MedSurg: Saunders MS
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 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 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 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 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 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 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 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.
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.
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.
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 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.
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 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 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 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 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 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.
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 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 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 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.
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 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.
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.
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.
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.
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 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.
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.
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.
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.
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 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 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.
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.
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 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 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 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.
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.
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.