Test 3 bones

1. A client who had a surgical fractured femur repair reports new-onset shortness of breath and increased respirations. What is the nurse's first action? A. Place the client in a high-Fowler position. b.Document the client's oxygen saturation level. c. Start oxygen therapy at 2 L/min via nasal cannula. d. Contact the primary health care provider.

A

11. In caring for a child with an open fracture, the nurse should carefully assess for A. infection. b. osteoarthritis C. epiphyseal disruption. d. periosteum thickening.

A

13. A nurse cares for a client placed in skeletal traction. The client asks, "What is the primary purpose of this type of traction?" How would the nurse respond? A. "Skeletal traction will assist in realigning your fractured bone." B. "This treatment will prevent future complications and back pain." C. "Traction decreases muscle spasms that occur with a fracture." D. "This type of traction minimizes damage as a result of fracture treatment."

A

14. Which statement by the mother of an adolescent being discharged after spinal fusion for severe scoliosis indicates the need for further teaching? A. -I am glad we chose surgery. Now it is all over and done. B. I'll see you in a month; we'll be back fairly regularly. C. I have to pick up some more T-shirts on the way home. d. -Those exercises the physical therapist showed us were not too hard.I

A

15. A priority nursing intervention when caring for a child in a Pavlik harness is: A. skin care. b. bowel function. c. feeding patterns. d. respiratory function.

A

17. The nurse is teaching a client how to use a cane after a right surgical fractured fibula repair. What health teaching would the nurse include? A. "Place the cane on your left side." b."Move the cane and your left leg at the same time." C. "Be sure the cane is parallel to your waist." d. "Use the cane only when your right leg is painful."

A

18. A nurse is caring for a client with diabetes mellitus who has fractured her arm. Which action would the nurse take first? a. Remove the medical alert bracelet from the fractured arm. B. Immobilize the arm by splinting the fractured site. C. Place the client in a supine position with a warm blanket. d. Cover any open areas with a sterile dressing.

A

2. Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions include which of the following? A. Avoiding using any latex product B. Using only non-allergenic latex products C. Administering medication for long-term desensitization d. Teaching family about long-term management of allergic manifestations

A

23. After teaching a client who is recovering from a vertebroplasty, the nurse assesses the patient's understanding. Which statement by the client indicates a need for additional teaching? A. "I can drive myself home after the procedure." B. "I will monitor the puncture site for signs of infection." C. "I can start walking tomorrow and increase my activity slowly." d. "I will remove the dressing the day after discharge."

A

3. A mother whose 7-year-old child has been placed in a cast for a fractured right arm reports that the child will not stop crying even after taking acetaminophen with codeine. The child also will not straighten the fingers on the right arm. What advice by the nurse is best? a. Take the child to the emergency department. b. Put ice on the injury. c. Avoid letting the child get so tired. d. Wait another hour; if the child is still crying, call back.

A

5. A child with osteomyelitis asks the nurse, -What is a _sed' rate? Il What is the best response for the nurse? a.It tells us how you are responding to the treatment. b. -It tells us what type of antibiotic you need. c. -It tells us whether we need to immobilize your extremity. d. - It tells us how your nerves and muscles are doing. I

A

5. A nurse assesses an older adult who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless with an oxygen saturation of 88%. Which action would the nurse take first? A. Administer oxygen via nasal cannula. B. Re-position to a semi-Fowler position. C. Increase the intavenous riow rate d. Assess response to pain medication.

A

9. Discharge planning for the child with juvenile arthritis includes the need for: A. routine ophthalmologic examinations to assess for visual problems. B. a low-calorie diet to decrease or control weight in the less mobile child. C. avoiding the use of NSAIDs to decrease gastric irritation. d. immobilizing the painful joints, which is the result of the inflammatory process.

A

4. A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery for a right hip fracture. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Elevate heels off the bed with a pillow. b. Ambulate the client on the first postoperative day. C. Push the client's patient-controlled analgesia button. d. Re-position the client every 2 hours. E. Use pillows to encourage subluxation of the hip.

ABD

1. A nurse teaches a client with a fractured tibia about external fixation. Which advantages of external fixation for the immobilization of fractures would the nurse share with the client? (Select all that apply.) a. It leads to minimal blood loss. B. it allows for earlv ambulation. C. It decreases the risk of infection. d. It increases blood supply to tissues. e. It promotes healing

ABE

3. A 14-year-old is in the intensive care unit after a spinal cord injury 2 days ago. Nursing care for this child includes (Select all that apply.) A. monitoring and maintaining systemic blood pressure. B. administering corticosterolas C. minimizing environmental stimuli. D. discussing long-term care issues with the family. E. monitoring for respiratory complications.

ABE

5. A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion activities would the nurse include in the health teaching? (Select all that apply.) A. "Frequently assesses the ergonomics of the equipment being used." B. "Take breaks to stretch fingers and wrists during working hours." C. "Do not participate in activities that require repetitive actions." d. "Take ibuprofen to decrease pain and swelling in wrists." E. "Adjust chair height to allow for good posture.

ABE

1. A child has a cast applied to the left forearm. Which interventions should the nurse include in the home care instructions for the parents? (Select all that apply.) a. Keep small toys away from the cast. b. Use a padded ruler to scratch the skin under the cast if it itches. c. Assess the cast daily for unusual odors. d. Elevate the extremity on pillows for the first 24 to 48 hours. e. Numbness and tingling in the extremity are expected.

ACD

2. A nurse should expect which cerebral spinal fluid (CS) laboratory results on a child diagnosed with bacterial meningitis? (Select all that apply.) a. Elevated white blood count (WBC) b. Decreased protein c. Decreased glucose d. Cloudy in color e. Increase in red blood cells (RBC)

ACD

3. The nurse is caring for a client who recently sustained a sports injury to his right leg. What nursing interventions are appropriate for this client? (Select all that apply.) a. Immobilize the right leg. B. Apply heat immediately after the injury. C. Use compression to support the leg. d. Obtain an x-ray to detect possible fracture. е.Elevate the right leg to decrease swelling. F. Administer an opioid every 4 to 6 hours.

ACDE

2. A child is in skeletal traction. Which interventions should the nurse implement to prevent complications of immobility? (Select all that apply.) A. Reposition the child every 2 hours. b. Avoid use of an egg-crate or sheepskin mattress. c. Limit fluid intake. D. Administer stool softeners as prescribed. e. Encourage coughing and deep breathing.

ADE

6. A nurse teaches a client about prosthesis care after amputation. Which statements would the nurse include in the health teaching? (Select all that apply.) A. "The device has been custom made specifically for you." B. "Your prosthetic is good for work but not for exercising. C. "A prosthetist will clean your inserts for you each month." D. "Make sure that you wear the correct liners with your prosthetic. E. "I have scheduled a follow-up appointment for you."

ADE

10. During painful episodes of juvenile arthritis, a plan of care should include what nursing intervention? a. A weight-control diet to decrease stress on the joints b. Proper positioning of the affected joints to prevent musculoskeletal complications c. Complete bed rest to decrease stress to joints d. High-resistance exercises to maintain muscular tone in the affected joints

B

12. What is the priority nursing intervention for the child with ascending paralysis as a result of Guillain-Barré syndrome (GBS)? a. Immunosuppressive medicatons B. Respiratory assessment C. Passive range-of-motion exercises D. Anticoagulant therapy

B

13. Juvenile arthritis should be suspected in a child who exhibits: A. frequent fractures. B. joint swelling and pain lasting longer than 6 weeks. c. increased joint mobility. d. lurching and abnormal gait with limited abduction.

B

14. What should be the nurse's first action when a child with a head injury complains of double vision and a headache, and then vomits? a. Immobilize the child's neck. b. Report this information to the physician. c. Darken the room and put a cool cloth on the child's forehead. d. Restrict the child's oral fluid intake.

B

15. The nurse is preparing a school-age child for computed tomography (CT scan) to assess cerebral function. Which statement should the nurse include when preparing the child? A. -Pain medication will be given. B. -The scan will not hurt. C. You will be able to move once the equipment is in place. d. -Unfortunately, no one can remain in the room with you during the test.I

B

16. A nurse plans care for a client who is recovering from a below-the-knee amputation of the left leg. Which intervention would the nurse include in this client's plan of care? A. Place pillows between the client's knees. B. Encourage range-of-motion exercises. C. Administer prophylactic antibiotics. d. Implement strict bedrest in a supine position.

B

16. During a well-child visit, the nurse identifies that an 18-month-old infant is bowlegged. What action by the nurse is most appropriate? a. Assess the infant's diet history. B. Document the finding in the chart. c. Facilitate a referral to an orthopedist. d. Perform further assessment of the musculoskeletal system.

B

19. A nurse cares for a client with a recently fractured tibia. Which assessment would alert the nurse to take immediate action? A. Pain of 4 on a scale of 0-10 B. Numbness in the extremity c. Swollen extremity at the injury site d. Feeling cold while lying in bed

B

2. A client who had a fractured ankle open reduction internal fixation (ORIF) 4 weeks ago reports burning pain and tingling in the affected foot. For which potential complication would the nurse anticipate? A. Delayed bone healing B. Complex regional pain syndrome c. Peripheral neuropathy d. Compartment syndrome

B

21. A client who had a traumatic above-the-knee amputation states that he fears he will never have an intimate relationship again. What is the nurse's best response? A. "You'll be able to get a leg prosthesis soon. b. "You think you won't be able to have sex again?" c. "I will ask the social worker to talk with you." D. "Are you married now or have a girl friend?"

B

3. What finding should cause the nurse to suspect a diagnosis of spastic cerebral palsy? A. Tremulous movements at rest and with activity B. Sudden jerking movement caused by stimuli C. Writhing, uncontrolled, involuntary movements D. Clumsy, uncoordinated movements

B

5. A child with a head injury remains asleep unless aroused, and when aroused responds briefly before falling back to sleep. What should the nurse chart for this child's level of consciousness? a.Disoriented b.Obtunded c. Lethargic D. Stuporous

B

7. What is the most appropriate nursing action when a child is in the tonic phase of a generalized tonic-clonic seizure? A. Guide the child to the floor if standing and go for help. B. Turn the child's body on the side. c. Place a padded tongue blade between the teeth. d.Quickly slip soft restraints on the child's wrists.

B

8. A client is admitted to the emergency department with a fractured femur resulting from a motor vehicle crash. What the nurse's priority action? a. Keep the client warm and comfortable. B. Assess airway, breathing, and circulation C. Maintain the client in a supine position. d. Immobilize the injured extremity with a splint.

B

7. The nurse is caring for a client who just had a kyphoplasty. What nursing care is needed for the client at this time? (Select all that apply.) a. Place the client in a prone position to prevent pressure on the surgical area. b.Apply an ice pack to the surgical area to help relieve pain. C. Assess the client's pain level to compare it with pain before the procedure. D. Take vital signs, including oxygen saturation, frequently. E. Monitor for complications such as bleeding or shortness of breath. f. Perform frequent neurologic assessments and report major changes.

BCDEF

2. The nurse assesses a client who is admitted with a pelvic fracture. Which assessments would the nurse monitor to prevent or detect a complication of this injury? (Select all that apply.) A. Temperature B. Urinary output C. Blood pressure d. Pupil reaction e. Skin color

BCE

1. What nursing actions are indicated when the nurse is administering phenytoin (Dilantin) by the intravenous route to control seizures? (Select all that apply.) A. It must be given with Ds 1/2 NS. B. Occasional blood levels will be assessed. c. Dilantin should be given with food because it causes gastrointestinal distress. d. It must be given in normal saline. E. It must be filtered.

BDE

1. Nursing care of the infant who has had a myelomeningocele repair should include a. securely fastening the diaper. b. measurement of pupil size. C. measurement or nead circumierence. D. administration of seizure medications.

C

1. When infants are seen for fractures, which nursing intervention is a priority? a. No intervention is necessary. It 1s not uncommon for intants to fracture bones b. Assess the family's safety practices. Fractures in infants usually result from falls. C.Assess for child abuse. Fractures in infants are often nonaccidental. d. Assess for genetic factors.

C

10. What is an appropriate nursing intervention for the child with a tension headache? A. Assess tor an aura. B. Maintain complete bed rest. C. Administer mild pain medication d. Assess for nausea and vomiting.

C

12. A 6-year-old patient who has been placed in skeletal traction has pain, edema, and fever. The nurse should assess which of the following? a. Neurologic status b. Range of motion of all extremities c. warmth at site of pain d. Blood pressure

C

15. A nurse is caring for a client recovering from an above-the-knee amputation of the right leg. The client reports pain in the right foot. Which prescribed medication would the nurse most likely administer? A. Intravenous morphine b.Oral acetaminophen C. Intravenous calcitonin d. Oral ibuprofen

C

16. Which neurologic diagnostic test gives a visualized horizontal and vertical cross section of the brain at any axis? A. Nuclear brain scan b. Echoencephalography c. CT scan D. MIRI

C

22. A nurse is caring for an older client who is recovering from a leg amputation surgery. The client states, "I don't want to live with only one leg. I should have died during the surgery." What is the nurse's best response? A. "Your vital signs are good, and you are doing just fine right now." b. "Your children are waiting outside. Do you want them to grow up without a father?" C. "This is a big change for you. What support system do you have to help you cope?" D. "You will be able to do some of the same things as before you became disabled."

C

4. A 4-year-old child with a long leg cast complains of -firell in his cast. Which action by the nurse is most appropriate? a. Notify the provider on his or her next rounds. b. Note the complaint in the nurse's notes. C. Notify the provider immediately. d. Report the complaint to the next nurse on duty.

C

4. What is the best response to a father who tells the nurse that his son -daydreams at home and that his teacher has observed this behavior at school? A. -Your son must have an active imagination. B. -Can you tell me exactly how many times this occurs in one dav? C. -Tell me about your son's activity when you notice the daydreams. d. -He is probably overtired and needs more rest.

C

7. Which factor is important to include in the teaching plan for parents of a child with Legg-Calvé-Perthes disease? a. It is an acute illness lasting 1 to 2 weeks. b. It affects primarily adolescents. c. There is a disturbance in the blood supply to the femoral epiphysis. d. It is caused by a virus.

C

8. A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, what response by the nurse is best? a. Traction is tried first. b. Surgical intervention is needed. c. Frequent, serial casting is tried first. d. Children outgrow this condition when they learn to walk.

C

9. The nurse is caring for a client who had a closed reduction of the left arm and notes a large wet area of drainage on the cast. What action is the most important? A. Cut off the old cast. B. Document the assessment. c. Notify the primary health care provider. d.Wrap the cast with gauze.

C

What actions should the nurse perform while caring for a school-age child who sprained his ankle playing football? (Select all that apply.) A. Turn the child every 1 to 2 hours. B. Assist with range-of-motion exercises every 2 hours. c. Apply ice to the affected ankle. D. Wrap the ankle with an ACE bandage. e. Elevate the affected extremity.

CDE

10. A nurse is caring for a client who is recovering from an above-the-knee amputation and reports pain in the limb that was removed. How would the nurse respond? A. "The pain you are feeling does not actually exist." B. "This type of pain is common and will eventually go away." C. "Would you like to learn how to use imagery to minimize your pain?" D. "How would you describe the pain that you are feeling?"

D

11. A nurse cares for a client who had a wrist cast applied 3 days ago. The client states, "The cast is loose enough to slide off." How would the nurse respond? A. "Keep your arm above the level of your heart." B. "As your muscles atrophy, the cast is expected to loosen." C. "I will wrap a bandage around the cast to prevent it from slipping." d."You need a new cast now that the swelling is decreased."

D

11. Which statement by an adolescent indicates an understanding about factors that can trigger migraine headaches? a. -I should avoid loud noises because this is a common migraine trigger. B. -Exercise can cause a migraine. I guess I won't have to take gym anymore. C. -I think I'll get a migraine if I go to bed at 9 PM on week nights. d. I am learning to relax because I get headaches when I am worried about stuff.

D

12. A nurse assesses a client with a pelvic fracture. Which assessment finding would the nurse identify as a complication of this injury? а.Hypertension B. Diarrhea C. Infection d. Hematuria

D

13. A child is brought to the emergency department in status epilepticus. Which medication should the nurse expect to be given initially in this situation? A. Clorazepate dipotassium (Tranxene) b.Fosphenytoin (Cerebyx) c. Phenobarbital d. Lorazepam (Ativan)

D

14. The nurse is caring for a postoperative client who have a regional nerve blockade for a surgical tibial fracture repair this morning. What assessment finding would the nurse expect? A. Client reports nausea and vomiting. b. Client reports tingling in the surgical leg. c. Client responds well to imagery. d. Client reports little to no pain

D

2. Which nursing intervention is appropriate to assess for neurovascular competency in a child who fell off the monkey bars at school and hurt his arm? a. The degree of motion and ability to position the extremity b. The length, diameter, and shape of the extremity C.The amount of swelling noted in the extremity and pain intensity d. The skin color, temperature, movement, sensation, and capillary refill of the extremity

D

20. After teaching a client with a fractured humerus, the nurse assesses the client's understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture? A. Baked fish with orange juice and a vitamin D supplement b.Bacon, lettuce, and tomato sandwich with a vitamin B supplement C. Vegetable lasagna with a green salad and a vitamin A supplement d. Roast beef with low-fat milk and a vitamin C supplement

D

24. A nurse plans care for a client who has an external fixator on the lower leg. Which intervention would the nurse include in the plan of care to decrease the client's risk for infection? A. Washing the frame of the fixator once a day B. Releasing fixator tension for 30 minutes twice a day c. Avoiding moving the extremity by holding the fixator d. Scheduling for pin care to be provided every shift

D

4. The nurse is performing a neurovascular assessment for an older client who has an extremity fracture. How many seconds would the nurse expect for a capillary refill in it is within normal range? A. 20 seconds B. 15 seconds c. 10 seconds D. 5 seconds

D

6. A nurse is caring for several clients with fractures. Which client would the nurse identify as being at the highest risk for developing deep vein thrombosis? a. An 18-year-old male athlete with a fractured clavicle B. A 36-year-old female with type 2 diabetes and fractured ribs C. A 55-year-old female prescribed ibuprofen for osteoarthritis D. A 74-year-old male who smokes and has a fractured pelvis

D

6. The nurse is assessing a 14-year-old who plays football and complains of knee pain when running and climbing stairs during football practice. The nurse should anticipate which action for this condition? a. Bedrest with range-of-motion exercises b. Prolonged IV antibiotics c. Electromyography d. NSAIDs or knee immobilizer

D

6. The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. What is the most essential part of nursing assessment to detect early signs of a WOrSening condition? a. Posturing b. Vital signs c. Focal neurologic signs d. Level or consciousness

D

7. A nurse teaches assistive personnel (AP) about providing hygiene for a client in traction. Which statement would the nurse include as part of the teaching about this client's care? A. "Remove the traction when re-positioning the client." B. "Assess the client's skin when performing a bed bath." C. "Provide pin care by using alcohol wipes to clean the sites." D. "Ensure that the weights remain freely hanging at all times."

D

8. The father of a newborn infant with myelomeningocele asks about the cause of this condition. What response by the nurse is most appropriate? A. One of the parents carries a defective gene that causes myelomeningocele. B. -A deficiency in folic acid in the father is the most likely cause. C. Offspring of parents who have a spinal abnormality are at greater risk for myelomeningocele. d. -There may be no definitive cause identified.I

D

9. Which change in status should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury? a. Rapid, shallow breathing B. Irregular, rapid heart rate C.Increased diastolic pressure with narrowing pulse pressure d. Confusion and altered mental status

D