prescription. The nurse would encourage fluid intake and teach the client leg exercises to promote circulation. Legs are not massaged; in addition, knee flexion is avoided for a prolonged period of time because these actions promote venous stasis and thromboembolism. The nurse would monitor vital signs at least every 4 hours and observe the client for bleeding. Any signs of complications are reported immediately to the surgeon.

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."

Answer: 1. "I need to avoid getting the cast wet." Rationale: A plaster cast must remain dry to keep its strength. The cast should be handled with the palms of the hands, not the fingertips, until fully dry; using the fingertips results in indentations in the cast and skin pressure under the cast. Air should circulate freely around the cast to help it dry; the cast also gives off heat as it dries. The client should never scratch under the cast because of the risk of altered skin integrity; the client may use a hair dryer on the cool setting to relieve an itch.

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

Answer: 3. Presence of a "hot spot" on the cast Rationale: Signs of infection under a casted area include odor or purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others. The health care provider should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished distal pulse, and edema.

The nurse has delegated the ambulation of a client to the unlicensed assistive personnel (UAP). Which actions by the UAP support a clear understanding of the appropriate steps to carry out this task safely? Select all that apply. 1. Remove clutter that may interfere with ambulation. 2. Assist client in applying nonskid shoes before ambulation. 3. Instruct client to sit up on the bedside and dangle before ambulation. 4. Observe the client for dizziness during ambulation and report immediately. 5. Understand that the client may experience nausea as a normal expectation during ambulation.

Answers: 1. Remove clutter that may interfere with ambulation. 2. Assist client in applying nonskid shoes before ambulation. 3. Instruct client to sit up on the bedside and dangle before ambulation. 4. Observe the client for dizziness during ambulation and report immediately. Rationale: When delegating the task of ambulation to a UAP, the nurse should ensure that the UAP understands instructions before ambulation, including making sure that clutter is removed in the area of ambulation; assisting the client in applying nonskid socks before ambulation; instructing the client to sit up on the bedside and dangle before ambulation; and observing the client for dizziness and reporting this finding immediately. The client should not experience nausea, dizziness, or diaphoresis or become pale during ambulation under normal conditions.

The home health nurse is planning to teach a client with osteoporosis about home modifications to reduce the risk of falls. Which recommendations would be necessary to include in the teaching plan? Select all that apply. 1. Use night lights. 2. Remove scatter rugs. 3. Use staircase railings. 4. Remove wall-to-wall carpeting. 5. Place hand rails in the bathroom.

Answers: 1. Use night lights. 2. Remove scatter rugs. 3. Use staircase railings. 5. Place hand rails in the bathroom. Rationale: Home modifications to reduce the risk for falls include using railings on all staircases, providing ample lighting, removing scatter rugs, and placing hand rails in the bathroom. Removing wall-to-wall carpeting is not necessary as long as it is in good condition.

The nurse has completed giving discharge instructions to a client after total knee arthroplasty and replacement with a prosthetic system. The nurse teaches the client about weight-bearing status. What information should the nurse include? 1. "You will use full weight bearing by discharge." 2. "You will use partial weight bearing by discharge." 3. "You will use toe-touch weight bearing by discharge." 4. "You will need to remain on bed rest even after discharge."

Answer: 1. "You will use full weight bearing by discharge." Rationale: After total knee arthroplasty, there is an emphasis on physical therapy as part of the plan of care. By discharge, the client should be using full weight bearing after working with therapy. The other options are incorrect.

A client is treated in a health care provider's office for a sprained ankle after a fall. Radiographic examination has ruled out a fracture. Before sending the client home, the nurse plans to teach the client to avoid which activity in the next 24 hours? 1. Resting the foot 2. Applying a heating pad 3. Applying an elastic compression bandage 4. Elevating the ankle on a pillow while sitting or lying down

Answer: 2. Applying a heating pad Rationale: Soft tissue injuries such as sprains are treated by RICE (rest, ice, compression, and elevation) for the first 24 hours after the injury. Ice is applied intermittently for 20 to 30 minutes at a time. Heat is not used in the first 24 hours because it could increase venous congestion, which would increase edema and pain.

the client is complaining of skin irritation from the edges of a cast applied the previous day. Which action should the nurse take? 1. Massage the skin at the rim of the cast. 2. Petal the cast edges with adhesive tape. 3. Use a rough file to smooth the cast edges. 4. Apply lotion to the skin at the rim of the cast.

Answer: 2. Petal the cast edges with adhesive tape. Rationale: The nurse petals the edges of the cast with tape to minimize skin irritation. If a client has a cast applied and returns home, the client can be taught to do the same. Massaging the skin and applying lotion will not alleviate irritation. Using a rough file could cause increased irritation.

The nurse is performing a musculoskeletal assessment of an immobile client for disuse osteoporosis. Which should the nurse assess to obtain the best information about the bone remodeling process? 1. Vitamin C 2. Vitamin A 3. Calcitonin 4. Thyroid hormone

Answer: 3. Calcitonin Rationale: Bone remodeling is the result of osteoblastic and osteoclastic activities, which are influenced by the degree of stress that is placed on the bone. The three substances that play an important role in this process are parathyroid hormone (which regulates calcium levels and bone resorption), vitamin D (which is active in bone formation and calcium resorption from bone), and calcitonin (which antagonizes parathyroid hormone and inhibits bone resorption). The other substances listed do not play a role in this process.

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

Answers: 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.

Which teaching point is the priority when the nurse is teaching the client about caring for a plaster cast? 1. The cast gives off heat as it dries. 2. The client can bear weight on the cast in 1 hour. 3. A stockinette and soft padding are put over the leg area before casting. 4. Immediately report any increase in drainage or interruption in cast integrity.

Answer: 4. Immediately report any increase in drainage or interruption in cast integrity. Rationale: Increases in drainage or interruption in cast integrity will affect healing and could lead to osteomyelitis. To apply a cast, the skin is washed and dried well. A stockinette is placed smoothly and evenly over the area to be casted, followed by a roll of padding. The plaster is then rolled onto the padding, and the edges are trimmed or smoothed if needed. A plaster cast gives off heat as it dries. A plaster cast can tolerate weight-bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast.

The nurse is planning discharge teaching for a client admitted with a fracture of the leg that does not extend all the way through the bone. The nurse should include information about which types of fractures? 1. Open 2. Displaced 3. Complete 4. Incomplete

Answer: 4. Incomplete Rationale: An incomplete fracture is one that extends through only part of the thickness of the bone. These fractures usually are nondisplaced, meaning that the bone remains in the normal position. An open (or compound) fracture is one in which the fractured bone protrudes through the skin, disrupting soft tissue. A complete fracture is one that extends through the full thickness of bone and often is displaced, meaning that the bone moves out of normal position.

A client has been diagnosed with subluxation of the shoulder. The nurse explains to the client that which injury has occurred to the joint? 1. It is strained. 2. It is contused. 3. It has completely dislocated. 4. It has incompletely dislocated.

Answer: 4. It has incompletely dislocated. Rationale: A dislocation is the disruption of a joint to the extent that the articulating surfaces are no longer in contact. A subluxation is an incomplete dislocation of the joint surfaces. Because the disruption is less severe, healing time is less prolonged. A strain occurs when a muscle or ligament is used beyond the limit of its functional ability. It is characterized by overstretching of the muscle or ligament and also could involve tearing if the strain is more severe (i.e., second- or third-degree strain versus first-degree strain). A contusion is a soft tissue injury that results in hemorrhage into the involved tissue.

A client who suffered a contusion after being hit on the thigh with a racquetball has been told that it is acceptable to apply heat to the area 72 hours after the injury. The nurse explains the rationale for this treatment to the client, stating that which is the physiological benefit of heat in this case? 1. It induces muscle relaxation. 2. It prevents abscess formation. 3. It reduces the likelihood of strain as a complication. 4. It promotes reabsorption of blood from the injured tissue.

Answer: 4. It promotes reabsorption of blood from the injured tissue. Rationale: The primary benefit from applying heat to a contusion is to speed up the rate of absorption of blood that has hemorrhaged into the affected soft tissue. Although heat also promotes muscle relaxation, this is not the intended benefit of this therapy in treating a contusion. Heat is not applied to reduce abscess formation or prevent muscle strain.

The nurse is preparing a client for an arthroscopy of the knee. When providing teaching, which information is essential for the nurse to include? 1. It will drain fluid that has accumulated below the knee. 2. It is used to obtain a muscle biopsy for pathology studies. 3. It will determine the degree of range of motion of the joint. 4. It will identify if there is joint injury and provide a route for surgical repair if indicated.

Answer: 4. It will identify if there is joint injury and provide a route for surgical repair if indicated. Rationale: Arthroscopy is used to diagnose acute and chronic conditions of the joint. In addition, surgical repairs can be done during this procedure. This procedure does not quantitate the degree of range of motion of the joint. Obtaining a muscle biopsy is not performed through an arthroscope, nor is this invasive procedure necessary to remove fluid from below the knee.

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

Answers: 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.

A client who sustained a severe sprain of the ankle is told by the health care provider that the pain experienced is caused by muscle spasm and swelling in the area of the injury. Which interventions should the nurse anticipate will be included in the client's initial plan of care? Select all that apply. 1. Ice bags 2. Elevation 3. Heating pad 4. Compression bandage 5. Range-of-motion exercises

Answers: 1. Ice bags 2. Elevation 4. Compression bandage Rationale: Reflex spasm of local muscles and swelling caused by rupture of local capillary beds can best be treated initially by remembering the acronym RICE, which stands for rest, ice, compression, and elevation. Heat and range-of-motion exercises are contraindicated because they would increase swelling.

The nurse is collecting data related to a client's risk factors associated with osteoporosis. Which data should the nurse include? Select all that apply. 1. Thin body build 2. Smoking history 3. Postmenopausal age 4. Chronic corticosteroid use 5. High intake of dairy products 6. Family history of osteoporosis

Answers: 1. Thin body build 2. Smoking history 3. Postmenopausal age 4. Chronic corticosteroid use 6. Family history of osteoporosis Rationale: A high intake of dairy products is not associated with osteoporosis because dairy products are high in calcium. Other than low calcium intake, other risk factors for osteoporosis include a thin body frame, sedentary lifestyle, cigarette smoking, excessive alcohol intake, chronic illness, long-term use of corticosteroids, postmenopausal age, and a family history of osteoporosis.

The nurse is providing dietary instructions to a client with osteoporosis and is discussing appropriate food items to include in the diet. Which food items should the nurse recommend as being high in calcium? Select all that apply. 1. Tofu 2. Salmon 3. Peaches 4. Spinach 5. Sardines

Answers: 1. Tofu 2. Salmon 4. Spinach 5. Sardines Rationale: Foods high in calcium include milk and milk products, dark green leafy vegetables, tofu and other soy products, sardines, salmon with bones, and hard water. Options 1, 2, 4, and 5 are all foods that are high in calcium. Peaches are high in vitamins A and C.

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

Answers: 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.

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.

Answers: 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.

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

Answers: 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.

A client who has had a total knee arthroplasty tells the nurse that there is pain with extension of the knee. The nurse should perform which action? 1. Administer an analgesic. 2. Notify the health care provider. 3. Immobilize the knee temporarily. 4. Put the client's knee through full passive range of motion.

Answer: 1. Administer an analgesic. Rationale: Pain with knee extension is a common complaint of clients after knee arthroplasty; therefore, administering an analgesic would be the appropriate action. Immobilizing the knee will not help. The pain may be the result of a flexion contracture that developed preoperatively as the client tried to reduce the pain by keeping the knee partially flexed much of the time. The nurse should encourage the client to keep the knee extended and administer analgesics as needed. Pain is expected postoperatively, so there is no need to notify the health care provider based on the symptom described. Full passive range of motion can be harmful to the knee replacement.

The nurse is obtaining a health history from a client and is assessing for risk factors associated with osteoporosis. The nurse would be most concerned if which data were obtained? Select all that apply. 1. The client reports that she doesn't exercise much at all. 2. The client reports that she smokes a few cigarettes a day. 3. The client reports that she is taking phenytoin to treat a seizure disorder. 4. The client reports that she consumes calcium and vitamin foods and supplements daily. 5. The client reports that she takes a daily low dose of prednisone to treat a chronic respiratory condition.

Answers: 1. The client reports that she doesn't exercise much at all. 2. The client reports that she smokes a few cigarettes a day. 3. The client reports that she is taking phenytoin to treat a seizure disorder. 5. The client reports that she takes a daily low dose of prednisone to treat a chronic respiratory condition. Rationale: Risk factors associated with osteoporosis include a sedentary lifestyle, cigarette smoking, excessive alcohol consumption, chronic illness, and long-term use of anticonvulsants and furosemide. Another risk factor associated with osteoporosis includes a diet that is deficient in calcium. Options 1, 2, 3, and 5 are risk factors associated with osteoporosis.

The community health nurse is providing a teaching session on osteoporosis to women living in the community. The nurse informs these community residents that which is a risk factor for this disorder? 1. A large skeletal frame 2. A diet low in vitamin D 3. Low thyroid hormone levels 4. A high dietary intake of calcium

Answer: 2. A diet low in vitamin D Rationale: Some of the risk factors related to osteoporosis in females are a small skeletal frame and elevated thyroid hormone. Low dietary intake of calcium and vitamin D also constitutes a risk factor for osteoporosis.

The nurse in the hospital emergency department is assessing a client with an open leg fracture. The nurse should inquire about the last time the client had which done? 1. Tuberculin test 2. Tetanus vaccine 3. Chest radiograph 4. Physical examination

Answer: 2. Tetanus vaccine Rationale: With an open fracture, the client is at risk for the development of osteomyelitis, gas gangrene, and tetanus. The nurse assesses for the date of the last tetanus immunization to ensure that the client has tetanus prophylaxis. The remaining options are unrelated to the current situation identified in the question.

A client is having a plaster cast placed on the lower extremity that will extend from mid-thigh to the center of the foot. Which instruction should be given to the client before hospital discharge? 1. How to petal the edges of the cast to prevent crumbling of these edges 2. The need to notify the nurse if the plaster cast becomes warm during the first 24 hours 3. The correct method of using a thin object when the client needs to scratch the area beneath the cast 4. The need to notify the health care provider immediately if the client notices numbness or swelling or if the foot becomes cold and pale

Answer: 4. The need to notify the health care provider immediately if the client notices numbness or swelling or if the foot becomes cold and pale Rationale: Numbness, swelling, and cool, pale skin are findings that indicate a state of neurovascular compromise. This can lead to significant problems and potential loss of the limb. Although teaching the client how to petal the edge of a cast is commonly done to keep the edges from crumbling, this is not the priority at this time. Chemical reaction occurs while a plaster cast dries, causing the cast to be warm. This effect can last from 24 to 48 hours, depending on how long it takes for the cast to dry. It is inappropriate to place any objects under the edge of the cast because such maneuvers can result in tissue injury and consequent infection.

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. Temperature of 101.6°F (38.7°C) orally 2. Complaints of discomfort during repositioning 3. Old bloody drainage outlined on the surgical dressing 4. Discomfort during coughing and deep-breathing exercises

Answer: 1. Temperature of 101.6°F (38.7°C) orally Rationale: The nursing assessment conducted after spinal surgery is similar to that done after other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101.6°F (38.7°C) should be reported.

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."

Answer: 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." 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 has provided discharge instructions to a client after a total hip replacement. Which statement by the client indicates a need for further instruction? 1. "I should sit in my recliner when I get home." 2. "I need to keep my legs apart while sitting or lying." 3. "I should try to obtain an elevated toilet seat for use at home." 4. "I should contact the health care provider if the incision becomes red or irritated or if I note any drainage."

Answer: 1. "I should sit in my recliner when I get home." Rationale: After total hip replacement, the client should be instructed to sit on a high, firm chair. The client should be instructed to keep the legs apart while sitting or lying to prevent disruption of the hip replacement; this may be accomplished by placing a blanket or a pillow between the legs. The use of an elevated toilet seat will prevent discomfort and pressure at the operative site. The health care provider should be notified if the client notes the development of any redness, irritation, or drainage at the incision site.

The nurse is talking to a client who had a below-the-knee amputation 2 days earlier. The client states, "I hate looking at this; I feel that I'm not even myself anymore." What client problem should the nurse incorporate in the plan of care based on the statement by this client? 1. Altered body image 2. Inability to care for self 3. Disruption in coping ability 4. Difficulty maintaining health

Answer: 1. Altered body image Rationale: Altered body image is characterized by negative verbalizations or feelings about a body part. This is a common response after amputation. The nurse supports the client and assists the client to work through these feelings. The client also may have the other problems as listed in the remaining options, but altered body image is the client problem that correlates best with the client's statement.

The home care nurse is providing instructions to a client regarding the use of crutches. The client asks the nurse to demonstrate the method for going down the stairs with the crutches. How should the nurse accurately demonstrate this technique? 1. Crutches and the affected leg down, followed by the unaffected leg 2. Crutches and the unaffected leg down, followed by the affected leg 3. Unaffected leg down first, followed by the crutches and the affected leg 4. Affected leg down first, followed by the crutches and the unaffected leg

Answer: 1. Crutches and the affected leg down, followed by the unaffected leg Rationale: When going down the stairs with crutches, the client should be instructed to move the crutches and the affected leg down and then to move the unaffected leg down. To go up the stairs, the client should first move up the unaffected leg and then move up the affected leg and crutches.

The nurse is preparing to perform pin site care for a client in skeletal traction. On assessment of the pin site, the nurse notes the presence of serous drainage. Which nursing action would be appropriate? 1. Document the findings. 2. Notify the health care provider (HCP). 3. Remove 2 pounds (0.9 kg) of weight from the traction. 4. Lift the weights and place them on the bed so that the HCP can assess the client.

Answer: 1. Document the findings. Rationale: A small amount of serous oozing is expected at the pin insertion site. The nurse would document the findings. It is not necessary to notify the HCP. The nurse would not add or remove any weight from the client's traction setup because this would disrupt the alignment of the fracture.

A client has skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should assess which area as high risk for pressure and breakdown? 1. Left heel 2. Scapulae 3. Right heel 4. Back of the head

Answer: 1. Left heel Rationale: Common areas that are under pressure and are at risk for breakdown include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the good leg (which is used as a brace when pushing up in bed). Other pressure points caused by the traction include the ischial tuberosity, popliteal space, and Achilles tendon. Scapulae and the back of the head are not common areas for pressure ulcers for this client. The right heel is elevated because of traction.

The home health nurse visits a client who is having an acute attack of gout. The nurse determines that the client needs further instruction regarding the treatment of gout if the client states to take which action? 1. Restricting fluids 2. Maintaining bed rest 3. Eating a low-purine diet 4. Taking nonsteroidal antiinflammatory drugs

Answer: 1. Restricting fluids Rationale: Ample fluid intake is encouraged to promote the excretion of uric acid. The client is placed on bed rest during an acute attack until the pain subsides. A diet low in purine normally is prescribed. Nonsteroidal antiinflammatory drugs (NSAIDs) are used to reduce pain and inflammation. Colchicine, which also may be prescribed, reduces the migration of leukocytes to the synovial fluid.

The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client? 1. The need for sensory stimulation 2. The amount of home care support available 3. The ability to perform activities of daily living 4. The type of transportation available for follow-up care

Answer: 1. The need for sensory stimulation Rationale: A psychosocial assessment of a client who is immobilized would most appropriately include the need for sensory stimulation. This assessment should also include such factors as body image, past and present coping skills, and coping methods used during the period of immobilization. Although home care support, the ability to perform activities of daily living, and transportation are components of an assessment, they are not as specifically related to psychosocial adjustment as is the need for sensory stimulation.

The nurse has reviewed activity restrictions with a client who is being discharged after insertion of a femoral head prosthetic system. What statement by the client will help the nurse determine that the client understands the material presented? 1. Use a raised toilet seat. 2. Bend carefully to put on socks and shoes. 3. Sit in chairs without arms for better mobility. 4. Exercise the leg past the point of 90-degree flexion.

Answer: 1. Use a raised toilet seat. Rationale: The client who has had an insertion of a femoral head prosthesis should use a raised toilet seat. The client should avoid putting on his or her own socks and shoes for 8 weeks after surgery because it would force the leg into acute flexion. The client should sit in chairs that have arms to provide assistance in rising from the sitting position. The client also should maintain the leg in a neutral, straight position when lying, sitting, or walking. The leg should not be adducted, internally rotated, or flexed more than 90 degrees.

The community health nurse is providing an educational session for community members regarding dietary measures that will assist in reducing the risk of osteoporosis. The nurse should instruct the community members to increase dietary intake of which food known to be helpful in minimizing this risk? 1. Yogurt 2. Turkey 3. Shellfish 4. Spaghetti

Answer: 1. Yogurt Rationale: The major dietary source of calcium is from dairy products including milk, yogurt, and a variety of cheeses. Calcium also can be added to certain products such as orange juice, which are then advertised as being fortified with calcium. Calcium supplements also are available and recommended for persons with typically low calcium intake. Turkey, shellfish, and spaghetti are not high-calcium products.

The nurse teaches a client who is going to have a plaster cast applied about the procedure. Which statement by the client indicates a need for further teaching? 1. "The cast will give off heat as it dries." 2. "I can bear weight on the cast in one-half hour." 3. "The cast edges may be trimmed with a cast knife." 4. "A stockinette will be placed over the leg area to be casted."

Answer: 2. "I can bear weight on the cast in one-half hour." Rationale: A plaster cast can tolerate weight bearing once it is dry, which takes from 24 to 72 hours, depending on the nature and thickness of the cast. A plaster cast gives off heat as it dries. The procedure for casting involves washing and drying the skin and placing a stockinette material over the area to be casted. A roll of padding is then applied smoothly and evenly. The plaster is rolled onto the padding, and the edges are trimmed or smoothed as needed.

A client has just had a cast removed, and the underlying skin is yellow-brown and crusted. The nurse gives the client instructions for skin care. The nurse determines that the client needs further teaching of the directions if he or she makes which statement? 1. "I need to soak the skin and wash it gently." 2. "I need to scrub the skin vigorously with soap and water." 3. "I need to apply an emollient lotion to enhance softening." 4. "I need to use a sunscreen on the skin if exposed to the sun for a period of time."

Answer: 2. "I need to scrub the skin vigorously with soap and water." Rationale: The skin under a casted area may be discolored and crusted with dead skin layers. The client should gently soak and wash the skin for the first few days. The skin should be patted dry, and a lubricating lotion should be applied. People often want to scrub the dead skin away, but scrubbing irritates the skin and should not be done. The client should avoid overexposing the skin to the sunlight.

The nurse is planning to teach a client how to stand on crutches. The nurse will incorporate into written instructions that the client should be told to place the crutches in what manner? 1. 3 inches (8 cm) to the front and side of the toes 2. 6 inches (15 cm) to the front and side of the toes 3. 15 inches (38 cm) to the front and side of the toes 4. 20 inches (51 cm) to the front and side of the toes

Answer: 2. 6 inches (15 cm) to the front and side of the toes Rationale: The classic tripod position is taught to the client before instructions on gait are given. The crutches are placed 6 inches (15 cm) in front and to the side of the client. This placement provides an adequate base of support to the client and improves balance.

A client is admitted to the nursing unit after a left below-the-knee amputation after a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How should the nurse interpret this client statement? 1. A normal response that indicates the presence of phantom limb pain 2. A normal response that indicates the presence of phantom limb sensation 3. An abnormal response that indicates that the client is in denial about the limb loss 4. An abnormal response that indicates that the client needs more psychological support

Answer: 2. A normal response that indicates the presence of phantom limb sensation Rationale: Phantom limb sensations are felt in the area of the amputated limb. These sensations can include itching, warmth, and cold. The sensations are caused by intact peripheral nerves in the area of the amputation. Whenever possible, the client should be prepared for these sensations. The client also may feel painful sensations in the amputated limb, called phantom limb pain. The origin of the pain is less well understood, but the client should be prepared for this, too, whenever possible.

The nurse has given instructions to a client returning home after 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 stay off the leg entirely for the rest of the day." 4. "I need to report a fever or swelling to my health care provider."

Answer: 4. "I need to report a fever or swelling to my health care provider." Rationale: After arthroscopy, the client usually can walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for at least a few days. The client may resume the usual diet. Signs and symptoms of infection should be reported to the health care provider.

The nurse is repositioning a client who has been returned to the nursing unit after internal fixation of a fractured right hip with a femoral head replacement. The nurse should use which method to reposition the client? 1. A trochanter roll to prevent abduction during turning 2. A pillow to keep the right leg abducted during turning 3. A pillow to keep the right leg adducted during turning 4. A trochanter roll to prevent external rotation during turning

Answer: 2. A pillow to keep the right leg abducted during turning Rationale: After femoral head replacement for a fractured hip with an intracapsular fracture, the client is turned to the affected side or the unaffected side as prescribed by the surgeon. Before moving the client, the nurse places a pillow between the client's legs to keep the affected leg in abduction. The nurse then repositions the client while maintaining proper alignment and abduction. A trochanter roll is useful in preventing external rotation, but it is used after the client has been repositioned. A trochanter roll is not used while the client is being turned.

A client who has had spinal fusion and insertion of hardware is extremely concerned with the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to prior employment. The nurse understands that the client's needs could best be addressed by referral to which member of the health care team? 1. The surgeon 2. A social worker 3. The physical therapist 4. The clinical nurse specialist

Answer: 2. A social worker Rationale: After spinal surgery, concerns about finances and employment are best handled by referral to a social worker. This professional can provide the most helpful information about resources available to the client. The clinical nurse specialist and the surgeon do not have information related to financial resources. The physical therapist has the best knowledge of techniques for increasing mobility and endurance.

A client has had surgery to repair a fractured left hip. When repositioning the client from side to side in the bed, what should the nurse plan to use as the most important item for this maneuver? 1. Bed pillow 2. Abductor splint 3. Adductor splint 4. Overhead trapeze

Answer: 2. Abductor splint Rationale: After surgery to repair a fractured hip, an abductor splint is used to maintain the affected extremity in good alignment. A bed pillow and an overhead trapeze also are used, but neither is the priority item to be used in repositioning the client from side to side.

A client has several fractures of the lower leg, which has been placed in an external fixation device. The client is upset about the appearance of the leg, which is edematous. The nurse documents which client problem in the plan of care? 1. Feeling isolated 2. Body image alteration 3. Inability to perform activities 4. Inability to engage in physical mobility

Answer: 2. Body image alteration Rationale: The client experiences an altered image of the body related to a change in the structure and function of the affected leg. No data in the question support a client's problem of feeling isolated or unable to perform activities or engage in physical mobility.

The nurse is evaluating goal achievement for a client in traction with impaired physical mobility. The nurse determines that the plan of care needs to be revised if which outcome is noted? 1. Intact skin surfaces 2. Bowel movement every 4 days 3. Active range of motion of uninvolved joints 4. Absence of redness and swelling in the affected extremity

Answer: 2. Bowel movement every 4 days Rationale: A bowel movement every 4 days is insufficient. The client should be having a bowel movement a minimum of every other day. Expected outcomes for impaired physical mobility for the client in traction include absence of thrombophlebitis (redness and swelling in the affected extremity), active range of motion to uninvolved joints, clear lung sounds, intact skin, and bowel movement every other day.

The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include which action in the plan? 1. Ensure that the knots are at the pulleys. 2. Check the weights to ensure that they are off of the floor. 3. Ensure that the head of the bed is kept at a 45- to 90-degree angle. 4. Monitor the weights to ensure that they are resting on a firm surface.

Answer: 2. Check the weights to ensure that they are off of the floor. Rationale: To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. Weights should not be kept resting on a firm surface. The head of the bed is usually kept low to provide countertraction.

The nurse is caring for a client who was just admitted to the hospital with a diagnosis of a fractured right hip sustained from a fall 5 hours earlier. The nurse creates a plan of care for the client and includes interventions related to monitoring for signs of fat embolism. Which findings should be listed in the care plan as a sign/symptom of fat embolism? 1. Fever and chills 2. Dyspnea and chest pain 3. External rotation of the right leg 4. Pallor, paresthesia, and pulselessness of the right lower leg

Answer: 2. Dyspnea and chest pain Rationale: The signs of fat embolism are associated with alterations in respiratory status or neurological status. Dyspnea, petechiae, and chest pain are signs of fat embolism. External rotation of the leg is indicative of the hip fracture itself. Fever and chills indicate signs of infection, and pallor, paresthesia, and pulselessness indicate signs of severe circulatory impairment.

The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg. The nurse notes the presence of edema in the foot below the cast. The nurse should make which interpretation about this finding? 1. Arterial insufficiency 2. Impaired venous return 3. Impaired arterial circulation 4. The presence of an infection

Answer: 2. Impaired venous return Rationale: Edema in the extremity indicates impaired venous return. Signs of impaired arterial circulation in the limb include coolness and pallor of the skin and a diminished arterial pulse. Signs of infection under a cast area would include odor or purulent drainage from the cast and the presence of "hot spots," which are areas of the cast that feel warmer to the touch than the rest of the cast.

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 range of motion while the client ambulates

Answer: 2. Injury to the brachial plexus nerves Rationale: Crutches are measured so that the tops are 2 to 3 finger widths from the axillae. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the crutch, which could result in injury to the nerves of the brachial plexus. Although the conditions in options 1, 3, and 4 can occur, they are not the most likely result from resting the axilla directly on the crutches.

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.

Answer: 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. Rationale: 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 is evaluating a client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performs which action? 1. Holds the cane on the right side 2. Moves the cane when the right leg is moved 3. Leans on the cane when the right leg swings through 4. Keeps the cane 6 inches (15 cm) out to the side of the right foot

Answer: 2. Moves the cane when the right leg is moved Rationale: The cane is held on the stronger side to minimize stress on the affected extremity and to provide a wide base of support. The cane is held 4 to 6 inches (10 to 15 cm) lateral to the fifth toe. The cane is moved forward with the affected leg. The client leans on the cane for added support while the leg on the stronger side swings through.

The nurse is caring for a client in skeletal traction. On assessing the pin sites, the nurse notes the presence of purulent drainage. Which nursing action is most appropriate? 1. Document the findings. 2. Notify the health care provider. 3. Apply antibiotic ointment to the pin sites. 4. Clean the pin sites more frequently than prescribed.

Answer: 2. Notify the health care provider. Rationale: A small amount of clear fluid drainage is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin sites are not expected findings and should be reported to the health care provider. Options 1, 3, and 4 are inappropriate nursing actions for this client before cleaning a newly assessed potentially infected pin site; the site would be cultured before either cleaning it or putting medication on it.

A client who had a body cast applied 2 days earlier begins to complain of anorexia, nausea, and abdominal discomfort. The nurse should take which immediate action? 1. Test the client's stool for guaiac. 2. Notify the health care provider. 3. Administer the prescribed as-needed antacid. 4. Administer the prescribed as-needed antiemetic.

Answer: 2. Notify the health care provider. Rationale: The client who has been placed in a body cast is at risk for the development of cast syndrome. This results from pressure on the mesenteric artery and can lead to intestinal obstruction. The immediate action is to report the client's complaints to the health care provider (HCP). Cast syndrome usually is treated with nasogastric decompression, intravenous therapy for hydration, and possibly application of a new cast. Testing the stool and administering an antacid or antiemetic delay necessary interventions.

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

Answer: 2. Numbness and tingling in the fingers Rationale: The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign. Pain that is out of proportion to the severity of the fracture, along with other symptoms associated with the pain, is not an early manifestation.

A client with a fractured femur experiences sudden dyspnea, tachypnea, and tachycardia. A set of arterial blood gas tests reveals the following: pH, 7.35 (7.35); Paco2, 43 mm Hg (43 mm Hg); Pao2, 58 mm Hg (58 mm Hg); HCO3, 23 mEq/L (23 mmol/L). The nurse interprets that the client probably has experienced fat embolus because of the result of which parameter? 1. pH 2. Pao2 3. HCO3 4. Paco2

Answer: 2. Pao2 Rationale: A significant feature of fat embolism is a significant degree of hypoxemia, with a Pao2often less than 60 mm Hg (60 mm Hg). The data in the question indicate that the items in the remaining options are normal blood gas results.

The nurse is creating a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client? 1. Urinary incontinence 2. Signs of skin breakdown 3. The presence of bowel sounds 4. Signs of infection around the pin sites

Answer: 2. Signs of skin breakdown Rationale: Skin traction is achieved by Ace wraps, boots, or slings that apply a direct force on the client's skin. Traction is maintained with 5 to 8 lb (2.3 to 3.6 kg) of weight, and this type of traction can cause skin breakdown. Urinary incontinence is not related to the use of skin traction. Although constipation can occur as a result of immobility and monitoring bowel sounds may be a component of the assessment, this intervention is not the priority assessment. There are no pin sites with skin traction.

The home care nurse has instructed a client how to perform the three-point gait with the use of crutches. The nurse observes the client using this gait to ensure correct performance of the maneuvers. Which observation, if made by the nurse, would indicate that the client understands how to perform this type of gait? 1. The client moves both crutches forward and then swings both feet forward to the crutches. 2. The client moves both crutches forward, along with the affected leg, and then moves the unaffected leg forward. 3. The client moves the right crutch forward, along with the left foot, and then brings the right foot and the left crutch forward. 4. The client moves the left crutch forward, along with the right foot, and then brings the left foot and the right crutch forward.

Answer: 2. The client moves both crutches forward, along with the affected leg, and then moves the unaffected leg forward. Rationale: In a three-point gait the client is instructed to simultaneously move both crutches and the affected leg forward and then to move the unaffected leg forward. Option 1 identifies a swing-through gait. Options 3 and 4 identify a four-point gait.

The nurse is planning to teach the client with below-the-knee amputation about care to prevent skin breakdown. Which point should the nurse include in developing the teaching plan? 1. The residual limb is washed gently and dried every other day. 2. The socket of the prosthesis must be dried carefully before it is used. 3. A residual limb sock must be worn at all times and changed twice a week. 4. The socket of the prosthesis is washed with a harsh bactericidal agent daily.

Answer: 2. The socket of the prosthesis must be dried carefully before it is used. Rationale: A residual limb sock must be worn at all times to absorb perspiration and is changed daily. The residual limb is washed, dried, and inspected for breakdown twice each day. The socket of the prosthesis is cleansed with a mild detergent and rinsed and dried carefully each day. A harsh bactericidal agent would not be used.

A client is complaining of pain underneath a cast in the area of a bony prominence. The nurse interprets that this client may need which intervention? 1. To have the cast bivalved 2. To have a window cut in the cast 3. To have the cast replaced with an air splint 4. To have extra padding put over this area of the cast

Answer: 2. To have a window cut in the cast Rationale: A window may be cut in a dried cast to relieve pressure in an area of a bony prominence, to assess pulses, to relieve discomfort, or to remove drains. Bivalving the cast involves splitting the cast along both sides to allow space for swelling, to facilitate taking radiographs, or to make a half-cast for use as an intermittent splint. The use of an air splint is not indicated. Padding is not placed on top of a cast.

The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client? 1. Calcium level of 9.0 mg/dL (2.25 mmol/L) 2. Uric acid level of 9.0 mg/dL (0.54 mmol/L) 3. Potassium level of 4.1 mEq/L (4.1 mmol/L) 4. Phosphorus level of 3.1 mg/dL (1.0 mmol/L)

Answer: 2. Uric acid level of 9.0 mg/dL (0.54 mmol/L) Rationale: In addition to the presence of clinical manifestations, gout is diagnosed by the presence of persistent hyperuricemia, with a uric acid level higher than 8 mg/dL (0.48 mmol/L); a normal value for a male ranges from 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L) and for a female, from 2.7 to 7.3 mg/dL (0.16 to 0.43 mmol/L). Options 1, 3, and 4 indicate normal laboratory values. In addition, the presence of uric acid in an aspirated sample of synovial fluid confirms the diagnosis. {You do NOT have to memorize the normal value of uric acid, knowing that hyperuricemia occurs in Gout Arthritis is enough}

The nurse develops a plan of care for a client with a spica cast that covers a lower extremity and documents that the client is at risk for constipation. When planning for bowel elimination needs, the nurse should include which in the plan of care? 1. Administer an enema daily. 2. Use a fracture pan for bowel elimination. 3. Use a bedside commode for all elimination needs. 4. Use a regular bedpan to prevent spilling of contents in the bed.

Answer: 2. Use a fracture pan for bowel elimination. Rationale: A fracture pan is designed to be used for clients with body or leg casts. A client with a spica cast (body cast) involving a lower extremity cannot bend at the hips to sit up; therefore, a regular bedpan and a commode would be inappropriate. Daily enemas are not a part of routine care.

The nurse has taught a client with a below-the-knee amputation about prosthesis and residual limb care. The nurse determines that the client has understood the instructions if the client makes which statement? 1. Wear a clean nylon residual limb sock daily. 2. Use a mirror to inspect all areas of the residual limb each day. 3. Toughen the skin of the residual limb by rubbing it with alcohol. 4. Prevent cracking of the skin of the residual limb by applying lotion daily.

Answer: 2. Use a mirror to inspect all areas of the residual limb each day. Rationale: Following amputation, the client should inspect all surfaces of the residual limb daily for irritation, blisters, or breakdown. The other options are incorrect. The client should wear a clean woolen residual limb sock each day. Nylon is a synthetic material that does not allow the best air circulation and holds in moisture. The stump is cleansed daily with a gentle soap and water and is dried carefully. Alcohol is avoided because it could cause drying or cracking of the skin. Oils, creams, and lotions also are avoided because they are too softening to the skin for safe prosthesis use.

The nurse is developing a plan of care for a client in Buck's traction. The plan of care should include assessing the client for which finding indicating a complication associated with the use of this type of traction? 1. Hypotension 2. Weak pedal pulses 3. Redness at the pin sites 4. Drainage at the pin sites

Answer: 2. Weak pedal pulses Rationale: Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage used to secure the traction system. This type of traction does not use pins; rather, elastic bandages or a prefabricated boot is worn by the client. Therefore, redness and/or drainage at the pin sites are incorrect. Hypotension is not directly associated with the use of this type of traction.

The nurse has completed giving discharge instructions to a client who has had a total joint replacement (TJR) of the knee with a metal prosthetic system. The nurse determines that the client understands the instructions if the client makes which statement? 1. "Changes in the shape of the knee are expected." 2. "Fever, redness, and increased pain are expected." 3. "All caregivers should be told about the metal implant." 4. "Bleeding gums or black stools may occur, but this is normal."

Answer: 3. "All caregivers should be told about the metal implant." Rationale: A TJR is also known as a total joint arthroplasty (TJA). The client must inform other caregivers of the presence of the metal implant because certain tests and procedures will need to be avoided. After total knee replacement, the client should report signs and symptoms of infection and any changes in the shape of the knee. These could indicate developing complications. With a metal implant, the client may be on anticoagulant therapy and should report adverse effects of this therapy, including bleeding from a variety of sources, and the client will need antibiotic prophylaxis for invasive procedures.

The nurse witnesses a client sustain a fall and suspects that the right leg may be broken. The nurse should take which priority action? 1. Take a set of vital signs. 2. Call the radiology department. 3. Reassure the client that everything will be fine. 4. Immobilize the right leg before moving the client.

Answer: 4. Immobilize the right leg before moving the client. Rationale: When a fracture is suspected, it is imperative that the area be splinted before the client is moved. Emergency help should be called for if the client is not hospitalized, and a health care provider is called for the hospitalized client. The nurse should remain with the client and provide realistic reassurance. The nurse does not prescribe radiographs. Telling the client that everything will be fine is nontherapeutic. Although vital signs will be taken, the priority is to immobilize the leg.

The nurse is planning discharge teaching for a client diagnosed and treated for compartment syndrome. Which information should the nurse include in the teaching? 1. "A bone fragment has injured the nerve supply in the area." 2. "An injured artery caused impaired arterial perfusion through the compartment." 3. "Bleeding and swelling caused increased pressure in an area that couldn't expand." 4. "The fascia expanded with injury, causing pressure on underlying nerves and muscles."

Answer: 3. "Bleeding and swelling caused increased pressure in an area that couldn't expand." Rationale: Compartment syndrome is caused by bleeding and swelling within a tissue compartment that is lined by fascia, which does not expand. The bleeding and swelling put pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms. The remaining options are inaccurate descriptions of compartment syndrome.

A male client arrives in the hospital emergency department and tells the nurse that he twisted his ankle while jogging. The client is seen by the health care provider and is diagnosed with a sprained ankle. The nurse provides instructions to the client regarding home care for the injury. Which statement, if made by the client, would indicate an understanding of appropriate care measures for the next 24 hours? 1. "I should place hot packs on my ankle." 2. "I should wrap my ankle with blankets." 3. "I should elevate my foot above the level of the heart." 4. "I should try to ambulate at least 10 minutes out of every hour."

Answer: 3. "I should elevate my foot above the level of the heart." Rationale: Soft tissue injuries such as sprains are treated with RICE (rest, ice, compression, and elevation) for the first 24 to 48 hours after the injury, depending on health care provider prescription. Ice is applied intermittently for 20 to 30 minutes at a time. Heat is not used for the first 24 hours because this could cause venous congestion, thereby increasing edema and pain. Blankets would produce heat to the affected area. The client should rest and not walk around, and the foot should be elevated and not placed in a dependent position.

The nurse is giving a client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed touch-down of the affected leg. The nurse should tell the client to perform which action? 1. Advance the crutches along with both legs simultaneously. 2. Advance the crutches along with the right leg, and then advance the left leg. 3. Advance the crutches along with the left leg, and then advance the right leg. 4. Advance the left leg along with right crutch, and then the right leg and left crutch.

Answer: 3. Advance the crutches along with the left leg, and then advance the right leg. Rationale: A three-point gait requires good balance and arm strength. The crutches are advanced with the affected leg, and then the unaffected leg is moved forward. Option 1 describes a swing-through gait. Option 2 describes a three-point gait used for a right leg problem. Option 4 describes a two-point gait.

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

Answer: 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.

The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which is the priority nursing action? 1. Provide pin care. 2. Medicate the client. 3. Call the health care provider. 4. Remove 2 pounds (0.9 kg) of weight from the traction system.

Answer: 3. Call the health care provider. Rationale: Severe pain in a client in skeletal traction may indicate a need for realignment, or the traction weights applied to the limb may be too heavy. The nurse realigns the client. If this measure is ineffective, the nurse then calls the health care provider. Severe leg pain once traction has been established indicates a problem. Providing pin care is unrelated to the problem as described. Medicating the client should be done after trying to determine and treat the cause. The nurse should never remove the weights from the traction system without a specific prescription to do so.

The nurse is preparing a plan of care for a client who is scheduled to return from the recovery room after a left total knee arthroplasty. The nurse includes in the plan of care to assess the client's neurovascular status the monitoring of which parameter? 1. The pain level of the client 2. Blood pressure and respiratory rate 3. Capillary refill, sensation, color, and pulse of the left foot 4. The range of motion of the left knee when a continuous passive motion machine is used

Answer: 3. Capillary refill, sensation, color, and pulse of the left foot Rationale: The nurse would check capillary refill, sensation, color, and pulse of the affected extremity in a neurovascular assessment. Monitoring the pain level may be a component of the assessment but is not specifically related to neurovascular status. Blood pressure and respiratory rate may also be components of the nursing assessment but are not specific to neurovascular status. Range of motion is related to musculoskeletal status, not neurovascular status.

The nurse is caring for a client after the application of a plaster cast for a fractured left radius. The nurse should suspect impairment with the neurovascular status of the client's casted extremity if which findings are noted? Select all that apply. 1. Capillary refill is less than 3 seconds 2. Pulses present and with swollen, pink fingers 3. Client report of severe, deep, unrelenting pain 4. Client report of pain as nurse assesses finger movement 5. Client report of numbness and tingling sensation in the fingers

Answer: 3. Client report of severe, deep, unrelenting pain 4. Client report of pain as nurse assesses finger movement 5. Client report of numbness and tingling sensation in the fingers Rationale: The pressure in compartment syndrome, if unrelieved, will cause permanent damage to nerve and muscle tissue distal to the pressure. Circulatory damage may result in necrosis. Nerve and muscle damage may result in permanent contractures, deformity of the extremity, and functional impairment. Normal capillary refill time is 3 seconds or less. Pink appearance and a pulse indicate adequate blood flow; swelling is expected after a fracture. Client report of severe, deep, unrelenting pain; client report of numbness and tingling sensation; and client report of pain as the nurse assesses finger movement are indicative of development of compartment syndrome.

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

Answer: 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 assessing a client with a shortened, adducted, and externally rotated left leg. On the basis of this finding, which condition should the nurse anticipate? 1. Fractured knee 2. Dislocated knee 3. Fracture of the femoral neck 4. Fracture of the midshaft of the femur

Answer: 3. Fracture of the femoral neck Rationale: Typical signs after femoral neck fracture include shortening of the affected leg, adduction, and external rotation. The client may report slight groin pain or pain in the medial side of the knee. Moving the fractured extremity increases the pain significantly. The signs noted in the question are not associated with a fractured or dislocated knee or a fractured femur.

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 elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain? 1. Infection under the cast 2. The anxiety of the client 3. Impaired tissue perfusion 4. The recent occurrence of the fracture

Answer: 3. Impaired tissue perfusion Rationale: Most pain associated with fractures can be minimized with rest, elevation, application of cold, and administration of analgesics. Pain that is not relieved by these measures should be reported to the health care provider because pain unrelieved by medications and other measures may indicate neurovascular compromise. Because this is a new closed fracture and cast, infection would not have had time to set in. Intense pain after casting is normally not associated with anxiety or the recent occurrence of the injury. Treatment following the fracture should assist in relieving the pain associated with the injury.

The nurse is caring for a client at risk for fat embolism because of a fracture of the left femur and pelvis sustained in a fall. The client also sustained a head injury, is comatose, and is unable to communicate verbally. Which assessment findings should the nurse identify as early signs of possible fat embolism? 1. Decreased heart rate and increased restlessness 2. Decreased heart rate and decreased respiratory rate 3. Increased heart rate and adventitious breath sounds 4. Increased heart rate and increased oxygen saturation

Answer: 3. Increased heart rate and adventitious breath sounds Rationale: Fat embolism commonly causes signs and symptoms related to respiratory or neurological impairment. Because the client is unable to speak, it may be difficult to immediately assess early changes in neurological status. However, adventitious breath sounds and an increased heart rate may be easily and quickly observed, even before the client demonstrates labored breathing. The remaining options are incorrect.

A client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse should anticipate that which type of wound care to the fasciotomy site will be prescribed? 1. Dry sterile dressings 2. Hydrocolloid dressings 3. Moist sterile saline dressings 4. One-half strength povidone-iodine dressings

Answer: 3. Moist sterile saline dressings Rationale: The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with moist sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. Because this is an open wound, dry dressings should not be used. A hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so povidone-iodine should not be required. Also, this agent is irritating to tissues.

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

Answer: 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.

The nurse is planning measures to increase bed mobility for a client in skeletal leg traction. Which item should the nurse consider to be most helpful for this client? 1. Television 2. Fracture bedpan 3. Overhead trapeze 4. Reading materials

Answer: 3. Overhead trapeze Rationale: The use of an overhead trapeze is extremely helpful for a client to move about in bed and to get on and off the bedpan. This device has the greatest value in increasing overall bed mobility. Television and reading materials, although helpful in reducing boredom and providing distraction, do not increase bed mobility. A fracture bedpan is useful in reducing discomfort with elimination.

The home care nurse visits a client who has a cast applied to the left lower leg. On assessment of the client, the nurse notes the presence of skin irritation from the edges of the cast. Which nursing intervention is most appropriate? 1. Contact the health care provider. 2. Massage the skin at the edges of the cast. 3. Petal the cast edges with appropriate material. 4. Place a small face cloth in the cast around the edges of the cast.

Answer: 3. Petal the cast edges with appropriate material. Rationale: If a client with a cast has skin irritation from the edges of the cast, the nurse would petal the edges of the cast with tape to minimize the irritation. It is not necessary to contact the health care provider unless skin breakdown is noted. Massaging the skin will not eliminate the problem. Placing a small facecloth in the cast around the edges of the cast is not appropriate.

The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information? 1. Apply restraints to the client. 2. Ask the family to stay with the client. 3. Place a clock and calendar in the client's room. 4. Ask the laboratory to perform electrolyte studies.

Answer: 3. Place a clock and calendar in the client's room. Rationale: An inactive older adult may become disoriented because of lack of sensory stimulation. The most appropriate nursing intervention would be to reorient the client frequently and to place objects such as a clock and a calendar in the client's room to maintain orientation. Restraints may cause further disorientation and should not be applied unless specifically prescribed; agency policies and procedures should be followed before the application of restraints. The family can assist with orientation of the client, but it is inappropriate to ask the family to stay with the client. It is not within the scope of nursing practice to prescribe laboratory studies.

The nurse is caring for a client in skeletal leg traction with an overbed frame. Which nursing intervention will best assist the client with self-positioning in bed? 1. Use the assistance of four nurses to reposition the client. 2. Place a draw sheet on the mattress for pulling the client up in bed. 3. Place a trapeze on the bed frame to provide a means for the client to lift the hips off the bed. 4. Encourage the client to push with the unaffected leg on the bed mattress to help with repositioning.

Answer: 3. Place a trapeze on the bed frame to provide a means for the client to lift the hips off the bed. Rationale: The nurse can best assist the client in skeletal traction with repositioning by providing a trapeze on the bed frame for the client's use. Although a draw sheet is helpful and client movement may be more easily facilitated with four nurses, these actions will not promote repositioning by the client. Encouraging the client to push with the unaffected leg on the bed mattress for repositioning may cause skin breakdown on the unaffected heel area.

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 health care provider (HCP). 3. Rewrap the residual limb with an elastic compression bandage. 4. Apply a dry, sterile dressing and elevate the residual limb on 1 pillow.

Answer: 3. Rewrap the residual limb with an elastic compression bandage. Rationale: If the client with an amputation has a cast or elastic compression bandage that slips off, the nurse must wrap the residual limb immediately with another elastic compression bandage. Otherwise, excessive edema will form rapidly, which could cause a significant delay in rehabilitation. If the client had a cast that slipped off, the nurse would have to call the HCP so that a new one could be applied. Elevation on 1 pillow is not going to impede the development of edema greatly once compression is released. Ice would be of limited value in controlling edema from this cause. If the HCP were called, the prescription likely would be to reapply the compression dressing anyway.

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

Answer: 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 clinic nurse is performing an assessment on a client with a diagnosis of rheumatoid arthritis (RA). The nurse checks for which assessment finding that is associated with RA? 1. Age of onset is generally 65 years of age or older 2. Complaints of pain that is more severe after activity 3. Systemic symptoms such as fatigue, anorexia, and weight loss 4. Joint pain is asymmetrical and associated with past injuries to the joint

Answer: 3. Systemic symptoms such as fatigue, anorexia, and weight loss Rationale: In clients diagnosed with RA, systemic symptoms such as fatigue, anorexia, weight loss, and nonspecific aching and stiffness may appear before joint manifestations. RA is characterized by chronic joint pain of variable intensity, which is more severe on rising in the morning. The age of onset for RA is most commonly between 30 and 50 years of age. Complaints of pain that is more severe after activity and asymmetrical joint pain associated with past injuries to the joint are more commonly seen in osteoarthritis.

A client has just been admitted to the hospital with a fractured femur and pelvic fractures. The nurse should plan to carefully monitor the client for which signs/symptoms? 1. Fever and bradycardia 2. Fever and hypertension 3. Tachycardia and hypotension 4. Bradycardia and hypertension

Answer: 3. Tachycardia and hypotension Rationale: Clients who experience fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and the thigh. This can occur with closed fractures as well as open fractures. Signs of hypovolemic shock include tachycardia and hypotension.

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 at the pin sites 3. Thick, yellow drainage from the pin sites 4. Clear, watery drainage from the pin sites

Answer: 3. Thick, yellow drainage from the pin sites Rationale: The nurse should monitor for signs of infection such as inflammation, purulent drainage, and pain at the pin site. However, some degree of inflammation, pain at the pin site, and serous drainage would be expected; the nurse should correlate assessment findings with other clinical findings, such as fever, elevated white blood cell count, and changes in vital signs. Additionally, the nurse should compare any findings to baseline findings to determine if there were any changes.

A client has had a bone scan done. The nurse determines that the client demonstrates understanding of post-procedure care when the client makes which statement? 1. "Flushing indicates a complication." 2. "I should stay on liquids for a couple of days." 3. "I need to ambulate every couple of hours faithfully for a few days." 4. "I need to drink plenty of water for 1 to 2 days after the procedure."

Answer: 4. "I need to drink plenty of water for 1 to 2 days after the procedure." Rationale: No special restrictions are necessary after a bone scan. The client is encouraged to drink large amounts of water for 24 to 48 hours to flush the radioisotope from the system. The very small amount of radioactivity from the isotope presents no hazard to the client or staff. The remaining options are unrelated to post-procedure care.

A client is being discharged to home after spinal fusion with insertion of instrumentation (rod). The unit nurse should consult with the continuing care nurse regarding the need for modification of the home environment if the client makes which statement? 1. "The bathroom has hand railings in the shower." 2. "There are three steps to get up to the front door." 3. "My family has rented a commode for me to use." 4. "My bedroom and bathroom are on the second floor of my home."

Answer: 4. "My bedroom and bathroom are on the second floor of my home." Rationale: Stair climbing may be restricted or limited for several weeks after spinal fusion with instrumentation. If stairs need to be climbed to reach a bathroom, hand rails should be installed and the area kept free of clutter. The nurse ensures that resources are in place before discharge so that the client may sleep and perform all activities of daily living on a single living level. From the options provided, options 1, 2, and 3 do not indicate a need for modification of the environment.

The nurse has provided instructions to a client with a diagnosis of rheumatoid arthritis about measures to protect the joints. Which statement by the client indicates a need for further instruction? 1. "I should slide objects rather than lifting them." 2. "I should try not to remain in the same position for a long period of time." 3. "I should use large joints instead of small joints when performing activities." 4. "Pain or fatigue is expected, and I should try to continue with the activity if this occurs."

Answer: 4. "Pain or fatigue is expected, and I should try to continue with the activity if this occurs." Rationale: The client should be instructed to use pain or fatigue as an indicator and guide to increase, maintain, or decrease an activity level. If pain or fatigue is experienced, the client should rest. The client should learn to slide objects rather than lifting them and not remain in the same position for a long time. Whenever possible, the client should use large joints instead of small joints for activities and should use the joints in their most natural position.

A client is being transferred to the nursing unit from the post-anesthesia care unit after spinal fusion with rod insertion. The nurse should prepare to transfer the client from the stretcher to the bed by using which best method? 1. A bath blanket and the assistance of four people 2. A bath blanket and the assistance of three people 3. A transfer (slider) board and the assistance of two people 4. A transfer (slider) board and the assistance of three people

Answer: 4. A transfer (slider) board and the assistance of three people Rationale: After spinal fusion, with or without instrumentation, the client is transferred from the stretcher to the bed using a transfer (slider) board and the assistance of three people with one at the head to protect or support the client's head and neck. This strategy permits optimal stabilization and support of the spine while allowing the client to be moved smoothly and gently.

The nurse is performing an assessment on a client after a closed reduction of a fractured right humerus and application of a plaster cast. To assess for signs of compartment syndrome, the nurse should perform which action? 1. Assess the client's cognitive level. 2. Assess the temperature of the cast. 3. Monitor for the presence of drainage or odors on or beneath the cast. 4. Assess capillary refill, temperature, color, and amount of pain in the right hand.

Answer: 4. Assess capillary refill, temperature, color, and amount of pain in the right hand. Rationale: The major signs and symptoms of compartment syndrome include pallor or cyanosis; pain, even following the administration of opioid analgesics; vascular compromise demonstrated by weakened or absent pulses and poor capillary refill; and edema of the extremity distal to the area of the fracture. Cognitive level, temperature of the cast, and the presence of drainage or odors on or beneath the cast are not assessments related to compartment syndrome.

The nurse provides instructions to a client with bilateral deformities of the joints of the fingers due to rheumatoid arthritis. When providing teaching about the disease process, the nurse should inform the client that the changes are most likely due to what type of response? 1. Allergic 2. Metabolic 3. Endocrine 4. Autoimmune

Answer: 4. Autoimmune Rationale: The most likely cause for rheumatoid arthritis is activation of an autoimmune response. This is thought to trigger antigen-antibody responses and release of lysosomes from phagocytic cells, which ultimately attack the cartilage and synovia, with resultant synovitis. Other theories related to the cause of rheumatoid arthritis have been proposed, but the most likely cause is an autoimmune reaction.

The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast is applied, the client reports a significant increase in pain level even after administration of the prescribed dose of opioid analgesic. What is the initial nursing action? 1. Elevate the casted leg. 2. Contact the health care provider. 3. Administer another dose of pain medication. 4. Check the neurovascular status of the toes on the casted leg.

Answer: 4. Check the neurovascular status of the toes on the casted leg. Rationale: An increase in pain level in an extremity at risk for neurovascular compromise (compartment syndrome) often is the first sign of increasing pressure within a tissue compartment. The nurse needs to obtain additional assessment data to determine if the health care provider needs to be notified immediately or whether other interventions are appropriate. Options 1, 2, and 3 are inappropriate and would delay necessary treatment.

The nurse is caring for a client with a radius fractured across the shaft and bone splintered into fragments. Information about which type of fracture should be included by the nurse in the client's education? 1. Simple fracture 2. Greenstick fracture 3. Compound fracture 4. Comminuted fracture

Answer: 4. Comminuted fracture Rationale: A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone: one side of the bone is fractured, and the other side is bent. A compound fracture, also called an open or complex fracture, is one in which the skin or mucous membrane has been broken and the resulting wound extends to the depth of the fractured bone.

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

Answer: 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 suggested specific leg exercises for a client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further instruction if the nurse observes the client performing which action? 1. Pulling up using the trapeze 2. Flexing and extending the feet 3. Doing quadriceps-setting and gluteal-setting exercises 4. Performing active range of motion to the right ankle and knee

Answer: 4. Performing active range of motion to the right ankle and knee Rationale: Active range of motion to the right ankle and knee would disrupt skeletal traction of the right lower leg. The client may pull up using the trapeze, perform active range of motion with uninvolved joints, and do isometric muscle-setting exercises (such as quadriceps- and gluteal-setting exercises). The client also may flex and extend the feet. These exercises are within therapeutic limits for the client in skeletal traction to maintain muscle strength and range of motion.

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

Answer: 4. Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels Rationale: Buck's (extension) traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps to immobilize the fracture. Traction does not allow for bony healing to begin or provide rigid immobilization. Traction does not lengthen the leg for the purpose of preventing blood vessel severance. This type of traction involves pulleys and wheels, not pins and screws.

A client who has been taking high doses of acetylsalicylic acid to relieve pain from osteoarthritis now has more generalized joint pain and an elevated temperature. The nurse should assess for which complication to determine whether the client has other signs of aspirin toxicity? 1. Diarrhea 2. Constipation 3. Double vision 4. Ringing in the ears

Answer: 4. Ringing in the ears Rationale: Mild intoxication with acetylsalicylic acid, called salicylism, commonly occurs when the daily dosage is more than 4 g. Tinnitus (ringing in the ears) is the most frequent effect noted with intoxication. Hyperventilation also may occur because a salicylate stimulates the respiratory center. Fever may result because a salicylate interferes with the metabolic pathways coupling oxygen consumption and heat production. The remaining options are not signs of aspirin toxicity.

A client with diabetes mellitus has had a right below-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

Answer: 4. Separation of the wound edges Rationale: Clients with diabetes mellitus are more prone to wound infection and delayed wound healing because of the disease. Postoperative hemorrhage and edema of the residual limb are complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long as the incision is dry and intact.

The nurse is caring for a client admitted for a fractured hip status post fall at home. On assessment of the client's affected lower extremity, which signs/symptoms would most likely be noted? 1. Shortening and abduction 2. Abduction and internal rotation 3. Shortening and internal rotation 4. Shortening and external rotation

Answer: 4. Shortening and external rotation Rationale: Signs of a hip fracture include shortening and deformity. The affected leg externally rotates as a result of discontinuation of the femur and loss of alignment and muscle control. The remaining options are not findings associated with a fractured hip.

A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful? 1. Telling the client that the saw makes a frightening noise 2. Reassuring the client that no one has had an arm lacerated yet 3. Stating that the hot cutting blades cause burns only very rarely 4. Showing the client the cast cutter and explaining how it works

Answer: 4. Showing the client the cast cutter and explaining how it works Rationale: Individuals may be fearful of having a cast removed because of misconceptions about the cast-cutting blade. The nurse should show the cast cutter to the client before it is used and explain that he or she may feel heat, vibration, and pressure. The cast cutter resembles a small electric saw with a circular blade. The nurse should reassure the client that the blade does not cut like a saw but instead cuts the cast by vibrating side to side. The remaining options will increase the client's fear about the procedure.

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.

Answer: 4. Stay with the victim and encourage him or her to remain still. Rationale: With a suspected fracture, the victim is not moved unless it is dangerous to remain in that spot. The nurse should remain with the victim and have someone else call for emergency help. A fracture is not reduced at the scene. Before the victim is moved, the site of fracture is immobilized to prevent further injury.

The nurse is preparing to teach a client how to safely use crutches. Before initiating the teaching, the nurse performs an assessment on the client. The priority nursing assessment should include which information? 1. The client's fear related to the use of crutches 2. The client's feelings about the restricted mobility 3. The client's understanding of the need for increased mobility 4. The client's vital signs, muscle strength, and previous activity level

Answer: 4. The client's vital signs, muscle strength, and previous activity level Rationale: Vital signs provide a baseline to determine how well the client will tolerate activity. Assessing muscle strength will help determine if the client has enough strength for crutch walking and if muscle-strengthening exercises are necessary. Previous activity level will provide information related to the tolerance of activity. The remaining options also are components of the assessment, but physiological needs take precedence over psychosocial needs.

The nurse is caring for a client with a long bone fracture at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by performing an assessment of which item(s)? 1. The client's mobility status 2. The renal and endocrine systems 3. The cardiovascular and renal systems 4. The neurological and respiratory systems

Answer: 4. The neurological and respiratory systems Rationale: The early signs of the complication of fat embolism include changes in the client's mental status and signs of impaired respiratory function as a result of impaired perfusion distal to the site of the embolus. Cardiovascular and renal impairments are likely to be secondary to impaired respiratory function. Effects on the endocrine system usually are not seen. The client's mobility status is unrelated to the signs of fat embolism.

The nurse is providing instructions to a client regarding ambulation after the application of a fiberglass cast to the lower leg. The nurse determines that the client understands the instructions if the client states that weight bearing on the casted leg can begin at which time period? 1. In 48 hours 2. In 24 hours 3. In approximately 8 hours 4. Within 20 to 30 minutes of application

Answer: 4. Within 20 to 30 minutes of application Rationale: A fiberglass cast is made of water-activated polyurethane material that is dry to the touch within minutes and reaches full rigid strength in about 20 minutes. Accordingly, the client can bear weight on the cast within 20 to 30 minutes. The remaining options are incorrect.

A client is complaining of knee pain. The knee is swollen, reddened, and warm to the touch. The nurse interprets that the client's signs and symptoms are compatible with which conditions? Select all that apply. 1. Infection 2. Recent injury 3. Inflammation 4. Degenerative disease 5. Developmental retardation

Answers: 1. Infection 2. Recent injury 3. Inflammation Rationale: Redness and heat are associated with musculoskeletal inflammation, infection, or a recent injury. Degenerative disease is accompanied by pain, but there is no redness. Swelling may or may not occur. These symptoms are not specifically associated with developmental retardation.

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.

Answers: 1. Keep the cast clean and dry. 2. Allow the cast 24 to 72 hours to dry. 3. Keep the cast and extremity elevated. Rationale: A plaster cast takes 24 to 72 hours to dry (synthetic casts dry in 20 minutes). The cast and extremity should be elevated to reduce edema if prescribed. A wet cast is handled with the palms of the hand until it is dry, and the extremity is turned (unless contraindicated) so that all sides of the wet cast will dry. A cool setting on the hair dryer can be used to dry a plaster cast (heat cannot be used on a plaster cast because the cast heats up and burns the skin). The cast needs to be kept clean and dry, and the client is instructed not to stick anything under the cast because of the risk of breaking skin integrity. The client is instructed to monitor the extremity for circulatory impairment, such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. The health care provider is notified immediately if circulatory impairment occurs.

The nurse is caring for a client who is an athlete and has sustained an injury to the anterior cruciate ligament. The nurse is providing education to the client regarding the potential treatment measures for this injury. What should the nurse include in the teaching? Select all that apply. 1. Physical therapy 2. Knee immobilizer 3. Aspiration of joint fluid 4. Ambulation with a walker 5. Antiinflammatory medications

Answers: 1. Physical therapy 2. Knee immobilizer 3. Aspiration of joint fluid 5. Antiinflammatory medications Rationale: The anterior cruciate ligament (ACL) runs diagonally in the middle of the knee. Injury to the ACL can result in a partial tear, a complete tear, and an avulsion. Treatment measures for this injury include physical therapy, use of a knee immobilizer or hinge brace, aspiration of joint fluid if an effusion occurs, ambulation with crutches, antiinflammatory medications, rest, ice, and possibly reconstructive surgery.