Assessment

A nurse is attending a patient who has sustained a fracture of the femur. What interventions should the nurse perform to ensure a healthy diet for optimal healing of the injured tissues?

-Include 1g/kg of protein daily -Include foods rich in vitamins C and D -Increase calcium-rich foods in the diet

A patient with a hip fracture has been treated with insertion of a prosthesis. What findings indicate dislocation of this prosthesis?

-Limb shortening -A lump in the buttock -External rotation of the limb

A client with no joint motion and slight evidence of muscle contractility

1

a client is undergoing diagnostic tests for Myasthenia gravis. which test would the nurse identify as the most specific for this diagnosis

Edrophonium chloride test

Which benign condition of the client's skin is associated with the grouping of normal cells derived from meloanocyte like precursor cells?

Nevi (moles)

A patient admitted with cellulitis and probable osteomyelitis received an injection of radioisotope at 9:00 AM before a bone scan. At what time should the nurse plan to send the patient for the bone scan?

11:00 AM

A client who can complete range of motion with gravity eliminated

2

A client who can completer range of motion against gravity

3

Which muscle - strength rating would the nurse record for a client who can complete a range of motion with some resistance?

4

which joint is an example of condyloid joint?

wrist joint

An adolescent displaying low self-esteem complains of inflamed, red, and painful lesions on his forehead. Which condition is likely?

Acne vulgaris

The nurse is grading a muscle-strength test on the patient and obtains a score of 4/5. What best describes this score?

Active movement against gravity and some resistance

Synovial joint movement that describes movement towards midline of the body

Adduction

what are types of movements that are possible at the shoulder joint in a patient suffering from elbow pain?

Adduction Abduction Circumduction

The registered nurse teaches a student nurse about care of a patient with a fracture of the humerus, compartment syndrome, and a plaster cast in place. The student nurse provides discharge education to the patient. Which statement made by the student nurse needs correction?

Elevate the extremity above the heart level.

Which type of laser is used in the treatment of vascular and other pigmented lesions?

Argon

The nurse is assessing a patient who has dark skin for cyanosis. What assessment findings would indicate cyanosis in individuals with dark skin?

Ashen or gray color noted in the conjunctiva of the eye, mucous membranes, and nail beds

A patient is treated for a vertebral injury. After the application of a body brace jacket, the patient reports abdominal pain and pressure, nausea, and vomiting. what is the nurse's priority assessment?

Assess the abdomen for decrease bowel sounds through a window in the brace.

which type of allergic skin condition is associated with immunologic irregularity, asthma, and allergic rhinitis?

Atopic dermatitis

A nurse is caring for a client who sustained a transection of the spinal cord with no other injuries. The nurse continually monitors this client for which medical emergency?

Autonomic Hyperflexia

Which joint helps in the gliding movement of the wrist?

Biaxial joint.

which radiographic test is used to view the entire skeleton?

Bone Scan

Which structures protect a client's internal organs, support blood cell production, and store minerals?

Bones

A middle-aged patient is reporting a sore shoulder after raking the yard. The nurse should suspect which problem?

Bursitis

A nurse asks a nursing student to determine the skin color of a patient whose skin is tanned in the exposed areas. Where is the best place on a patient's body to accurately determine skin color?

Buttocks

A patient with musculoskeletal fatigue is weak. How does the nurse best provide safety when the patient needs to go to the bathroom?

By assessing the patient's ability to walk to the bathroom

The nurse is caring for a patient with a fractured femur. which nursing action (s) by the nurse is the priority?

Elevating the extremity Providing analgesia as necessary. Compressing the involved extremity Applying ice compresses to the injured area Stopping the activity and limiting movement.

The nurse is completing a neurovascular assessment on the patient with a tibial fracture and a cast. The feet are pulseless, pale, and cool. The patient says they are numb. What should the nurse suspect is occurring?

Compartment syndrome

when a client has a superficial tumor involving only 1 vocal cord, which surgery would the nurse anticipate?

Cordectomy

A nurse is assessing a fracture of a patient's hand. Which phenomenon would the nurse note as the bone fragments rub against each other?

Crepitation

Which test provides information on bladder capacity, bladder pressure, and voiding reflexes?

Cystometrography (CMG)

A patient reports excessive itchiness all over the body that has caused an inability to sleep for three days. what nursing assessment finding indicates a lack of proper sleep?

Dark circles under the eyes

A nurse is conducting a class on the physiology of the integumentary system for a group of nursing students. To test the students' knowledge, the nurse asks them the reason for the greying of hair. What are appropriate responses? Select all that apply.

Decrease in the production of melanin Decreased in the number of melanocytes

Which infection is caused due to fungus?

Dermatophytosis

The nurse is assessing a patient who has a traumatic leg injury. What intervention is the most important in the initial assessment?

Determine the extremity's color and temperature in the area of the injury

A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns?

Directly proportional

which synovial joint movement is described as turning the sole away from the midline of the body?

Eversion

which type of biopsy is required for the removal of entire lesions on the skin?

Excisional biopsy

Which data would a nurse consider least important during an assessment of skin integrity?

Family history of pressure ulcers

On assessment, a linear crack from the epidermis to the dermis is noted at the corner of the patient's mouth. How should the nurse document this finding?

Fissure

which secondary skin lesion may include athlete's foot as an example?

Fissure

A patient is admitted to the hospital with Boutonnière deformity. What are the signs and symptoms that the nurse is likely to find during assessment? Select all that apply.

Flexion of proximal interphalangeal joint Hyperextension of the distal interphalangeal joint

which skin infection is caused by bacteria?

Foliculitis

Which sexually transmitted infection is caused by a virus?

Genital warts

The patient is brought to the emergency department after a car accident and has a femur fracture. What nursing intervention should the nurse implement to prevent a fat embolus in this patient?

Immobilize the fracture preoperatively

A patient is scheduled for a technetium [Tc]-99m bone scan. What nursing interventions are appropriate for this patient?

Increase fluid intake after the examination. ensure that the patient's bladder is emptied before scan. Explain to the patient that radiosotope is given 2 hours before the procedure.

Which characteristics does the nurse associate with a punch biopsy?

It is performed using a circular cutting instrument 2 to 6 mm in diameter

A patient is scheduled for magnetic resonance imaging (MRI). What nursing interventions should thenurse perform to prepare the patient for the procedure? Select all that apply.

Offer ear plugs or music. Inform the patient to remain still throughout the procedure. Ensure that patient is not wearing metal such as zippers or jewelry. Explain that the machine will make loud tapping noises intermittently, and there is no cause for alarm.

In reviewing bone remodeling, what should the nurse know about the involvement of bone cells?

Osteoblasts deposit new bone.

A nurse is assessing a male client who reports small papules and pustules in the beard area. The papules started appearing after he shaved his beard the previous day. Based on this information, what is the most likely patient diagnosis?

Pseudofolliculitis

Which benign condition shows silver scaly plaques on the skin?

Psoriasis

which estrogen antagonist would the health care provider prescribe a client for the prevention and treatment of osteoprosis in post menopausal women?

Raloxifene

Which mechanism of action for wet-to-damp saline-moistened gauze for wound debridement is correct?

Removing the necrotic tissue machanically

which surgery is used to treat excessive wrinkling or sagging of facial skin?

Rhytidectomy

During the change-of- shift report, the outgoing nurse reports a new finding of petechiae in a new patient admitted with a yet-to-be diagnosed hematologic disorder. On assessment of this patient, what should the incoming nurse expect to find?

Tiny, Purple spots on the skin

A nurse scrapes off the superficial layer of the skin lesion of the patient. This specimen is sent to the laboratory for culture. What is the purpose of this culture?

To identify a fungal infection

While explaining the structure of the skin to a patient, the nurse says that the outermost layer of the skin consists mainly of dead cells. The patient asks the nurse, "Why do our bodies need these dead cells?" What is the most appropriate answer for the nurse to give?

To protect the viable cells underneath

During a physical assessment, the nurse asks the patient to perform inversion movement of the foot. What instruction should the nurse give to the patient?

Turn the sole inward toward the midline of the body.

The nurse understands that there are tree types of muscles in the body. which body parts are made up of smooth muscles?

Uterus Arteries Urinary bladder

Which body part of the patient is at risk for superior mesenteric artery syndrome when sustaining a fracture?

Vertebrae

Which action would the nurse take for a client with a diagnosis of conversion disorder manifesting as paralysis of the legs?

Avoid focusing on the client's physical symptoms.

During the nursing musculoskeletal assessment, the nurse assesses the joint movements. On the nurse's instruction, the patient flexes the ankle and toes toward the shin. As what should the nurse record this movement?

Dosiflexion

A nurse is interviewing a client with a tentative diagnosis of Parkinson disease. What should the nurse expect the client to report about how the onset of symptoms occurred?

Gradually

A patient experiences an unstable wrist fracture. Which type of cast will be most beneficial for the patient?

Long Cast

A patient asks the nurse why an arthrogram has been scheduled. The nurse should reply that this test is designed to identify which condition?

Disorders of the cartilage

A nurse is taking the health history of a patient suffering from severe knee pain. Which question related to the sexuality-reproductive pattern are important in this scenario for assessment?

Do you face any sexual concerns related to your mobility?

What questions should the nurse ask a patient with severe back pain in the lumbar region when taking the health history?

Does your work involve lifting any heavy objects? Has this pain affected your social or professional life? Do you consume any dietary supplements like calcium or vitamin D? Do you require frequent change of position while you are sleeping because of the pain?

A nurse is performing a skin assessment on a female patient. The patient has excessive hair on the chest and the face. The nurse expects that what test will be performed?

Estrogen Test.

which form is a source of the dermal regeneration template graft?

Glycosaminoglycan bonded to silicone membrane

When assessing the range of motion in a patient, which instrument should the nurse use?

Goniometer

which skin infection would cause facial paralysis?

Herpes zoster

When working with patients, the nurse knows that patients have the most difficulties with diarthrodial joints. Which joints are included in this group of joints (select all that apply)?

Hinge joint of the kneeBall and socket joint of the shoulder or hip.

A teenaged patient reports having blackheads all over the face for the past year. The nurse recognizes that, for this patient, the blackheads are due to excessive sebum production most likely caused by what?

Hormonal alterations

Scald injuries could be caused by contact with which item?

Hot liquids or Steam

When assessing a dark-skinned patient, the nurse finds that there are dark longitudinal bands in the patient's nail beds. What is the most likely interpretation of this finding?

It is a normal finding in this patient.

The patient has diffuse distribution of moles on the body. A biopsy of one on the patient's back will be done to assess for malignancy. The nurse knows that what is the rationale for doing a punch biopsy?

It provides a full-thickness of skin.

The nurse is caring for the patient with skeletal traction for an extremity fracture. What action(s) by the nurse are most appropriate?

Keep the weights off of the floor -Elevate the end of the bed as needed -Make sure that the traction ranges from 5 to 45 pounds (2.3 to 20.4 kg)

which description describes a coalesced type of skin lesion configuration?

Lesions merge together and appear confluent.

which disorder is a cause of systemic altered inflammatory response in impaired wound healing?

Leukemia

Which description is associated with fissures?

Linear cracks in the epidermis that extend into the dermis

A patient experiences a knee fracture. During a follow up visit, the patient reports an increase in muscle spasms. Which action performed by the patient may be the cause of the spasms?

Massaging the muscle

A patient presents with severe pain in the left lower extremity and also has difficulty ambulating. The left leg appears to be slightly shorter than the right. What points should the nurse consider when taking the measurement of the lower extremity? Select all that apply.

Measure the muscle mass circumferentially at the largest area. Measure the length and circumference at the same points of opposite limb. Measure the length of the extremity from the anterior superior iliac spine to the medial malleolus.

A patient injured his or her arm after doing an activity he or she had not done before. What factor wasmost likely the cause of the injury?

Muscle fatigue

A nurse is performing a musculoskeletal assessment on a patient. What are the findings that denote a normal musculoskeletal system? Select all that apply.

Muscle strength of 5 No joint swelling, deformity, or crepitation Full range of motion of all joints without pain or laxity No tenderness on palpation of spine, joints, or muscles

When jaundice is suspected in a patient, which areas should the nurse check for skin color?

Nailbeds conjunctiva Buccal Mucosa

when teaching a client about their disease process, which term would the nurse use to describe bone loss greater than normal but less than that caused by osteoporosis?

Osteopenia

`The nurse is performing a physical examination on a patient who is suffering from extreme pain in the right knee as well as weakness in the right leg. What should the nurse consider when performing palpation? Select all that apply.

Palpate the muscles as well as joints Rub your hands together before palpating. Palpate from above to below (cephalopedal direction).

To obtain information about temperature, turgor, moisture, and texture, which assessment technique should the nurse use?

Palpation of skin with the hand

when a client injures the amphiarthrodial joint which joint did the client injure?

Pelvic joint.

A patient is examined by the nurse and found to have pink-purple, nonblanching macular pinpoint lesions. which term best describes these findings?

Petechiae

A nurse is completing the discharge sheet for a patient with hip fracture, who has been treated by insertion of a prosthesis using a posterior approach. What instructions should be given to this patient before discharge?

Place a chair inside the tub and remain seated while washing -Inform the dentist about the prosthesis before any dental work -Keep the hip in a neutral, straight position when sitting or lying

The nurse is performing a health history assessment on the older patient. The nurse knows that which of these illnesses can affect the older patient's musculoskeletal status? Select all that apply.

Poliomyelitis Tuberculosis Diabetes mellitus

A client newly diagnosed with myasthenia gravis voiced concerns about fluctuations in physical condition and generalized weakness. when providing care for this client, which nursing intervention would the nurse implement?

Preplan the spacing of activities throughout the day

Synovial joint movement that described as turning the palm downwards

Pronation

The nurse is reviewing the function of the skin layers. which of these is the primary function of the epidermis layer of the skin?

Protection

The nurse is providing discharge education to a patient with a fiberglass cast. What should the nurse be sure to include with the education?

Skin irritation is more common than with a plaster cast.

A nurse is taking a patient's health history related to musculoskeletal system. What are the common symptoms of musculoskeletal impairments? Select all that apply.

Stiffness Weakness Joint crepitation

Synovial joint movement that describes turning the palm upwards

Supination

The nurse suspects that a patient is experiencing a fat embolism after sustaining a femur fracture. What clinical manifestations does the nurse expect?

Tachypnea, tachycardia, shortness of breath, petechial rash on the chest and neck

During an assessment interview of a female patient, the nurse finds that she is taking isotretinoin to treat acne. On further assessment, the patient expresses that she plans to conceive. Which is the most important nursing action?

Tell the patient to stop this medication because it would have adverse effects on the fetus.

A nurse is caring for a patient who has taken a potassium hydroxide (KOH) skin test. The results of the test are positive. What would be the interpretation of this test?

The patient has a fungal infection of the skin.

Which feture is associated with the "maturation phase" of normal wound healing?

The scar is firm and inelastic on palpation

A patient will undergo electromyography. What information should the nurse give to the patient? Select all that apply.

There may be some discomfort because of the needles. Small-gauge needles are inserted into certain muscles. It is useful in identifying any lower motor neuron dysfunction or primary muscle diseases.

Which treatment is beneficial for a client with muscle spasm?

Thermotherapy

A nurse is assessing a patient with chalky white patches on the face. The nurse learns that the patient's parent and grandparent have had similar signs. On the basis of this information, what is the most likely patient diagnosis?

Vitiligo

A nurse is taking the health history of a patient with severe pain in the right knee and lower right extremity. What are the important questions related to the dietary behavior of the patient that the nurse should ask about? Select all that apply.

What is your usual daily intake of food? Do you have difficulties preparing your food? Do you consume any calcium or vitamin D supplements?

which finding in older adult clients is associated with aging?

decrease in height

When assessing the skin of an older adult, which finding would the nurse consider normal?

dry skin wrinkling decreased turgor

A nurse is caring for a patient who has just sustained a hip fracture. Which nursing action should be performed first?

immobilizing the affected extremity

A patient experiences a compound fracture. What assessment findings does the nurse expect?

soft tissue injury The skin is broken, exposing the bone