Adult II Exam 3❌

An older adult client who has osteoporosis is discharged from the hospital. What does the nurse include in client teaching related to the client's home safety?

"Keep walkways free of clutter."

Which statement indicates to the nursing instructor that the nursing student understands the normal healing process of bone after a fracture?

"A hematoma forms at the site of the fracture."

A client is scheduled to undergo closed magnetic resonance imaging (MRI) without contrast medium. Which information does the nurse give to the client before the test?

"All jewelry and clothing with zippers or metal fasteners must be removed."

A client with a fracture asks the nurse about the difference between an open fracture and a simple fracture. Which statement by the nurse is correct?

"An open fracture involves a break in the bone, with damage to the skin."

A client diagnosed with rheumatoid arthritis (RA) is started on methotrexate (Rheumatrex). Which statement made by the client indicates to the nurse that further teaching is needed regarding drug therapy?

"Any side effects of this drug will be mild."

A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include?

"Avoid acetaminophen in OTC medications" "It may take several weeks to become effective on pain" "Stay away from large crowds and people who are ill" "You may find that folic acid, a B vitamin, reduces side effects"

A nurse is teaching a client with psoriatic arthritis about the medication golimumab (Simponi). What information is most important to include?

"Avoid large crowds or people who are ill."

A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client?

"Buy and install an elevated toilet seat" "Install grab bars in the shower and by the toilet" "Remove all throw rugs throughout the house" "Use a shower chair while taking a shower"

A nurse delegates care of a client in traction to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene care for this client?

"Ensure that the weights remain freely hanging at all times."

Which statement indicates to the nurse that a client with fibromyalgia syndrome is using a complementary therapy to help relieve symptoms?

"Focusing on the slow stretching movements and my breathing in tai chi helps me relax."

A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion activities should the nurse include in this clients teaching?

"Frequently assess the ergonomics of the equipment being used" "Take breaks to stretch fingers and wrists during working hours" "Adjust chair height to allow for good posture"

The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the clients blood glucose readings have been elevated. What question by the nurse is most appropriate?

"Have you been taking glucosamine supplements?"

A nursing student is studying the skeletal system. Which statement best indicates to the nursing instructor that the student understands a normal physiologic function of the skeletal system?

"Hematopoiesis occurs in the red marrow, which is where blood cells are produced."

A client experiencing kyphosis appears withdrawn and does not initiate any conversation with the nurse when medications are given each day. Which statement by the nurse is most supportive of this client?

"How do you feel about the pain in your spine? I am here if you want to talk."

A nurse is caring for a client who is recovering from an above-the-knee amputation. The client reports pain in the limb that was removed. How should the nurse respond?

"How would you describe the pain that you are feeling?"

A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement?

"I always wear long sleeves, pants, and a hat when outdoors."

A client has been prescribed denosumab (Prolia). What instruction about this drug is most appropriate?

"Make appointments to come get your shot."

After teaching a client who is recovering from a vertebroplasty, the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching?

"I can drive myself home after the procedure."

A client recently had an amputation of the right hand. Which statement by the client, who was right-handed, indicates that he or she is coping effectively?

"I can learn to write with my left hand."

A nurse is teaching a client who has SLE about self-care. Which of the following statements by the client indicates an understanding of the teaching?

"I should use mild hair shampoo"

A nurse is teaching a client how to manage an external fixation device upon discharge. Which of the following statements by the client indicates understanding?

"I will clean the pins more often if drainage from the pins increases" "I will use a separate cotton swab for each pin" "I will report loosening of the pins to my doctor" "I will report increased redness at the pin sites"

The home health nurse conducts a community presentation on Lyme disease for the residents of an assisted-living facility. Which statement from the audience indicates to the home health nurse that further instruction is needed?

"I will gently remove the tick with tissue and then burn it to prevent the spread of the disease."

A nurse is discharging a client after a total hip replacement. What statement by the client indicates good potential for self-management?

"I will not sit with my legs crossed."

A nurse is completing preoperative teaching for a client who is to undergo an arthroscopy to repair a shoulder injury. Which of the following statements should the nurse include?

"Inspect your incision daily for indications of infection" "Apply ice packs to the area for the first 24 hours" "Perform isometric exercises"

A nurse teaches a client with a fractured tibia about external fixation. Which advantages of external fixation for the immobilization of fractures should the nurse share with the client?

"It leads to minimal blood loss" "It allows for early ambulation" "It promotes healing"

The nurse is caring for a middle-aged client diagnosed with rheumatoid arthritis. Which client statement requires further assessment for unproductive coping strategies?

"My husband is getting used to having sex only once a month."

A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important?

"Notify your provider at once if you get a fever."

A 25-year-old female client whose mother and grandmother have osteoporosis asks whether she needs to take steps to prevent this disease in herself. What will the nurse tell this client?

"Now is the time to begin building strong bones."

A phone triage nurse speaks with a client who has an arm cast. The client states, "My arm feels really tight and puffy." How should the nurse respond?

"Please come to the clinic today to have your arm checked by the provider."

A nurse cares for a client placed in skeletal traction. The client asks, "What is the primary purpose of this type of traction?" How should the nurse respond?

"Skeletal traction will assist in realigning your fractured bone."

A nurse is providing education to a community women's group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover?

"Strengthing exercises are important" "Take recommended calcium and vitamin D" "Walk 30 minutes at least 3 times a week"

The nurse is instructing a client who has been prescribed calcium citrate (Citracal). Which instruction does the nurse include?

"Take Citracal with food."

The nurse is caring for an older, alert adult client diagnosed with osteoarthritis. Which client statement indicates to the nurse that the client is using effective coping strategies?

"The bus is coming to pick me up from the senior center three times a week so I can play cards."

A nurse teaches a client about prosthesis care after amputation. Which statements should the nurse include in this clients teaching?

"The device has been custom made specifically for you" "Make sure that you wear the correct liners with your prosthetic" "I have scheduled a follow-up appointment for you"

The nurse is teaching a client about the difference between rheumatoid arthritis (RA) and osteoarthritis (OA). Which statement by the client indicates a need for further teaching?

"The disease pattern of RA is usually unilateral and is seen in a single joint, whereas OA is usually bilateral and symmetric, and is noted in multiple joints."

A patient is admitted to the ICU with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. Which of the following statements is true about his spinal cord injury?

"The patient has a central cord syndrome."

A client has fibromyalgia and is prescribed duloxetine hydrochloride (Cymbalta). The client calls the clinic and asks the nurse why an antidepressant drug has been prescribed. What response by the nurse is best?

"This drug works in the brain to decrease pain."

A nurse cares for an older adult 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." How should the nurse respond?

"This is a big change for you. What support system do you have to help you cope?"

Which of the following statements is true about a patient with a blunt cardiac injury/cardiac contusion?

"Treatment can require insertion of a temporary pacemaker for conduction control."

A client has rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best?

"Try a paraffin wax dip 20 minutes before you quilt."

A nurse coordinates care for a client with a wet plaster cast. Which statement should the nurse include when delegating care for this client to an unlicensed assistive personnel (UAP)?

"Use a cloth-covered pillow to elevate the clients leg."

A client has sustained a fracture of the left tibia. The extremity is immobilized using an external fixation device. Which postoperative instruction does the nurse include in this client's teaching plan?

"Use pain medication as prescribed to control pain."

The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal injury. What information does the nurse include in the teaching plan?

"Wear helmets when riding a motorcycle."

In teaching a client with acute secondary gout, which instruction about preventing recurrence is most important for the nurse to include?

"Weight Watchers has healthy meal plans."

A nurse is teaching a client who has a new diagnosis of RA. Which of the following statements should the nurse include in the teaching?

"You can experience morning stiffness when you get out of bed"

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 should the nurse respond?

"You need a new cast now that the swelling is decreased."

A client with peripheral vascular disease will undergo a Syme amputation. What will the nurse teach this patient when providing education about this procedure?

"You will be able to bear weight without needing a prosthesis."

A nurse is teaching a client who is going to have a bone scan. Which of the following statements should the nurse include?

"You will have to urinate just before the procedure"

A client had a bunionectomy with osteotomy. The client asks why healing may take up to 3 months. What explanation by the nurse is best?

"Your feet have less blood flow, so healing is slower."

The nurse is caring for a client who is diagnosed with osteopenia. Which T-score will the nurse expect to see for this client after a bone mineral density (BMD) test?

-2

A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching?

Acetaminophen (Tylenol)

The nurse is using a common scale to grade a client's muscle strength. The client is able to complete range of motion (ROM) only with gravity eliminated. Which grade does the nurse document in this client's record?

2

A client has sustained a rotator cuff tear while playing baseball. The nurse anticipates that the client will receive which immediate conservative treatment?

Activity limitations for the affected arm

The client has sustained a traumatic amputation of the left arm after a machine accident. In what order should the following nursing actions be taken? 1. Apply direct pressure to the amputated site. 2. Elevate the extremity above the client's heart. 3. Assess the client for breathing problems. 4. Examine the amputation site.

3, 4, 1, 2

A patient has suffered a traumatic brain injury (TBI). Less than 48 hours later, the patient is on ventilatory support with continuous intracranial pressure and hemodynamic monitoring. The Glasgow Coma Scale (GCS) score on this patient is most likely:

7

Nursing management of the patient with spinal cord injury (SCI) includes avoiding hypotension. For the first 7 days after acute SCI, the preferred mean arterial blood pressure for the patient is:

90 mm Hg.

A client has been diagnosed with fibromyalgia syndrome but does not want to take the prescribed medications. What nonpharmacologic measures can the nurse suggest to help manage this condition?

Acupuncture Stretching Tai Chi

A nurse is performing health screenings at a health fair. Which of the following clients have a risk factor for osteoporosis?

A 40-year-old client who has been taking prednisone for 4 months A 45-year-old client who takes phenytoin for seizures A 65-year-old client who has a sedentary lifestyle A 70-year-old client who has smoked for 50 years

A trauma nurse cares for several clients with fractures. Which client should the nurse identify as at highest risk for developing deep vein thrombosis?

A 74-year-old man who smokes and has a fractured pelvis

A nursing student studying the musculoskeletal system learns about important related hormones. What information does the student learn?

A lack of vitamin D can lead to rickets Estrogens stimulate osteoblast activity Parathyroid hormone stimulates osteoclastic activity

Signs and symptoms of compartment syndrome in the lower extremities include

Increased pain Paresis Pain the affected extremity Swelling in the affected extremity

Which of the following will cause a nurse to suspect that a patient's pulmonary contusion is worsening?

Increased peak airway pressures on the ventilator

A rock climber has sustained an open fracture of the right tibia after a 20-foot (6 meter) fall. The nurse plans to assess the client for which potential complications?

Acute Compartment Syndrome/ACS Fat Embolism Syndrome/FES Osteomyelitis

A nurse is providing care for a client who had a vertebroplasty of the thoracic spine. Which of the following actions should the nurse take?

Place the client in a supine position

Which is the best way to decrease the risk for osteoporosis in a client who has just been determined to be at high risk for the disease?

Walk for 30 minutes three times a week.

A client with chronic osteomyelitis is being discharged from the hospital. What information is important for the nurse to teach this client and family?

Adherence to the antibiotic regimen Eating high-protein and high-carbohydrate foods Proper use of IV equpiment

A nurse cares for a client with a fracture injury. Twenty minutes after an opioid pain medication is administered, the client reports pain in the site of the fracture. Which actions should the nurse take?

Administer additional opioids as prescribed Elevate the extremity on pillows Apply ice to the fracture site

A nurse is caring for a client who had an above-the-knee amputation. The client reports a sharp, stabbing type of phantom pain. Which of the following actions should the nurse take?

Administer an antiepileptic medication

A nurse cares for a client who had a long-leg cast applied last week. The client states, "I cannot seem to catch my breath and I feel a bit light-headed" Which action should the nurse take next?

Administer oxygen to keep saturations greater than 92%.

A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The clients vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first?

Administer oxygen via nasal cannula.

What action by the perioperative nursing staff is most important to prevent surgical wound infection in a client having a total joint replacement?

Administer preoperative antibiotic as ordered.

Before administering prednisone IV push to a middle-aged adult with rheumatoid arthritis (RA), the nurse notes that the client's random blood glucose level is 139 mg/dl (7.7 mmol/L). Which action is most important for the nurse to take?

Administer the prescribed prednisone on schedule.

A patient is admitted to the ICU with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. Caring for the patient would include which of the following interventions?

Administering intravenous methylprednisolone for the first 24 hours after the injury

A patient was thrown 30 feet from an open-top Jeep and straddled a row of mailboxes before she landed on the ground. She has an open pelvic fracture. The nurse admitting the patient into the ICU knows that

Aggressive fluid and blood replacement will probably be needed.

When opening the airway of an unresponsive trauma patient in the emergency department, which of the following considerations is correct?

Airway assessment must incorporate cervical spine immobilization.

A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components?

Alcohol Caffeine Carbonated beverages Vitamin D

During the secondary survey, AMPLE stands for:

Allergies Pregnancy Last meal Environmental factors

A client with fibromyalgia is in the hospital for an unrelated issue. The client reports that sleep, which is always difficult, is even harder now. What actions by the nurse are most appropriate?

Allow the client uninterrupted rest time Assess the clients usual bedtime routine Limit environmental noise as much as possible Offer a massage or warm shower at night

A nurse is assessing a client who has a new diagnosis of SLE. Which of the following findings should the nurse expect?

Alopecia

A nurse is assessing a client who has a casted compound fracture of the femur. Which of the following findings is a manifestation of a fat embolus?

Altered mental status

An older client returning to the postoperative nursing unit after a hip replacement is disoriented and restless. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)?

Apply an abduction pillow to the clients legs Place pillows under the heels to keep them off the bed Take and record vital signs per facility policy

The nurse is caring for a postoperative client with total joint arthroplasty. What actions does the nurse take to prevent venous thromboembolism (VTE) postoperatively?

Apply elastic stockings. Administer anticoagulants.

A nurse is providing information to a client who has osteoarthritis of the hip and knee. Which of the following information should the nurse include in the information?

Apply heat to joints to alleviate pain Reduce the amount of exercise done on days with increased pain Active ROM is more effective than passive

A client with Pagets disease is hospitalized for an unrelated issue. The client reports pain and it is not yet time for more medication. What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)?

Applying a heating pad Providing a massage

A 65-year-old female client has chronic hip pain and muscle atrophy from an arthritic disorder. Which musculoskeletal assessment finding does the nurse expect to see in the client?

Antalgic gait

An older adult client with diabetes who had arthroscopic surgery on the right knee the previous day has a red, swollen, and painful right knee. The nurse anticipates that the health care provider will request which type of medication?

Antibiotic

A nurse is completing discharge teaching to a client who had a wound debridement for osteomyelitis. Which of the following information should the nurse include?

Antibiotic therapy should continue for 3 months

The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease?

Antibodies lead to inflammation It consists of an autoimmune process

A client with osteoporosis is going home, where the client lives alone. What action by the nurse is best?

Arrange a home safety evaluation.

A client has been advised to perform weight-bearing exercises to help minimize osteoporosis. The client admits to not doing the prescribed exercises. What action by the nurse is best?

Ask the client about fear of falling.

A client is distressed at body changes related to kyphosis. What response by the nurse is best?

Ask the client to explain more about these feelings.

A nurse is planning care for a client who is postoperative following an arthroscopy of the knee. Which of the following actions should the nurse take?

Assess color and temperature of the extremity Place pillows under the extremity Administer analgesic medication Assess pulse and sensation in the foot

A nurse is planning care for a client who will undergo an EMG. Which of the following actions should the nurse include?

Assess for bruising Determine whether the client takes muscle relaxants Instruct the client to flex muscles during needle insertion

A client is undergoing computed tomography (CT) of a joint. What action by the nurse is most important before the test?

Assess for seafood or iodine allergy.

A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best?

Assess medication records for steroid use.

The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The clients surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best?

Assess neurovascular status in both legs.

A client is in the internal medicine clinic reporting bone pain. The clients alkaline phosphatase level is 180 units/L. What action by the nurse is most appropriate?

Assess the client for leg bowing.

A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a low-grade fever that started when the weather changed and several joints started acting up, especially both hips and knees. What action by the nurse is best?

Assess the client for the presence of subcutaneous nodules or Bakers cysts.

A client has scoliosis with a 65-degree curve to the spine. What action by the nurse takes priority?

Assess the clients cardiac and respiratory systems.

A client with bone cancer is hospitalized for a limb salvage procedure. How can the nurse best address the clients psychosocial needs?

Assess the clients coping skills and support systems.

A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best?

Assess the clients culture more thoroughly.

A client is admitted with a bone tumor. The nurse finds the client weak and lethargic with decreased deep tendon reflexes. What actions by the nurse are best?

Assess the daily serum calcium level Consult the provider about a loop diuretic Instruct the client to call for help out of bed

A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to be pale and cool, with 1+/4+ pedal pulses. What action by the nurse is best?

Assess the neurovascular status of the right leg.

An emergency department nurse cares for a client who sustained a crush injury to the right lower leg. The client reports numbness and tingling in the affected leg. Which action should the nurse take first?

Assess the pedal pulses.

The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the client. What finding by the nurse indicates goals for this client problem are being met?

Attends meetings of a book club

A nurse is developing a plan of care for a patient with a T5 spinal cord injury that includes a bowel and bladder regimen because these patients are at risk for:

Autonomic dysreflexia.

An alert client who recently underwent total hip arthroplasty and is on anticoagulants is preparing for discharge from the hospital. Which information is most important for the nurse to provide to the client and caregiver?

Avoid using a straight razor.

A patient is admitted for a spinal cord injury (SCI) after a 10-foot fall from a rooftop where he landed on his buttocks. The type of injury that the nurse can expect to see with this SCI is:

Axial loading.

The nurse studying osteoporosis learns that which drugs can cause this disorder?

Barbiturates Corticosteroids Loop diuretics

A school nurse is conducting scoliosis screening. In screening the client, what technique is most appropriate?

Bending forward from the hips

A patient is admitted to the ICU for observation of his grade II splenic laceration. Which of the following signs and symptoms would suggest that he has had a delayed rupture of his splenic capsule and is now in hemorrhagic shock?

BP, 90/70 mm Hg; HR, 140 beats/min; Hct, 21 mg/dL; UO, 10 mL/hr; pale, cool, clammy skin; confused

When assessing gait, what features does the nurse inspect?

Balance Ease of stride Length of stride Steadiness

The nursing care plan of a patient with a diffuse axonal injury (DAI) would involve which of the following considerations?

Blood pressure and temperature elevations are common.

Major trauma patients are at a high risk of developing deep venous thrombosis and pulmonary embolism because of

Blood stasis Injury to the intimal surface of the vessel Hypercoagulability Immobility

Motor vehicle crashes (MVCs) and falls are the greatest cause of

Blunt thoracic trauma

A student nurse learns about changes that occur to the musculoskeletal system due to aging. Which changes does this include?

Bone changes lead to potential safety risks Osteoarthritis occurs due to cartilage degeneration Some muscle tissue atrophy occurs with aging

The clients chart indicates genu varum. What does the nurse understand this to mean?

Bow-legged

A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure?

Bronchitis 2 weeks ago

A spinal cord injured patient is complaining of numbness on the left side and is unable to move the right and left arms. The nurse notes that the patient can feel temperature and pain only on the left side during a neurologic assessment. The nurse suspects this patients injury is:

Brown-Séquard syndrome.

A nurse in the emergency department is planning care for a client who has a right hip fracture. Which of the following immobilization devices should the nurse anticipate in the plan of care?

Buck's traction

The nurse admits an older adult client who sustained a left hip fracture and is in considerable pain. The nurse anticipates that the client will be placed in which type of traction prior to surgical repair?

Buck's traction

Which factor indicates to the nurse the only similarity between discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE)?

Disfiguring and embarrassing rash

A 55 year-old female client has a high familial risk for osteoporosis and tells the nurse that her mother and an older sister both developed spine and hip fractures as a result of the disease. Which diagnostic test will be appropriate to help determine this client's risk for spine and hip fractures?

CT-based absorptiometry

A nurse is admitting a client to the orthopedic unit following a total knee arthroplasty. Which of the following actions by the nurse are appropriate?

Check CPM device settings Palpate dorsal pedal pulses Elevate the HOB

A client with an open fracture of the left femur is admitted to the emergency department after a motorcycle crash. Which action is most essential for the nurse to take first?

Check the dorsalis pedis pulses.

Which nursing action does the nurse on the orthopedic unit plan to delegate to unlicensed assistive personnel (UAP)?

Checking the vital signs for a client who was admitted after a total knee replacement 3 hours ago.

A 75-year-old man is admitted for transient ischemic attack with left-sided weakness. During the admission assessment, the patient states he is also experiencing absentmindedness, vomiting, and intermittent photophobia. The patient is on warfarin (Coumadin) therapy. The patient cannot recall any significant injury involving a blow to his head. Based on this information, what is the most likely cause of his symptoms?

Chronic subdural hematoma

A nurse is planning discharge teaching for a client who had a total knee arthroplasty. Which of the following should the nurse include in the teaching?

Clean the incision daily with soap and water Sit in a straight-backed armchair Use a raised toilet seat

A nurse sees clients in an osteoporosis clinic. Which client should the nurse see first?

Client taking raloxifene (Evista) who reports unilateral calf swelling

The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which client should the nurse see first?

Client with a fever and cough who is taking tofacitinib (Xeljanz)

A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first?

Client with a red, hot, swollen right wrist

The nurse sees several clients with osteoporosis. For which client would bisphosphonates not be a good option?

Client with a spinal cord injury who cannot tolerate sitting up

A nurse works with several clients who have gout. Which types of gout and their drug treatments are correctly matched?

Colchicine/Colcrys= Acute Gout Febuxostat/Uloric =Chronic Gout Indomethacin/Indocin =Acute Gout Probenecid/Benemid =Chronic Gout

Which diagnostic test requires the nurse to know whether the client is allergic to iodine-based contrast?

Computed tomography (CT)

A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests the celecoxib in addition to the morphine. What action by the nurse is best?

Consult with the health care provider about administering both drugs to the client.

The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further?

Creatinine: 3.9 mg/dL

A client is scheduled for a bone biopsy. What action by the nurse takes priority?

Ensuring that informed consent is on the chart

Clinical manifestations of abdominal compartment syndrome include which of the following?

Decreased cardiac output Decreased urine output Hypoxia Hypotension

Care of the older adult may be affected by which physiologic change in the musculoskeletal system?

Decreased range of motion (ROM)

Which mechanisms caused by circulating myoglobin can lead to the development of kidney failure?

Decreased renal perfusion Cast formation with tubular obstruction Toxic effects of myoglobin in the kidney tubules

A client has had a sequestrectomy of the right fibula for osteomyelitis 1 day ago. Which assessment finding requires the nurse to immediately contact the surgeon?

Decreased sensation of right lower extremity

A nurse is caring for a client with systemic sclerosis. The clients facial skin is very taut, limiting the clients ability to open the mouth. After consulting with a registered dietitian for appropriate nutrition, what other consultation should the nurse facilitate?

Dentist

An older client who lives at home has been receiving intravenous linezolid to treat methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis for 2 weeks and is ready to be discharged from the hospital to undergo continued treatment. The client does not want to go to a skilled nursing facility (SNF). What will the nurse do?

Discuss administering oral linezolid at home with the provider.

A nurse is discussing gout with a client who is concerned about developing the disorder. Which of the following findings should the nurse identify as risk factors for this disease?

Diuretic use Obesity Cardiovascular disease

The nurse is assessing a client for chronic osteomyelitis. Which features distinguish this from the acute form of the disease?

Draining sinus tracts Presence of foot ulcers

The nurse is teaching a client with gout dietary strategies to prevent exacerbations or other problems. Which statement by the nurse is most appropriate?

Drink 1 to 2 liters of water each day.

The nurse assesses a client diagnosed with Sjögren's syndrome. The nurse anticipates that the client will also have which common condition?

Dry eyes

The nurse is working with clients who have connective tissue diseases. Which disorders are correctly paired with their manifestations?

Dry, scaly skin rash= SLE Esophageal dysmotility= Systemic sclerosis Vasculitis causing organ damage = RA

A client is suspected to have muscular dystrophy. About what diagnostic testing does the nurse educate the client?

EMG Muscle biopsy Serum aldolase Serum creatinine kinase

A nurse is caring for a client who has RA. Which of the following laboratory tests are used to diagnose this disease?

ESR ANA titer WBC count

A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome?

Edema (Increased capillary permeability) Unequal pulses (Increased production of lactic acid) Cyanosis (Anaerobic metabolism)

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 should the nurse include in this clients plan of care?

Elevate the heels off the bed with a pillow Ambulate the client on the first postoperative day Re-position the client every 2 hours

A nurse is presenting information to a group of clients at a health fair about measures to reduce the risk of amputation. Which of the following information should the nurse provide?

Encourage clients who smoke to consider smoking cessation programs Encourage clients who have diabetes to maintain blood glucose within the expected range Instruct clients to unplug electrical equipment when performing repairs

A nurse is completing a preoperative teaching plan for a client who is scheduled to have a total hip arthroplasty. Which of the following should the nurse include in the teaching plan?

Encourage complete autologous blood donation Use an abductor pillow when turning the client Perform isometic exercises

A nurse is caring for a client following a below-the-elbow amputation. Which of the following actions should the nurse take?

Encourage dependent positioning of the residual limb Inspect for presence and amount of drainage Implement shrinkage intervention of residual limb Assess for feelings of body image changes

A nurse plans care for a client who is recovering from a below-the-knee amputation of the left leg. Which intervention should the nurse include in this clients plan of care?

Encourage range-of-motion exercises.

A nurse is assessing an older client and discovers back pain with tenderness along T2 and T3. What action by the nurse is best?

Encourage the client to use ibuprofen (Motrin).

A nurse is providing teaching for a client who has a history of low back injury. Which of the following instructions should the nurse give the client to prevent future problems of low back pain?

Engage in regular exercise including walking Create a smoking cessation plan Wear low-heeled shoes

A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic and the surgeon states the client may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important?

Ensure that a consent for transfusion is on the chart.

A client is having a myelography. What action by the nurse is most important?

Ensure that informed consent is on the chart.

A client in a nursing home refuses to take medications. She is at high risk for osteomalacia. What action by the nurse is best?

Ensure the client gets 15 minutes of sun exposure daily.

Which of the following interventions would be included in the primary survey of a trauma patient?

Evaluate ventilation and gas exchange by inspection, palpation, and auscultation. Locate peripheral and central pulses. Assess patients level of consciousness. Remove all clothing to inspect body surfaces and cover to provide warmth.

The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA?

Feltys syndrome Joint deformity Weight loss

The nurse is attempting to perform a quick assessment of a client's hip discomfort. The client is sitting upright in a wheelchair. What is the nurses initial action?

Flex and extend the client's knee to assess for discomfort.

A strategy to minimize secondary brain injury in head-injured patients is

Fluid resuscitation as needed to keep the systolic blood pressure greater than 90 mm Hg.

What information does the nurse teach a women's group about osteoporosis?

For 5 years after menopause you lose 2% of bone mass yearly.

A client is started on etanercept (Enbrel). What teaching by the nurse is most appropriate?

Giving subcutaneous injections

The nurse plans to use which tool to measure joint range of motion (ROM)?

Goniometer

A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)?

Grab bars to reach high items Long-handled bath scrub brush Toothbrush with built-up handle

A client has a metastatic bone tumor. What action by the nurse takes priority?

Handle the affected extremity with caution.

A hospitalized client is being treated for Ewings sarcoma. What action by the nurse is most important?

Handling and disposing of chemotherapeutic agents per policy

A client is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important?

Have adequate help to transfer the client.

A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute exacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another hospitalization disrupting the family. What action by the nurse is best?

Help the client create backup plans to minimize disruption.

A nurse assesses a client with a pelvic fracture. Which assessment finding should the nurse identify as a complication of this injury?

Hematuria

A patient's condition has deteriorated. Changes in condition include trachea shift, absence of breath sounds on the left side, and hypotension. The nurse suspects that the patient has developed a(n)

Hemothorax

A nurse is assessing a client who has osteoarthritis of the knees and fingers. Which of the following manifestations should the nurse expect to find?

Herberden's nodes Enlarged joint size Limp when walking

Which risk factors are shared by male clients who have osteoporosis or osteopenemia?

High alcohol intake A history of smoking

A nurse is providing community education about preventing traumatic musculoskeletal injuries related to car crashes. Which group does the nurse target as the priority for this education?

High school football team

Assessment findings reveal that an older adult client with severe osteoarthritis of the left hip can no longer perform activities of daily living (ADLs) and has had several falls in the home over the past month. To which community resource does the nurse refer the client?

Home health care agency

The nurse is assessing a client with osteomalacia. Which findings does the nurse expect to observe?

Hypophosphatemia Looser's lines or zones Unsteady gait

A trauma patient arrives in the critical care unit. Pertinent history includes report of a prolonged extrication time from a motor vehicle. The nurse knows to expect potential complications related mostly to:

Hypotension and hypothermia.

A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply?

Ice packs

A nurse notes crepitation when performing range-of-motion exercises on a client with a fractured left humerus. Which action should the nurse take next?

Immobilize the left arm.

A shift to the left of the oxyhemoglobin dissociation curve can result from infusion of large volumes of banked blood, hypocarbia, alkalosis, or hypothermia. This shift is directly related to what factor?

Impaired pulmonary gas diffusion

A nurse assesses a client with a rotator cuff injury. Which finding should the nurse expect to assess?

Inability to initiate or maintain abduction of the affected arm at the shoulder

A patient with multisystem trauma has been in the ICU for 6 days after sustaining a closed head injury, a right-sided pneumothorax, right rib fractures, a grade IV liver laceration, a pancreatic contusion, and a right acetabular fracture. The patient is still intubated and mechanically ventilated and has a chest tube, Foley catheter, and two abdominal drains. The patient's hemodynamic assessment reveals the following values: BP, 94/66 mm Hg; HR, 118 beats/min; T, 38.7° C; CVP, 5 cm H2O; wedge pressure, 6 mm Hg; cardiac index, 6.1; and systemic vascular resistance, 450 dyns/sec. The patient is at the greatest risk to develop

Infection

A nurse is caring for a patient with blunt chest trauma after a motor vehicle accident. The patient starts to complain of pain from the chest to the shoulder and a sense of impending doom. Upon assessing the patient, the nurse notes that the patient has diminished breath sounds on the left side, jugular vein distention, and tracheal deviation to the right. The nurse anticipates:

Insertion of a chest tube

A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the client for Heberdens nodules. What assessment technique is correct?

Inspect the clients distal finger joints.

A client is in skeletal traction. Which nursing intervention ensures proper care of this client?

Inspect the skin at least every 8 hours.

Which nursing intervention helps to reduce the incidence of osteomyelitis for a client receiving hemodialysis?

Instructing the client to brush teeth after every meal

A nurse is assessing a client who had an external fixation device applied 2 hours ago for a fracture of the left tibia and fibula. Which of the following findings is a manifestation of compartment syndrome?

Intense pain when the client's left foot is passively moved Hard, swollen muscle in the client's left leg Burning and tingling of the client's left foot Client report of minimal pain relief following a second dose of opioid medication

A nurse cares 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 should the nurse administer first?

Intravenous calcitonin

A nurse is providing dietary teaching about calcium-rich foods to a client who has osteoporosis. Which of the following foods should the nurse include in the instructions?

Kale

An older adult client has had an open reduction and internal fixation of a fractured right hip. Which intervention does the nurse implement for this client?

Keep the client's heels off the bed at all times.

The nurse is caring for a client with systemic sclerosis (SSc). What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)?

Keep the room at a comfortably warm temperature Place a foot cradle at the end of the bed to lift sheets Remind the client to elevate the head of the bed after eating

The nurse is assessing a client with Ewing's sarcoma. Which finding does the nurse expect to observe?

Leukocytosis

The nurse is conducting a musculoskeletal history in an older adult client who requires a caregiver to perform all activities of daily living (ADLs). Which level of functioning does the nurse record in the client's history using Gordon's Functional Health Patterns?

Level IV

Which of the following physiologic changes caused by aging is the most likely contributor to the high mortality rate in older trauma patients compared with younger trauma patients?

Limited cardiovascular physiologic reserve in the elderly

A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)?

Lose weight if needed

A nurse is admitting an adult client who has suspected osteoporosis. Which of the following findings are risk factors for osteoporosis?

Loss of heigh of 2 inches BMI of 18 Kyphotic curve at the upper thoracic spine History of lactose intolerance

When assessing a female client, the nurse learns that the client has several risk factors for osteoporosis. Which risk factor will be the priority for client teaching?

Low calcium and vitamin D intake

A nurse reviews prescriptions for an 82-year-old client with a fractured left hip. Which prescription should alert the nurse to contact the provider and express concerns for client safety?

Meperidine (Demerol) 50 mg IV every 4 hours

The ambulatory surgery post anesthesia care unit (PACU) nurse has just received report about clients who had arthroscopic surgery. Which client will the nurse plan to assess first?

Middle-aged adult client who returned to the PACU 25 minutes ago after left knee arthroscopic surgery under epidural anesthesia

A client is suspected of having muscular dystrophy (MD). Which laboratory test result does the nurse anticipate with this disease?

Moderately elevated aspartate aminotransferase (AST)

A client sustains a fracture of one arm and the provider applies a plaster cast to the extremity. What will the nurse teach the client to do during the first 24 hours after discharge from the emergency department?

Monitor neuromuscular status for decreased circulation and sensation in the extremity.

An older clients serum calcium level is 8.7 mg/dL. What possible etiologies does the nurse consider for this result?

Normal age-related decrease in serum calcium Possible occurrence of osteoporosis or osteomalacia

The nurse plans to refer a client diagnosed with osteoporosis to which community resource?

National Osteoporosis Foundation

Before administering low-molecular-weight heparin (LMWH) to an older adult client after total knee arthroplasty, the nurse notes that the client's platelet count is 50,000/mm3 (50 x 109/L). What action is most important for the nurse to take?

Notify the health care provider of the platelet count.

A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like pins and needles and that the neck is very painful since returning from surgery. What action by the nurse is best?

Notify the provider immediately.

The nurse performs a neurovascular assessment on a client with closed multiple fractures of the right humerus who is experiencing increased pain even with maximum ordered doses of morphine. The nurse notes distal capillary refill of 3 seconds and coolness of the hand and fingers. The client reports numbness of the hand and is unable to wiggle the thumb. Which nursing action is indicated?

Notify the provider of these findings.

After a total knee replacement, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the clients pulses are 2+/4+ bilaterally; the skin is pale pink, warm, and dry; and the client is unable to dorsiflex or plantarflex the affected foot. What action does the nurse perform next?

Notify the surgeon or anesthesia provider immediately.

A nurse cares for a client with a fractured fibula. Which assessment should alert the nurse to take immediate action?

Numbness in the extremity

The nurse anticipates providing collaborative care for a client with a traumatic amputation of the right hand with which health care team members?

OT PT Psychologist

Which element is a risk factor for osteoarthritis (OA)?

Obesity

A client has undergone an elective below-the-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse instructs the client to notify the health care provider immediately if which change occurs?

Observation of a large amount of serosanguineous or bloody drainage

A nurse cares for a client in skeletal traction. The nurse notes that the skin around the clients pin sites is swollen, red, and crusty with dried drainage. Which action should the nurse take next?

Obtain a prescription to culture the drainage.

A client is admitted with a large draining wound on the leg. What action does the nurse take first?

Obtain cultures of the leg wound.

The most important aspect of a secondary survey is to

Obtain patient history

The charge nurse in the hospital-based day surgery center is making client assignments for the staff. Which client is most appropriate to assign to a nurse who has floated from the general surgical unit?

Older adult who has undergone arthroscopic surgery of the shoulder under local anesthesia

The majority of falls accounting for traumatic injury occur in what population?

Older adults

Fat embolism syndrome can occur as a complication of

Orthopedic trauma

Which aspect of postoperative management will the nurse plan to discuss with a client about to undergo an arthroscopic repair of the knee?

Physical therapy for exercises

A nurse obtains the health history of a client with a fractured femur. Which factor identified in the clients history should the nurse recognize as an aspect that may impede healing of the fracture?

Pagets disease

A nurse is assessing a client who is scheduled to undergo a right knee arthroplasty. The nurse should expect which of the following findings?

Pain when bearing weight Joint crepitus Swelling of the affected joint Limited joint motion

A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate?

Pallor of toes with cold exposure

The nurse is caring for a client with prostate cancer who has bone metastasis. The nurse anticipates that the health care provider will prescribe which medication?

Pamidronate (Aredia)

Signs and symptoms associated with a flail chest include

Paradoxical respiratory movement

Aggressive pulmonary care must be instituted for the patient with a traumatic brain injury. However, endotracheal suctioning can elevate intracranial pressure (ICP). Techniques to eliminate elevation in ICP with suctioning include all of the following except:

Pass the suction catheter all the way to the carina.

A nurse cares for an older adult client with multiple fractures. Which action should the nurse take to manage this clients pain?

Patient-controlled analgesia (PCA) pump with morphine

An older adult client has multiple tibia and fibula fractures of the left extremity after a motor vehicle crash. Which pain medication does the nurse anticipate will be requested for this client?

Patient-controlled analgesia (PCA) with morphine

During assessment of a patient who is new to the critical unit, the nurse observes perianal ecchymosis. The nurse suspects the patient has a

Pelvic fracture

An older client with diabetes is admitted with a heavily draining leg wound. The clients white blood cell count is 38,000/mm3 but the client is afebrile. What action does the nurse take first?

Place the client on contact isolation.

A client has a bone density score of 2.8. What action by the nurse is best?

Planning to teach about bisphosphonates

A nurse is preparing a plan of care to prevent a client from developing flexion contractions following a below-the-knee amputation 24 hours ago. Which of the following actions should the nurse include?

Position the client prone several times a day

A client undergoes a surgical amputation of a lower extremity after a motor vehicle crash. The client's vital signs are stable. What is a priority nursing action in the early postoperative period to help prevent complications in this client?

Positioning and range-of-motion of the affected extremity

A nurse is reviewing the plan of care for a client who has SLE. The client reports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following laboratory findings should the nurse anticipate?

Positive ANA titer 2 + urine protein Elevated BUN

A client has a possible connective tissue disease and the nurse is reviewing the clients laboratory values. Which laboratory values and their related connective tissue diseases (CTDs) are correctly matched?

Positive human leukocyte antigen B27/HLA-B27 (Retiters syndrome or ankylosing spondylitis) Positive rheumatoid factor (Possible kidney disease)

A client has symptoms of rheumatoid arthritis (RA). Which laboratory finding indicates to the nurse that the client may have RA?

Positive total antinuclear antibody (ANA)

A nurse is caring for four clients. After the hand-off report, which client does the nurse see first?

Post-microvascular bone transfer client whose distal leg is cool and pale

Which is a priority problem for the older adult client diagnosed with bone cancer?

Potential for injury related to weakness and drug therapy

The nurse is reviewing the medication history for a client scheduled for a left total hip replacement. The nurse plans to contact the health care provider if the client is taking which medication?

Prednisone (Deltasone) to treat asthma

An older client is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate?

Prepare to administer epoetin alfa (Epogen).

Which client information is most essential for the nurse to report to the health care provider before a client with knee pain undergoes magnetic resonance imaging (MRI)?

Presence of a permanent pacemaker

A client diagnosed with exacerbation of systemic sclerosis (SSc) asks the nurse why a foot board and a bed cradle have been placed on the bed. The nurse explains that they are used for what purpose?

Promote comfort from Raynaud's phenomenon

A nurse is discharging a client to a short-term rehabilitation center after a joint replacement. Which action by the nurse is most important?

Providing a verbal hand-off report to the facility

A nurse is providing information about capsaicin cream to a client who reports continuous knee pain from osteoarthritis. Which of the following information should the nurse include in the discussion?

Put gloves on before applying the cream to other parts of the body

An emergency department nurse triages a client with diabetes mellitus who has fractured her arm. Which action should the nurse take first?

Remove the medical alert bracelet from the fractured arm.

A nurse is planning discharge teaching on home safety for an adult client who has osteoporosis. Which of the following information should the nurse include in the teaching?

Remove throw rugs in walkways Use prescribed assistive devices Remove clutter from the environment Maintain lighting of doorway areas

A nurse is caring for a client who received a lower back injury during a fall and describes sharp pain in the back and down the left leg. In which of the following positions should the nurse plan to place the client to attempt to decrease the pain?

Semi-Fowler's with a pillow under the knees

A home health nurse assesses a client with diabetes who has a new cast on the arm. The nurse notes the clients fingers are pale, cool, and slightly swollen. Which action should the nurse take first?

Raise the arm above the level of the heart.

A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed?

Raise the lower siderail on the affected side.

A nurse is working in an outpatient clinic is assessing a client who has RA. The client reports increased joint tenderness and swelling. Which of the following findings should the nurse expect?

Recent influenza Decreased ROM Pain at rest

The nurse knows that hematopoiesis occurs in what part of the musculoskeletal system?

Red marrow

After teaching a client with a fractured humerus, the nurse assesses the clients understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture?

Roast beef with low-fat milk and a vitamin C supplement

A patient with blunt trauma to the thorax has a positive Kehr's sign. Kehr's sign in this trauma patient most likely indicates a:

Ruptured spleen.

A nurse plans care for a client who is prescribed skeletal traction. Which intervention should the nurse include in this plan of care to decrease the clients risk for infection?

Schedule for pin care to be provided every shift.

A patient with multisystem trauma has been in the ICU for 6 days after sustaining a closed head injury, a right-sided pneumothorax, right rib fractures, a grade IV liver laceration, a pancreatic contusion, and a right acetabular fracture. The patient is still intubated and mechanically ventilated and has a chest tube, Foley catheter, and two abdominal drains. The patient's hemodynamic assessment reveals the following values: BP, 94/66 mm Hg; HR, 118 beats/min; T, 38.7° C; CVP, 5 cm H2O; wedge pressure, 6 mm Hg; cardiac index, 6.1; and systemic vascular resistance, 450 dynes/sec. What is the most likely cause of this hemodynamic picture?

Septic shock

The nurse is assessing four clients with musculoskeletal disorders. The nurse should assess the client with which laboratory result first?

Serum phosphorus: 2 mg/dL

The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement?

Severe osteoporosis

The nurse suspects that a client may have plantar fasciitis if the client has which assessment finding?

Severe pain in the arch of the foot, especially when getting out of bed

A nurse is assessing a client who has arteriosclerosis and is scheduled for a possible right lower extremity amputation. Which of the following are expected findings in the affected extremity?

Skin cool to touch from mid-calf to toes Lack of hair on the lower leg Blackened areas on several toes

Battle's sign in a patient with head trauma most likely indicates a:

Skull fracture

The nurse is caring for a client using a continuous passive motion (CPM) machine and has delegated some tasks to the unlicensed assistive personnel (UAP). What action by the UAP warrants intervention by the nurse?

Storing the CPM machine under the bed after removal

The nurse is reviewing the medication history for a client diagnosed with rheumatoid arthritis (RA) who has been ordered to start sulfasalazine (Azulfidine) therapy. The nurse plans to contact the health care provider if the client has which condition?

Sulfa allergy

Which intervention does the nurse suggest to a client who has undergone a leg amputation to help cope with loss of the limb?

Talking with an amputee close to the client's age who has a similar amputation

A patient who was an unrestrained driver in a high-speed, head-on motor vehicle collision presents with dyspnea, tachycardia, hypotension, jugular venous distention, tracheal deviation to the left, and decreased breath sounds on the right side. What is the most likely diagnosis?

Tension pneumothorax

A hospitalized clients strength of the upper extremities is rated at 3. What does the nurse understand about this clients ability to perform activities of daily living (ADLs)?

The client is able to perform ADLs but not lift some items.

A nurse is educating clients at a health fair about DXA scans. Which of the following information should the nurse include?

The hip and spine are the usual areas the device scans Bone pain can indicate a need for a scan Females should have a baseline scan during their 40s

A patient has sustained an epidural hematoma after a 10-foot fall from a roof. Which of the following is true about epidural hematomas?

They are usually arterial in nature.

A patient's condition has deteriorated. Changes in condition include trachea shift, absence of breath sounds on the left side, and hypotension. A chest tube was inserted on the left side with 1800 mL of blood removed. The nurse expects that the patient will be taken to surgery for a

Thoracotomy

A nurse assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert the nurse to urgently contact the health provider?

Traction weights are resting on the floor

Which finding does the nurse expect to observe in a client with suspected common chronic osteomyelitis?

Ulceration of the skin

An emergency nurse assesses a client who is admitted with a pelvic fracture. Which assessments should the nurse monitor to prevent a complication of this injury?

Urinary output Blood pressure Skin color

Which information about a client who was admitted with a pelvic fracture after being crushed by a tractor is most important for the nurse to assess to monitor for serious complications from this type of injury?

Urine dipstick for the presence of red blood cells.

An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury?

Use an abduction pillow.

A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection?

Use aseptic technique for dressing changes.

Which instructions for joint protection does the nurse recommend for a client with a connective tissue disease?

Use long-handled devices such as a reacher. Use adaptive devices such as Velcro closures.

A client has a grade III open fracture of the right tibia. To prevent infection, which intervention does the nurse implement?

Use strict aseptic technique when cleaning the site.

The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjogrens syndrome?

Visual acuity

The nurse is caring for an older adult client diagnosed with osteomalacia. The nurse anticipates that the health care provider will request which supplement?

Vitamin D3

A client has an ingrown toenail. About what self-management measure does the nurse teach the client?

Warm moist soaks

The nurse is completing an admission assessment on a client scheduled for arthroscopic knee surgery. Which information will be most essential for the nurse to report to the health care provider?

Warm, red, and swollen knee

The nurse is developing a teaching plan for a client diagnosed with osteoarthritis (OA). The nurse includes which instruction in the teaching plan?

Wear supportive shoes.

The nurse is taking the history of an adult female client. Which factor places the client at risk for osteoporosis?

Working at a desk and playing the piano for a hobby

A 50-year-old woman has osteoporosis and is at risk for developing vertebral fractures. She asks the nurse about exercises to help minimize this risk. Which exercise will the nurse recommend?

Yoga