Exam 3 medsurg, 62, 64 OA/R, fractures

Which information should the nurse include when preparing teaching materials for a patient who has an exacerbation of rheumatoid arthritis? Affected joints should not be exercised when pain is present Applying cold packs before exercise may decrease joint pain Exercises should be performed passively by someone other than the patient Walking may substitute for range-of-motion (ROM) exercises on some days

Applying cold packs before exercise may decrease joint pain

A patient whose employment requires frequent lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates the teaching has been effective? "I will keep my back straight when I lift above than my waist." "I will begin doing exercises to strengthen and support my back." "I will tell my boss I need a job where I can stay seated at a desk." "I can sleep with my hips and knees extended to prevent back strain."

"I will begin doing exercises to strengthen and support my back."

The nurse teaches a patient with osteoarthritis (OA) of the hip about how to manage the OA. Which patient statement indicates to the nurse a need for additional teaching? "A shower in the morning will help relieve stiffness." "I can exercise every day to help maintain joint mobility." "I will take 1 gram of acetaminophen (Tylenol) every 4 hours." "I can use a cane to decrease the pressure and pain in my hip."

"I will take 1 gram of acetaminophen (Tylenol) every 4 hours."

When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate. The patient tells the nurse, "My arthritis isn't that bad yet. The side effects of methotrexate are worse than the arthritis." The most appropriate response by the nurse is "You have the right to refuse to take the methotrexate." "Methotrexate is less expensive than some of the newer drugs." "It is important to start methotrexate early to decrease the extent of joint damage." "Methotrexate is effective and has fewer side effects than some of the other drugs

"It is important to start methotrexate early to decrease the extent of joint damage." Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible.

A patient being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take? a. Draw blood for rheumatoid factor analysis. b. Teach the patient about injections for the nodules. c. Assess the nodules for skin breakdown or infection. d. Discuss the need for surgical removal of the nodules.

C Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor, and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence.

A patient with dermatomyositis is receiving long-term prednisone therapy. Which assessment finding by the nurse is important to report to the health care provider? a. The patient has painful hematuria. b. Acne is noted on the patient's face. c. Fasting blood glucose is 112 mg/dL. d. The patient has an increased appetite.

Corticosteroid use is associated with an increased risk for infection, so the nurse should report the urinary tract symptoms immediately to the health care provider. The increase in blood glucose, increased appetite, and acne are also adverse effects of corticosteroid use but do not need diagnosis and treatment as rapidly as the probable urinary tract infection.

The day after a 60-yr-old patient has open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the nurse identifies the priority nursing diagnosis as a. activity intolerance related to deconditioning. b. risk for constipation related to prolonged bed rest. c. risk for impaired skin integrity related to immobility. d. risk for infection related to disruption of skin integrity.

D A patient having ORIF is at risk for problems such as wound infection and osteomyelitis. After ORIF, patients typically are mobilized starting the first postoperative day, so the other problems caused by immobility are not as likely.

After change-of-shift report, which patient should the nurse assess first? a. Patient with a repaired mandibular fracture who is complaining of facial pain b. Patient with an unrepaired intracapsular left hip fracture whose leg is externally rotated c. Patient with an unrepaired Colles' fracture who has right wrist swelling and deformity d. Patient with repaired right femoral shaft fracture who is complaining of tightness in the calf

D Calf swelling after a femoral shaft fracture suggests hemorrhage and risk for compartment syndrome. The nurse should assess the patient rapidly and then notify the health care provider. The other patients have symptoms that are typical for their injuries but do not require immediate intervention.

The nurse assesses a 78-yr-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management. Which information requires a discussion with the health care provider about an urgent change in the treatment plan? a. Knee crepitation is noted with normal knee range of motion. b. Patient reports embarrassment about having Heberden's nodes. c. Patient's knee pain while golfing has increased over the last year. d. Laboratory results indicate blood urea nitrogen (BUN) is elevated.

D Older patients are at increased risk for renal toxicity caused by nonsteroidal antiinflammatory drugs (NSAIDs) such as naproxen. The other information will also be reported to the health care provider but is consistent with the patient's diagnosis of osteoarthritis and will not require an immediate change in the patient's treatment plan.

Which finding will the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee? Presence of Heberden's nodules Discomfort with joint movement Redness and swelling of the knee joint Stiffness that increases with movement

Discomfort with joint movement

Which assessment finding for a 55-yr-old patient should alert the nurse to the presence of osteoporosis? Bowed legs Loss of height Report of frequent falls Aversion to dairy products

Loss of height

An assessment finding for a 55-yr-old patient that alerts the nurse to the presence of osteoporosis is bowed legs. a loss of height. the report of frequent falls. an aversion to dairy products.

a loss of height.

The nurse suspects a neurovascular problem based on assessment of a. exaggerated strength with movement. b. increased redness and heat below the injury. c. decreased sensation distal to the fracture site. d. purulent drainage at the site of an open fracture.

c. decreased sensation distal to the fracture site.

To assess for neurologic status in a patient with a fractured humerus, what should the nurse ask the patient to do? a. Evert, invert, dorsiflex, and plantar flex the foot. b. Assess the location, quality, and intensity of pain below the site of the injury. c. Abduct the fingers, oppose the thumb and small fingers, and flex and extend the wrist. d. Assess the color, temperature, capillary refill, peripheral pulses, and edema in the extremity.

16. c. Neurologic assessment includes evaluation of sensation, motor function, and pain in the upper extremity. Ask the patient to abduct the fingers (ulnar nerve), oppose the thumb and small fingers (median nerve), and flex and extend the wrist (or fingers if in a cast) (radial nerve). The nurse will assess pain and sensory perception in the fingers. Evaluation of the feet would occur in lower extremity injuries. Assessment of color, temperature, capillary refill, peripheral pulses, and edema evaluates vascular status.

A patient who has had open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next? a. Notify the health care provider. b. Assess the incision for redness. c. Reposition the left leg on pillows. d. Check the patient's blood pressure.

A The patient's clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.

A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding is most important for the nurse to communicate to the health care provider? a. There is bruising at the shoulder area. b. The patient reports arm and shoulder pain. c. The right arm appears shorter than the left. d. There is decreased shoulder range of motion.

C A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion should also be reported, but these do not indicate emergent treatment is needed to preserve function.

After a motorcycle accident, a patient arrives in the emergency department with severe swelling of the left lower leg. Which action will the nurse take first? a. Elevate the leg on 2 pillows. b. Apply a compression bandage. c. Assess leg pulses and sensation. d. Place ice packs on the lower leg.

C The initial action by the nurse will be to assess circulation to the leg and observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment.

A patient with a fracture of the left femoral neck has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should a. loosen the traction and help the patient turn onto the unaffected side. b. place a pillow between the patient's legs and turn gently to each side. c. have the patient lift the buttocks slightly by using a trapeze over the bed. d. turn the patient partially to each side with the assistance of another nurse.

C The patient can lift the buttocks slightly off the bed by using a trapeze. This will not affect the fracture fragments on the right leg. Turning the patient will tend to move the fracture fragments, causing pain and possible nerve impingement. Disconnecting the traction will interrupt the weight needed to decrease muscle spasms.

When reviewing the health record for a new patient with rheumatoid arthritis, the nurse reads that the patient has swan neck deformities. Which deformity will the nurse expect to observe when assessing the patient?

D Swan neck deformity involves distal interphalangeal joint hyperflexion and proximal interphalangeal joint hyperextension of the hands. The other deformities are also associated with rheumatoid arthritis: ulnar drift, boutonniere deformity, and hallux vagus.

A patient who had open reduction and internal fixation (ORIF) of left lower leg fractures continues to report severe pain in the leg 15 minutes after receiving the prescribed IV morphine. The nurse determines pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next? Notify the health care provider. Assess the incision for redness. Reposition the left leg on pillows. Check the patient's blood pressure.

Notify the health care provider.

Number in sequence from 1 to 6 the pathophysiologic processes that occur in osteoarthritis (OA). _____ a. Erosion of articular surfaces _____ b. Incongruity in joint surfaces _____ c. Reduction in motion _____ d. Joint cartilage becomes yellow and granular _____ e. Osteophytes form at joint edges _____ f. Cartilage becomes softer and less elastic

a. 3; b. 5; c. 6; d. 1; e. 4; f. 2

What emergency considerations must be included with facial fractures (select all that apply)? a. Airway patency b. Oral examination c. Cervical spine injury d. Cranial nerve assessment e. Immobilization of the jaw

a. Airway patency c. Cervical spine injury Airway patency and cervical spinal cord injury are the emergency considerations with facial fractures. Oral examination and cranial nerve assessment will be done after the patient is stabilized. Immobilization of the jaw is done surgically for a mandibular fracture.

. A patient with a pelvic fracture should be monitored for a. changes in urine output. b. petechiae on the abdomen. c. a palpable lump in the buttock. d. sudden increase in blood pressure

a. changes in urine output.

A client with a fracture develops compartment syndrome. Which of the following signs should alert the nurse to impending organ failure? a) Jaundice. b) Dark, scanty urine. c) Generalized edema. d) Crackles.

b) Dark, scanty urine.

The patient asks, "What does the doctor mean when he says that I have an avulsion fracture in my leg? I thought I had a sprain!" What is the best response by the nurse? a. "It is a fracture with more than two fragments." b. "It means that a ligament pulled a bone fragment loose." c. "The line of the fracture is twisted along the shaft of the bone." d. "The line of the fracture is at right angles to the longitudinal axis of the bone."

b. An avulsion fracture occurs when a ligament pulls a bone fragment loose, with pain similar to a sprain. A fracture with two or more fragments is a comminuted fracture. It is a spiral fracture when it is twisted around a bone shaft. It is a transverse fracture when the line of fracture is at right angles to the longitudinal axis.

In a patient with a stable vertebral fracture, what should the nurse teach the patient to do? a. Remain on bed rest until the pain is gone. b. Logroll to keep the spine straight when turning. c. How to use bone cement to correct the problem. d. Take as much analgesic as needed to relieve the pain.

b. The spine should be kept straight by turning the shoulders and hips together (logrolling). This keeps the spine in good alignment until union has been accomplished. Bed rest may be required for a short time but not until the pain is gone. Bone cement is used by the surgeon to stabilize vertebral compression fractures. Analgesics should be taken only as ordered. If they do not relieve the pain, the HCP should be notified.

A patient is scheduled for total ankle replacement. The nurse should tell the patient that after surgery he should avoid a. lifting heavy objects. b. sleeping on the back. c. abduction exercises of the affected ankle. d. bearing weight on the affected leg for 6 weeks.

d. bearing weight on the affected leg for 6 weeks.

A factory line worker has repetitive strain syndrome in the left elbow. The nurse will plan to teach the patient about a. surgical options. c. wearing a left wrist splint. b. elbow injections. d. modifying arm movements.

d. modifying arm movements. D Treatment for repetitive strain syndrome includes changing the ergonomics of the activity. Elbow injections and surgery are not initial options for this type of injury. A wrist splint might be used for hand or wrist pain.

A patient with a stable, closed humeral fracture has a temporary splint with bulky padding applied with an elastic bandage. The nurse notifies the provider of possible early compartment syndrome when the patient has a. increasing edema of the limb. b. muscle spasms of the lower arm. c. bounding pulse at the fracture site. d. pain when passively extending the fingers.

d. pain when passively extending the fingers.

An appropriate nursing intervention for a patient who has acute low back pain and muscle spasms is to teach the patient to keep both feet flat on the floor when prolonged standing is required. twist gently from side to side to maintain range of motion in the spine. keep the head elevated slightly and flex the knees when resting in bed. avoid the use of cold packs because they will exacerbate the muscle spasms.

keep the head elevated slightly and flex the knees when resting in bed.

What should the nurse include when teaching older adults at a community recreation center about ways to prevent fractures? Tack down scatter rugs on the floor in the home. Expect most falls to happen outside the home in the yard. Buy shoes that provide good support and are comfortable to wear. Get instruction in range-of-motion exercises from a physical therapist.

3- good footwear can prevent falls

The patient with osteoporosis had a spontaneous hip fracture. How should the nurse document this before the x-ray results return? a. Open fracture b. Oblique fracture c. Pathologic fracture d. Greenstick fracture

3. c. A pathologic fracture is a spontaneous fracture at the site of bone disease, such as osteoporosis. An open fracture is when there is communication with the external environment. The oblique fracture has a slanted fracture line. A greenstick fracture is splintered on the convex side, and the other side is in intact with a concave bend.

Which action will the nurse take in order to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the right femur? a. Assess for hip pain. c. Check peripheral pulses. b. Assess for contractures. d. Monitor for hip dislocation.

A Buck's traction keeps the leg immobilized and reduces painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Buck's traction.

The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage activities of daily living suggests they should a. avoid activities requiring repetitive use of the same muscles and joints. b. protect the knee joints by sleeping with a small pillow under the knees. c. stand rather than sit when performing daily household and yard chores. d. strengthen small hand muscles by wringing out sponges or washcloths.

A Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase joint stress. Patients are encouraged to position joints in the extended (neutral) position. Sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion.

A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which information will the nurse teach? a. "Check and clean the pin insertion sites daily." b. "Remove the external fixator for your shower." c. "Remain on bed rest until bone healing is complete." d. "Take prophylactic antibiotics until the fixator is removed."

A Pin insertion sites should be cleaned daily to decrease risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given during external fixator use.

Which finding for a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis is likely to be an adverse effect of the medication? a. Blurred vision c. Abdominal cramping b. Joint tenderness d. Elevated blood pressure

A Plaquenil can cause retinopathy. The medication should be stopped. Other findings are not related to the medication although they will also be reported.

Which nursing action for a patient who has had right hip arthroplasty can the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Reposition the patient every 1 to 2 hours. b. Assess for skin irritation on the patient's back. c. Teach the patient quadriceps-setting exercises. d. Determine the patient's pain intensity and tolerance.

A Repositioning of orthopedic patients is within the scope of practice of UAP (after they have been trained and evaluated in this skill). The other actions should be done by licensed nursing staff members.

A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action should the nurse take? a. Check the patient's prescribed weight-bearing status. b. Use a mechanical lift to transfer the patient to the chair. c. Delegate the transfer to nursing assistive personnel (NAP). d. Decrease the pain medication before getting the patient up.

A The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given because the movement is likely to be painful for the patient. The registered nurse (RN) should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish the transfer.

Before assisting a patient with ambulation 2 days after total hip arthroplasty, which action is most important for the nurse to take? Observe output from the surgical drain. Administer prescribed pain medication. Instruct the patient about benefits of early ambulation. Change the dressing and document the wound appearance.

Administer prescribed pain medication.

Which action will the urgent care nurse take for a patient with a possible knee meniscus injury? a. Encourage bed rest for 24 to 48 hours. b. Apply an immobilizer to the affected leg. c. Avoid palpation or movement of the knee. d. Administer intravenous opioids for pain management.

B A knee immobilizer may be used for several days after a meniscus injury to stabilize the knee and minimize pain. Patients are encouraged to ambulate with crutches. The knee is assessed by flexing, internally rotating, and extending the knee (McMurray's test). The pain associated with a meniscus injury will not typically require IV opioid administration. Nonsteroidal antiinflammatory drugs (NSAIDs) are usually recommended for pain management.

Which action will the nurse include in the plan of care for a patient with a new diagnosis of rheumatoid arthritis (RA)? a. Instruct the patient to purchase a soft mattress. b. Encourage the patient to take a nap in the afternoon. c. Teach the patient to use lukewarm water when bathing. d. Suggest exercise with light weights several times daily.

B Adequate rest helps decrease the fatigue and pain associated with RA. Patients are taught to avoid stressing joints, use warm baths to relieve stiffness, and use a firm mattress. When the disease is stabilized, a therapeutic exercise program is usually developed by a physical therapist to include exercises that improve flexibility and strength of affected joints, as well as the patient's general endurance.

Which nursing intervention will be included in the plan of care after a patient with a right femur fracture has a hip spica cast applied? a. Avoid placing the patient in prone position. b. Ask the patient about abdominal discomfort. c. Discuss remaining on bed rest for several weeks. d. Use the cast support bar to reposition the patient.

B Assessment of bowel sounds, abdominal pain, and nausea and vomiting will detect the development of abdominal cast syndrome. To avoid breakage, the cast support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical therapy personnel and may be turned to the prone position.

The nurse will instruct the patient with a fractured left radius that the cast will need to remain in place a. for several months. b. for at least 3 weeks. c. until swelling of the wrist has resolved. d. until x-rays show complete bony union.

B Bone healing starts immediately after the injury, but because ossification does not begin until 3 weeks after injury, the cast will need to be worn for at least 3 weeks. Complete union may take up to 1 year. Resolution of swelling does not indicate bone healing.

Which information obtained by the nurse about a patient with a lumbar vertebral compression fracture requires an immediate report to the health care provider? a. Patient refuses to be turned due to back pain. b. Patient has been incontinent of urine and stool. c. Patient reports lumbar area tenderness to palpation. d. Patient frequently uses oral corticosteroids to treat asthma.

B Changes in bowel or bladder function indicate possible spinal cord compression and should be reported immediately because surgical intervention may be needed. The other findings are also pertinent but are consistent with the patient's diagnosis and do not require immediate intervention.

Which information will the nurse include when preparing teaching materials for a patient with an exacerbation of rheumatoid arthritis? a. Affected joints should not be exercised when pain is present. b. Applying cold packs before exercise may decrease joint pain. c. Exercises should be performed passively by someone other than the patient. d. Walking may substitute for range-of-motion (ROM) exercises on some days.

B Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints and improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises.

Which assessment information obtained by the nurse indicates a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone? a. The patient has joint pain and stiffness. b. The patient's blood glucose is 165 mg/dL. c. The patient has experienced a recent 5-pound weight loss. d. The patient's erythrocyte sedimentation rate (ESR) has increased.

B Corticosteroids have the potential to cause diabetes mellitus. The finding of elevated blood glucose reflects this side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR with no improvement in symptoms would indicate the prednisone was not effective but would not be side effects of the medication.

Which assessment finding for a patient using naproxen (Naprosyn) to treat osteoarthritis is likely to require a change in medication? a. The patient has gained 3 lb. b. The patient has dark-colored stools. c. The patient's pain affects multiple joints. d. The patient uses capsaicin cream (Zostrix).

B Dark-colored stools may indicate the patient is experiencing gastrointestinal bleeding caused by the naproxen. The patient's ongoing pain and weight gain will also be reported and may indicate a need for a different treatment and/or counseling about avoiding weight gain, but these are not as large a concern as the possibility of gastrointestinal bleeding. Use of capsaicin cream with oral medications is appropriate.

A young adult arrives in the emergency department with ankle swelling and severe pain after twisting an ankle playing basketball. Which of these prescribed interprofessional interventions will the nurse implement first? a. Send the patient for ankle x-rays. b. Wrap the ankle and apply an ice pack. c. Administer naproxen (Naprosyn) 500 mg PO. d. Give acetaminophen with codeine (Tylenol #3).

B Immediate care after a sprain or strain injury includes application of cold and use of compression to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.

Which finding will the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee? a. Presence of Heberden's nodules b. Discomfort with joint movement c. Redness and swelling of the knee joint d. Stiffness that increases with movement

B Initial symptoms of OA include pain with joint movement. Heberden's nodules occur on the fingers. Redness of the joint is associated with inflammatory arthritis such as rheumatoid arthritis. Stiffness in OA is worse right after the patient rests and decreases with joint movement.

A 29-yr-old woman is taking methotrexate to treat rheumatoid arthritis. Which information from the patient's health history is important for the nurse to report to the health care provider related to the methotrexate? a. The patient had a history of infectious mononucleosis as a teenager. b. The patient is trying to get pregnant before her disease becomes more severe. c. The patient has a family history of age-related macular degeneration of the retina. d. The patient has been using large doses of vitamins and health foods to treat the RA.

B Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy.

After the nurse has finished teaching a patient with osteoarthritis (OA) of the right hip about how to manage the OA, which patient statement indicates a need for more teaching? a. "I can exercise every day to help maintain joint motion." b. "I will take 1 g of acetaminophen (Tylenol) every 4 hours." c. "I will take a shower in the morning to help relieve stiffness." d. "I can use a cane to decrease the pressure and pain in my hip."

B No more than 4 g of acetaminophen (1 g every 6 hours) should be taken daily to decrease the risk for liver damage. Regular exercise, moist heat, and supportive equipment are recommended for OA management.

A patient who is to have no weight bearing on the left leg is learning to walk using crutches. Which observation by the nurse indicates the patient can safely ambulate independently? a. The patient moves the right crutch with the right leg and then the left crutch with the left leg. b. The patient advances the left leg and both crutches together and then advances the right leg. c. The patient uses the bedside chair to assist in balance as needed when ambulating in the room. d. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.

B Patients are usually taught to move the crutches and the injured leg forward at the same time and then to move the unaffected leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid brachial plexus damage. If the 2- or 4-point gaits are to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg.

A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing assessment finding indicates a potential complication of the fracture? a. The patient states the pelvis feels unstable. b. Abdomen is distended and bowel sounds are absent. c. The patient complains of pelvic pain with palpation. d. Ecchymoses are visible across the abdomen and hips.

B The abdominal distention and absent bowel sounds may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal bruising would be expected with this type of injury.

A patient with two school-age children has recently been diagnosed with rheumatoid arthritis (RA) and tells the nurse that home life is very stressful. Which initial response by the nurse is most appropriate? a. "You need to see a family therapist for some help with stress." b. "Tell me more about the situations that are causing you stress." c. "Your family should understand the impact of your rheumatoid arthritis." d. "Perhaps it would be helpful for your family to be involved in a support group."

B The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment.

The nurse's discharge teaching for a patient who has had a repair of a fractured mandible will include information about a. administration of nasogastric tube feedings. b. how and when to cut the immobilizing wires. c. the importance of high-fiber foods in the diet. d. the use of sterile technique for dressing changes.

B The jaw will be wired for stabilization, and the patient should know what emergency situations require the wires to be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high-fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge, the patient will swallow liquid through a straw.

After being hospitalized for 3 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? a. Stay with the patient and offer reassurance. b. Administer prescribed PRN O2 at 4 L/min. c. Check the patient's legs for swelling or tenderness. d. Notify the health care provider about the symptoms.

B The patient's clinical manifestations and history are consistent with a pulmonary embolism, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for O2 is a higher priority. The health care provider should be notified after the O2 is started and pulse oximetry obtained concerning suspected fat embolism or venous thromboembolism.

When caring for a patient who is using Buck's traction after a hip fracture, which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Remove and reapply traction periodically. b. Ensure the weight for the traction is hanging freely. c. Monitor the skin under the traction boot for redness. d. Check for intact sensation and movement in the affected leg.

B UAP can be responsible for maintaining the integrity of the traction after it has been established. The RN should assess the extremity and assure manual traction is maintained if the traction device has to be removed and reapplied. Assessment of skin integrity and circulation should be done by the registered nurse (RN).

A patient has a long-arm plaster cast applied for fracture immobilization. Until the cast has completely dried, the nurse should a. keep the left arm in dependent position. b. avoid handling the cast using fingertips. c. place gauze around the cast edge to pad any roughness. d. cover the cast with a small blanket to absorb the dampness.

B Until a plaster cast has dried, using the palms rather than the fingertips to handle the cast helps prevent creating protrusions inside the cast that could place pressure on the skin. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying.

Anakinra (Kineret) is prescribed for a patient with rheumatoid arthritis (RA). When teaching the patient about this drug, the nurse will include information about a. avoiding concurrent aspirin use. b. symptoms of gastrointestinal (GI) bleeding. c. self-administration of subcutaneous injections. d. taking the medication with at least 8 oz of fluid.

C Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this medication. Because the medication is injected, instructions to take it with 8 oz of fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDs), and these should not be discontinued.

Based on the information in the accompanying figure obtained for a patient in the emergency room, which action will the nurse take first? History · Age 23 years · Right lower leg injury Physical Assessment · Reports severe right lower leg pain · Reports feeling short of breath · Bone protruding from right lower leg Diagnostic Exam · CBC: WBC 9400/μL; Hgb 11.6 g/dL · Right leg x-ray; right tibial fracture a. Administer the prescribed morphine 4 mg IV. b. Contact the operating room to schedule surgery. c. Check the patient's O2 saturation using pulse oximetry. d. Ask the patient about the date of the last tetanus immunization.

C Because fat embolism can occur with tibial fracture, the nurse's first action should be to check the patient's O2 saturation. The other actions are also appropriate but not as important at this time as obtaining the patient's O2 saturation.

Which laboratory result is important to communicate to the health care provider for a patient who is taking methotrexate to treat rheumatoid arthritis (RA)? a. Rheumatoid factor is positive. b. Fasting blood glucose is 90 mg/dL. c. The white blood cell (WBC) count is 1500/μL. d. The erythrocyte sedimentation rate is elevated.

C Bone marrow suppression is a possible side effect of methotrexate, and the patient's low WBC count places the patient at high risk for infection. The elevated erythrocyte sedimentation rate and positive rheumatoid factor are expected in RA. The blood glucose is normal.

Which information will the nurse teach seniors at a community recreation center about ways to prevent fractures? a. Tack down scatter rugs in the home. b. Expect most falls to happen outside the home. c. Buy shoes that provide good support and are comfortable to wear. d. Get instruction in range-of-motion exercises from a physical therapist.

C Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range of motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries.

Which statement by the patient indicates a good understanding of the nurse's teaching about a new short-arm synthetic cast? a. "I can get the cast wet as long as I dry it right away with a hair dryer." b. "I should avoid moving my fingers and elbow until the cast is removed." c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." d. "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast."

C Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.

When giving home care instructions to a patient who has comminuted left forearm fractures and a long-arm cast, which information should the nurse include? a. Keep the left shoulder elevated on a pillow or cushion. b. Avoid nonsteroidal antiinflammatory drugs (NSAIDs). c. Call the health care provider for numbness of the hand. d. Keep the hand immobile to prevent soft tissue swelling.

C Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat mild to moderate pain after a fracture.

Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce the risk for osteoarthritis (OA)? a. A 56-yr-old man who has a sedentary office job b. A 38-yr-old man who plays on a summer softball team c. A 56-yr-old woman who works on an automotive assembly line d. A 38-yr-old woman who is newly diagnosed with diabetes mellitus

C OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces the risk for OA. Diabetes is not a risk factor for OA. Sedentary work is not a risk factor for OA.

When a patient arrives in the emergency department with a facial fracture, which action will the nurse take first? a. Assess for nasal bleeding and pain. b. Apply ice to the face to reduce swelling. c. Use a cervical collar to stabilize the spine. d. Check the patient's alertness and orientation.

C Patients who have facial fractures are at risk for cervical spine injury, and should be treated as if they have a cervical spine injury until this is ruled out. The other actions are also necessary, but the most important action is to prevent cervical spine injury.

A patient is admitted to the emergency department with a left femur fracture. Which information obtained by the nurse is most important to report to the health care provider? a. Ecchymosis of the left thigh b. Complaints of severe thigh pain c. Slow capillary refill of the left foot d. Outward pointing toes on the left foot

C Prolonged capillary refill may indicate complications such as compartment syndrome. The other findings are typical with a left femur fracture.

A patient who slipped and fell in the shower at home has a proximal left humerus fracture immobilized with a long-arm cast and a sling. Which nursing intervention will be included in the plan of care? a. Use surgical net dressing to hang the arm from an IV pole. b. Immobilize the fingers of the left hand with gauze dressings. c. Assess the left axilla and change absorbent dressings as needed. d. Assist the patient in passive range of motion (ROM) for the right arm.

C The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side.

A high school teacher with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for arthroplasty of several joints in the left hand. Which patient statement to the nurse indicates a realistic expectation for the surgery? a. "This procedure will correct the deformities in my fingers." b. "I will not have to do as many hand exercises after the surgery." c. "I will be able to use my fingers with more flexibility to grasp things." d. "My fingers will appear more normal in size and shape after this surgery."

C The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Hand exercises will be prescribed after the surgery.

A patient with rheumatoid arthritis (RA) complains to the clinic nurse about having chronically dry eyes. Which action by the nurse is appropriate? a. Ask the HCP about discontinuing methotrexate b. Remind the patient that RA is a chronic health condition. c. Suggest the patient use over-the-counter (OTC) artificial tears. d. Teach the patient about adverse effects of the RA medications.

C The patient's dry eyes are consistent with Sjögren's syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes are not a side effect of methotrexate. A focus on the prognosis for RA is not helpful. The dry eyes are not caused by RA treatment but by the disease itself.

In which order will the nurse take these actions when caring for a patient in the emergency department with a right leg fracture after a motor vehicle crash? (Put a comma and a space between each answer choice [A, B, C, D, E, F].) a. Obtain x-rays. b. Check pedal pulses. c. Assess lung sounds. d. Take blood pressure. e. Apply splint to the leg. f. Administer tetanus prophylaxis.

C, D, B, E, A, F c. Assess lung sounds. d. Take blood pressure. b. Check pedal pulses. e. Apply splint to the leg. a. Obtain x-rays. f. Administer tetanus prophylaxis. The initial actions should be to ensure adequate airway, breathing, and circulation. This should be followed by checking the neurovascular condition of the leg (before and after splint application). Application of a splint to immobilize the leg should be done before sending the patient for x-ray examination. The tetanus prophylaxis is the least urgent of the actions.

Which finding in a patient with a Colles' fracture of the left wrist is most important to communicate immediately to the health care provider? a. Swelling is noted around the wrist. b. The patient is reporting severe pain. c. The wrist has a deformed appearance. d. Capillary refill to the fingers is prolonged.

D Swelling, pain, and deformity are common findings with a Colles' fracture. Prolonged capillary refill indicates decreased circulation and risk for ischemia. This is not an expected finding and should be immediately reported.

The home health nurse is making a follow-up visit to a patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates more patient teaching is needed? a. The patient takes a 2-hour nap each day. b. The patient has been taking 16 aspirins each day. c. The patient sits on a stool while preparing meals. d. The patient sleeps with two pillows under the head.

D The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping. Rest, aspirin, and energy management are appropriate for a patient with RA and indicate teaching has been effective.

Which information will the nurse include when teaching a patient with acute low back pain (select all that apply)? Keep in a prone position with the legs extended. Keep the knees straight when leaning forward to pick something up. Expect symptoms of acute low back pain to improve in a few weeks. Avoid activities that require twisting of the back or prolonged sitting. Use ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) to relieve pain.

Expect symptoms of acute low back pain to improve in a few weeks. Avoid activities that require twisting of the back or prolonged sitting. Use ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) to relieve pain.

Which information should the nurse include when teaching a patient with acute low back pain? (Select all that apply.) Sleep in a prone position with the legs extended. Keep the knees straight when leaning forward to pick something up. Expect symptoms of acute low back pain to improve in a few weeks. Avoid activities that require twisting of the back or prolonged sitting. Use ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) to relieve pain.

Expect symptoms of acute low back pain to improve in a few weeks. Avoid activities that require twisting of the back or prolonged sitting. Use ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) to relieve pain.

What should the nurse include in the teaching plan for ae patient who has acute low back pain and muscle spasms? Keep both feet flat on the floor when prolonged standing is required. Twist gently from side to side to maintain range of motion in the spine. Keep the head elevated slightly and flex the knees when resting in bed. Avoid the use of cold packs because they will exacerbate the muscle spasms

Keep the head elevated slightly and flex the knees when resting in bed.

The nurse assesses a 78-yr-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management. Which information requires a discussion with the health care provider about an urgent change in the treatment plan? Knee crepitation is noted with normal knee range of motion. Patient reports embarrassment about having Heberden's nodes. Patient's knee pain while golfing has increased over the last year. Laboratory results indicate blood urea nitrogen (BUN) is elevated.

Laboratory results indicate blood urea nitrogen (BUN) is elevated.

Which menu choice by a patient with osteoporosis indicates the nurse's teaching about appropriate diet has been effective? Pancakes with syrup and bacon Whole wheat toast and fresh fruit Egg-white omelet and a half grapefruit Oatmeal with skim milk and fruit yogurt

Oatmeal with skim milk and fruit yogurt

A patient who is to have no weight bearing on the left leg is learning to use crutches. Which observation by the nurse indicates the patient can safely ambulate independently? The patient moves the right crutch with the right leg and then the left crutch with the left leg. The patient advances the left leg and both crutches together and then advances the right leg. The patient uses the bedside chair to assist in balance as needed when ambulating in the room. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.

The patient advances the left leg and both crutches together and then advances the right leg.

The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with a brief routine of isometric exercises. a warm bath followed by a short rest. active range-of-motion (ROM) exercises. stretching exercises to relieve joint stiffness

a warm bath followed by a short rest. Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased.

Which of the following should be included in the teaching plan for a client with osteoporosis? Select all that apply. a) Choose good calcium sources, such as figs, broccoli, and almonds. b) Use of assistive devices like canes or walkers c) Reduce smoking to a couple of cigarettes a day d) Try swimming as a good exercise to maintain bone mass. e) Maintain a diet with adequate amounts of vitamin D C

a) Choose good calcium sources, such as figs, broccoli, and almonds. b) Use of assistive devices like canes or walkers

A client suffers a broken leg as a result of a car accident and is taken to the emergency department. A plaster cast is applied. Before discharge, the nurse provides the client with instructions regarding cast care. Which instructions are appropriate? Select all that apply. a) Exercise joints above and below cast b) Apply powder to the inside of the cast after it dries. c) Notify the physician if itching occurs under the cast. d) Avoid putting straws or hangers inside the cast. e) Place ice over fracture site for first 24 hours

a) Exercise joints above and below cast d) Avoid putting straws or hangers inside the cast. e) Place ice over fracture site for first 24 hours

The x-ray shows that the patient's fracture is at the remodeling stage. What characteristics of the fracture healing process are happening at this stage (select all that apply)? a. Radiologic union b. Absorption of excess bone cells c. Return to preinjury strength and shape d. Semisolid blood clot at the ends of fragments e. Deposition and absorption of bone in response to stress f. Unorganized network of bone woven around fracture parts

a, b, c, e. When the remodeling stage of healing occurs, radiologic union is present. Excess bone tissue is resorbed in the final stage of healing and union is complete. The bone gradually returns to its preinjury structure strength and shape. The osteoblasts and osteoclasts function normally in response to physical loading stress. The fracture hematoma stage is when the hematoma at the ends of the fragments becomes a semisolid blood clot. There is an unorganized network of bone composed of cartilage, osteoblasts, calcium, and phosphorus woven around fracture parts in the callus formation stage.

A patient with a fractured femur experiences the complication of malunion. The nurse recognizes that what happens with this complication? a. The fracture heals in an unsatisfactory position. b. The fracture fails to heal properly despite treatment. c. Fracture healing progresses more slowly than expected. d. Loss of bone substances occurs as a result of immobilization.

a. A malunion occurs when the bone heals in the expected time but in an unsatisfactory position, possibly resulting in deformity or dysfunction. Nonunion occurs when the fracture fails to heal properly despite treatment. Delayed union is healing of the fracture at a slower rate than expected. In posttraumatic osteoporosis, the loss of bone substances occurs as a result of immobilization.

A patient with a fractured right hip has an anterior ORIF of the fracture. What should the nurse plan to do postoperatively? a. Get the patient up to the chair on the first postoperative day. b. Ambulate the patient with partial weight bearing by discharge. c. Keep the leg abductor pillow on the patient even when bathing. d. Position the patient only on the back and the nonoperative side.

a. Because the fracture site is internally fixed with pins or plates, the fracture site is stable and the patient is moved from the bed to the chair on the first postoperative day. Ambulation begins on the first or second postoperative day without weight bearing on the affected leg. Weight bearing on the affected extremity is usually restricted for 6 to 12 weeks until adequate healing is evident on x-ray. Abductor pillows are used for patients who have total hip replacements. The patient may be positioned on the operative side following internal fixation as prescribed by the HCP.

A patient taking ibuprofen for treatment of OA has good pain relief but is experiencing increased dyspepsia and nausea with the drug's use. The nurse consults the patient's HCP about doing what? a. Adding misoprostol to the patient's drug regimen b. Substituting naproxen (Naprosyn) for the ibuprofen c. Returning to the use of acetaminophen but at a dose of 5 g/day instead of 4 g/day d. Administering the ibuprofen with antacids to decrease the gastrointestinal (GI) irritation

a. Common side effects of nonsteroidal antiinflammatory drugs (NSAIDs) include gastrointestinal (GI) irritation and bleeding, dizziness, rash, headache, and tinnitus. Misoprostol is used to prevent NSAID-induced gastric ulcers and gastritis and would increase the patient's tolerance of any of the NSAIDs. The use of naproxen could cause the same gastric effects as ibuprofen. It is generally recommended that the daily dose of acetaminophen should not exceed 3 g/day to prevent liver damage. Antacids interfere with the absorption of NSAIDs.

When is a fat embolism most likely to occur? a. 24 to 48 hours following a fractured tibia b. 36 to 72 hours following a skull fracture c. 4 to 5 days following a fractured femur d. 5 to 6 days following a pelvic fracture

a. Initial manifestations of fat embolism usually occur 24 to 48 hours after injury and are associated with fractures of long bones and multiple fractures related to pelvic injuries, including fractures of the femur, tibia, ribs, and pelvis. Venous thromboemboli (VTE) tend to form later after injury of the extremities and pelvis.

Which description is most characteristic of osteoarthritis (OA) when compared to rheumatoid arthritis (RA)? a. Not systemic or symmetric b. Rheumatoid factor (RF) positive c. Most commonly occurs in women d. Morning joint stiffness lasts 1 to several hours

a. OA is not systemic or symmetric. In OA, morning joint stiffness resolves in about 30 minutes. Rheumatoid arthritis (RA) is rheumatoid factor (RF) positive, occurs more in women than men, and is characterized by being systemic and affecting small joints symmetrically. In RA, morning joint stiffness lasts 60 minutes to all day.

What is a disadvantage of open reduction and internal fixation (ORIF) of a fracture compared to closed reduction? a. Infection b. Skin irritation c. Nerve impairment d. Complications of immobility

a. Open reduction uses a surgical incision to correct bone alignment with infection as the main disadvantage, as well as anesthesia complications or the effect of preexisting medical conditions. Skin irritation and nerve impairment is most likely with skin traction. Prolonged immobility is possible with skeletal traction.

If needed, which surgical treatment will the nurse first prepare the patient for in the presence of compartment syndrome? a. Fasciotomy b. Amputation c. Internal fixation d. Release of tendons

a. Soft tissue edema in the area of the injury may cause an increase of pressure within the closed spaces of the tissue compartments formed by the nonelastic fascia, creating compartment syndrome. If symptoms occur, it may be necessary to incise the fascia surgically, a procedure known as a fasciotomy. Amputation is usually necessary only if the limb becomes septic because of untreated compartment syndrome.

A patient with OA asks the nurse whether he could try glucosamine and chondroitin for control of his symptoms. The best response by the nurse includes what information? a. Some patients find these supplements helpful for relieving arthritis pain and improving mobility. b. Although these substances may not help, there is no evidence that they can cause any untoward effects. c. These supplements are a fad that has not been shown to reduce pain or increase joint mobility in patients with OA. d. Only dosages of these supplements available by prescription are high enough to provide any benefit in treatment of OA.

a. Some obtain relief for moderate to severe osteoarthritic pain but not for all patients using over- the-counter glucosamine and chondroitin sulfate. These substances should be discontinued if there are no effects after consistent use over 90 to 120 days. They may decrease the effectiveness of antidiabetic drugs and increase the risk of bleeding.

The nurse teaches the patient with an above-the-knee amputation that the residual limb should not be routinely elevated because this position promotes a. hip flexion contracture. b. clot formation at the incision. c. skin irritation and breakdown. d. increased risk for wound dehiscence.

a. hip flexion contracture.

After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis? a) Infection b) Fat embolism c) Volkmann's ischemic contracture d) Compartment syndrome

b) Fat embolism

A patient is discharged from the outpatient clinic following application of a synthetic fiberglass long arm cast for a fractured ulna. Before discharge, the nurse instructs the patient to do what? a. Never get the cast wet. b. Move the shoulder and fingers frequently. c. Place tape petals around the edges of the cast when it is dry. d. Use a sling to support the arm at waist level for the first 48 hours.

b. A patient with any type of cast should exercise the joints above and below the cast frequently and moving the fingers frequently will improve circulation and help to prevent edema. Unlike plaster casts, thermoplastic resin or fiberglass casts are relatively waterproof and, if they become wet, can be dried with a hair dryer on low setting. Tape petals are used on plaster casts to protect the edges from breaking and crumbling but are not necessary for synthetic casts. After the cast is applied, the extremity should be elevated at about the level of the heart to promote venous return and ice may be used to prevent edema.

Which laboratory result will the nurse monitor to determine if prednisone has been effective for a patient with an acute exacerbation of rheumatoid arthritis? a. Blood glucose b. C-reactive protein c. Serum electrolytes d. Liver function tests

b. C-reactive protein C-reactive protein is a serum marker for inflammation, and a decrease would indicate the corticosteroid therapy was effective. Blood glucose and serum electrolytes will also be monitored to assess for side effects of prednisone. Liver function is not routinely monitored in patients receiving corticosteroids.

The patient has had RA for some time but has not had success with previous medications. Although there is an increased risk for tuberculosis, which tumor necrosis factor (TNF) inhibitor is used with methotrexate to best treat symptoms? a. Parenteral gold b. Certolizumab (Cimzia) c. Tocilizumab (Actemra) d. Hydroxychloroquine (Plaquenil)

b. Certolizumab is a monoclonal antibody that is a TNF inhibitor and stays in the system longer and may show a more rapid reduction in RA symptoms. Parenteral gold alters immune responses that may suppress synovitis of active RA, but it takes 3 to 6 months to be effective. Tocilizumab blocks the action of the proinflammatory cytokine interleukin-6 (IL-6). Hydroxychloroquine is slow-acting antimalaria drug used initially for mild RA and requires periodic eye examinations to assess for retinal damage.

A patient is brought to the emergency department (ED) with an injured lower left leg following a fall while rock climbing. The nurse identifies the presence of a fracture based on what cardinal sign of fracture? a. Muscle spasms b. Obvious deformity c. Edema and swelling d. Pain and tenderness

b. Deformity is the cardinal sign of fracture but may not be apparent in all fractures. Other supporting signs include edema and swelling, localized pain and tenderness, muscle spasm, ecchymosis, loss of function, crepitation, and an inability to bear weight.

Which drug that prevents binding of the tumor necrosis factor and inhibits the inflammatory response is used in the management of RA? a. Anakinra (Kineret) b. Entanercept (Enbrel) c. Leflunomide (Arava) d. Azathioprine (Imuran)

b. Etanercept binds to tumor necrosis factor (TNF) and blocks its interaction with the TNF cell surface receptors, which decreases the inflammatory response. Anakinra is an interleukin-1 receptor antagonist, thus decreasing the inflammatory response. Leflunomide is an antiinflammatory that blocks immune cell overproduction. Azathioprine is an uncommonly used immunosuppressant that inhibits DNA, RNA, and protein synthesis.

After teaching a patient with RA about the prescribed therapeutic regimen, the nurse determines that further instruction is needed when the patient says what? a. "It is important for me to perform my prescribed exercises every day." b. "I should perform most of my daily chores in the morning when my energy level is highest." c. "An ice pack to a joint for 10 minutes may help to relieve pain and inflammation when I have an acute flare." d. "I can use assistive devices such as padded utensils, electric can openers, and elevated toilet seats to protect my joints."

b. Most patients with RA experience morning stiffness, and morning activities should be scheduled later in the day after the stiffness subsides. A warm shower in the morning and time to become more mobile before activity are advised. Ice for 10 minutes or splinting are helpful during increased disease activity. Management of RA includes daily exercises for the affected joints and protection of joints with devices and movements that prevent joint stress.

A patient recovering from an acute exacerbation of RA tells the nurse that she is too tired to bathe. What should the nurse do for this patient? a. Give the patient a bed bath to conserve her energy. b. Allow the patient a rest period before showering with the nurse's help. c. Tell the patient that she can skip bathing if she will walk in the hall later. d. Inform the patient that it is important for her to maintain self-care activities.

b. Pacing activities and alternating rest with activity are important in maintaining self-care and independence of the patient with RA, in addition to preventing deconditioning and a negative attitude. The nurse should not carry out activities for patients that they can do for themselves but instead should support and assist patients as necessary. A warm shower or sitting in a tub with warm water and towels over the shoulders may help to relieve some stiffness.

To preserve function and the ability to perform activities of daily living (ADLs), what should the nurse teach the patient with OA? a. Avoid exercise that involves the affected joints. b. Plan and organize task performance to be less stressful to joints. c. Maintain normal activities during an acute episode to prevent loss of function. d. Use mild analgesics to control symptoms when performing tasks that cause pain.

b. Principles of joint protection and energy conservation are critical in being able to maintain functional mobility in the patient with OA, and patients should be helped to find ways to perform activities and tasks with less stress. Range-of-motion (ROM), isotonic, and isometric exercises of the affected joints should be balanced with joint rest and protection but during an acute flare of joint inflammation, the joints should be rested. If a joint is painful, it should be used only to the point of pain and masking the pain with analgesics may lead to greater joint injury.

Which other extraarticular manifestation of RA is most likely to be seen in the patient with rheumatoid nodules? a. Lyme disease b. Felty syndrome c. Sjögren's syndrome d. Spondyloarthropathies

b. Rheumatoid nodules develop in about half of patients with RA. Felty syndrome is most common in patients with long-standing RA. It is characterized by splenomegaly and leukopenia. Sjögren's syndrome occurs as a disease by itself or with other arthritic disorders. Lyme disease is a spirochetal infection transmitted by an infected deer tick bite. Spondyloarthropathies are interrelated multisystem inflammatory disorders that affect the spine, peripheral joints, and periarticular structures but they do not have serum antibodies.

A patient is admitted with an open fracture of the tibia following a bicycle accident. During assessment of the patient, about what specifically should the nurse question the patient? a. Any previous injuries to the leg b. The status of tetanus immunization c. The use of antibiotics in the last month d. Whether the injury was exposed to dirt or gravel

b. Tetanus prevention is always indicated if the patient has not been immunized or does not have current boosters. Infection is the greatest risk with an open fracture, and all open fractures are considered contaminated. Prophylactic antibiotics are often used in management of open fractures, but recent antibiotic therapy is not relevant, nor is previous injury to the site. Dirt or gravel contamination will be evident on physical assessment.

A patient with osteoarthritis is scheduled for total hip arthroplasty. The nurse explains the purpose of this procedure is to (select all that apply) a. fuse the joint. b. replace the joint. c. prevent further damage. d. improve or maintain ROM. e. decrease the amount of destruction in the joint.

b. replace the joint. d. improve or maintain ROM.

Which of the following nursing measures is most useful in preventing the development of osteoporosis in a client who is immobilized? a) Increasing the client's calcium intake in the diet. b) Teaching the client to perform isometric exercises. c) Beginning weight-bearing activities as soon as possible. d) Performing passive range-of-motion (ROM) exercises four times a day.

c) Beginning weight-bearing activities as soon as possible.

The nurse should closely monitor the client with an open fracture for which of the following complications? a) Avascular necrosis. b) Fat embolism syndrome. c) Infection d) Compartment syndrome

c) Infection

The nurse is caring for a client with a fracture of a long bone. Which of the following assessments would be the earliest symptom of a fat embolism? a) Fever. b) Petechiae. z) Respiratory distress. d) Confusion.

c) Respiratory distress.

The woman with osteoporosis slipped on the ice and now her wrist hurts. If there is a fracture, what type of fracture is expected? a. Dislocation b. Open fracture c. Colles' fracture d. Incomplete fracture

c. A Colles' fracture most often occurs in patients over 50 years of age with osteoporosis and frequently when the patient attempts to break a fall with an outstretched arm and hand. Dislocation is the complete separation of articular surfaces of the joint caused by a ligament injury. Open fracture is when there is communication with the external environment. A fracture is incomplete if only part of the bone shaft is fractured and the bone is still in one piece.

A patient with an extracapsular hip fracture is admitted to the orthopedic unit and placed in Buck's traction. The nurse explains to the patient that the purpose of the traction is to do what? a. Pull bone fragments back into alignment b. Immobilize the leg until healing is complete c. Reduce pain and muscle spasms before surgery d. Prevent damage to the blood vessels at the fracture site

c. Although surgical repair is the preferred method of managing intracapsular and extracapsular hip fractures, initially patients frequently may be treated with skin traction, such as Buck's traction, to immobilize the limb temporarily and to relieve the painful muscle spasms before surgery is performed. Prolonged traction would be required to reduce the fracture or immobilize it for healing, creating a very high risk for complications of immobility.

A 70-yr-old patient is being evaluated for symptoms of RA. The nurse recognizes what as the major problem in the management of RA in the older adult? a. RA is usually more severe in older adults. b. Older patients are not as likely to comply with treatment regimens. c. Drug interactions and toxicity are more likely to occur with multidrug therapy. d. Laboratory and other diagnostic tests are not effective in identifying RA in older adults.

c. Because older adults are more likely to take many drugs, the use of multidrug therapy in RA is particularly problematic because of the increased likelihood of adverse drug interactions and toxicity. Rheumatic disorders affect younger and older adults. Older adults are not less compliant with drug regimens but may need help with complex regimens. Interpretation of laboratory values in older adults is more difficult in diagnosing RA because of age-related serologic changes, but the disease can be diagnosed.

The nurse will anticipate the need to teach a patient who has osteoarthritis (OA) about which medication? a. Prednisone ) b. Adalimumab (Humira) c. Capsaicin cream (Zostrix d. Sulfasalazine (Azulfidine)

c. Capsaicin cream (Zostrix C Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with rheumatoid arthritis.

The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first? a. Take the blood pressure. saturation. b. Assess patient orientation. c. Check the O2 d. Observe for facial asymmetry.

c. Check the O2 The patient's history and clinical manifestations suggest a fat embolism. The most important assessment is oxygenation. The other actions are also appropriate but will be done after the nurse assesses O2 saturation.

During the physical assessment of the patient with early to moderate RA, what should the nurse expect to find? a. Hepatomegaly b. Heberden's nodes c. Spindle-shaped fingers d. Crepitus on joint movement

c. In early disease, the fingers of the patient with moderate RA may become spindle shaped from synovial hypertrophy and thickening of the joint capsule, have no joint deformities but may have limited joint mobility, have adjacent muscle atrophy, and may be inflamed. Splenomegaly may be found with Felty syndrome in patients with severe nodule-forming RA. Heberden's nodes and crepitus on movement are associated with osteoarthritis.

A patient with a fractured tibia accompanied by extensive soft tissue damage initially has a splint applied and held in place with an elastic bandage. What early sign should alert the nurse that the patient is developing compartment syndrome? a. Paralysis of the toes b. Absence of peripheral pulses c. Distal pain unrelieved by opioid analgesics d. Skin over the injury site is blanched when the bandage is removed

c. Pain that is distal to the injury and is unrelieved by opioid analgesics is the earliest sign of compartment syndrome; paresthesia is also an early sign. Paralysis and absence of peripheral pulses will eventually occur if it is not treated but these are late signs that often appear after permanent damage has occurred. The overlying skin may appear normal because the surface vessels are not occluded.

25. The nurse suspects a fat embolism rather than a pulmonary embolism from a venous thrombosis when the patient with a fracture develops what? a. Tachycardia and dyspnea b. A sudden onset of chest pain c. Petechiae around the neck and upper chest d. Electrocardiographic (ECG) changes and decreased PaO2

c. Patients with fractures are at risk for both fat embolism and pulmonary embolism from VTE, but there is a difference in the time of occurrence, with fat embolism occurring shortly after the injury and thrombotic embolism occurring several days after immobilization. They both may cause pulmonary symptoms of chest pain, tachypnea, dyspnea, apprehension, tachycardia, and cyanosis. However, fat embolism may cause petechiae located around the neck, anterior chest wall, axilla, buccal membrane of the mouth, and conjunctiva of the eye, which differentiates it from thrombotic embolism.

The nurse teaches the patient with RA that which exercise is one of the most effective methods of aerobic exercise? a. Ballet dancing b. Casual walking c. Aquatic exercises d. Low-impact aerobic exercises

c. The best aerobic exercise is aquatic exercises in warm water to allow easier joint movement because of the buoyancy of the water. Water produces more resistance and can strengthen the muscles. Tai Chi is also a good form of gentle, stretching exercise that would be appropriate. Dancing and walking impact the joints of the feet and even low-impact aerobics could be damaging. Exercises for patients with RA should be gentle.

Which type of fracture can occur when there is radial nerve and brachial artery damage and the fracture is reduced with a hanging arm cast? a. Fractured tibia b. Colles' fracture c. Fractured humerus d. Femoral shaft fracture

c. The fractured humerus may cause radial nerve and brachial artery damage, and it may be reduced nonsurgically with a hanging arm cast. A fractured tibia and femur are in the leg. The Colles' fracture is in the wrist and manifests with pronounced swelling and obvious deformity of the wrist; it is treated with closed manipulation and immobilization.

A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. The initial action by the nurse should be to a. elevate the right leg. b. splint the lower leg. c. assess the pedal pulses. d. verify tetanus immunization.

c. assess the pedal pulses. The initial nursing action should be assessment of the neurovascular condition of the injured leg. After assessment, the nurse may need to splint and elevate the leg based on the assessment data. Information about tetanus immunizations should be obtained if there is an open wound.

A patient with a comminuted fracture of the tibia is to have an open reduction with internal fixation (ORIF) of the fracture. The nurse explains that ORIF is indicated when a. the patient is unable to tolerate prolonged immobilization. b. the patient cannot tolerate the surgery for a closed reduction. c. other nonsurgical methods cannot achieve adequate alignment. d. a temporary cast would be too unstable to provide normal mobility.

c. other nonsurgical methods cannot achieve adequate alignment.

Which assessment finding for a patient who has had surgical reduction of an open fracture of the right radius requires notification of the health care provider? report the patient's complaint to the surgeon. check the chart for preoperative assessment data. check the vital signs for indications of hemorrhage. turn the patient to the left to relieve pressure on the right leg.

check the chart for preoperative assessment data.

A child is admitted with a fracture of the femur and placed in skeletal traction. What should the nurse assess? a) The dressings for tightness. b) The pull of traction on the pin. c) The compression bandage. d) The pin sites for signs of infection.

d) The pin sites for signs of infection.

A 72-yr-old man tells the nurse that he cannot perform most of the physical activities he could do 5 years ago because of overall joint aches and pains. What can the nurse do to assist the patient to prevent further deconditioning and decrease the risk for developing musculoskeletal problems? a. Limit weight-bearing exercise to prevent stress on fragile bones and possible hip fractures. b. Advise the patient to avoid the use of canes and walkers because they increase dependence on ambulation aids. c. Advise the patient to increase his activity by more frequently climbing stairs in buildings and other environments with steps. d. Discuss the use of stretching and warm up, as well as strengthening exercises to decrease aches and pain so that exercise can be maintained.

d. Almost all older adults have some degree of decreased muscle strength, joint stiffness, and pain with motion. Warming up before and stretching after exercise as well as strengthening exercises help to decrease aches and pains so that exercise can be maintained. Musculoskeletal problems in the older adult can be prevented with appropriate strategies, especially exercise. Walkers and canes should be used as necessary to decrease stress on joints so that activity can be maintained. Stair walking can create enough stress on fragile bones to cause a hip fracture and use of ramps may help to prevent falls. NSAIDs may also be prescribed.

A 60-yr-old woman has pain on motion in her fingers and asks the nurse whether this is just a result of aging. What information is the best response by the nurse? a. Joint pain with functional limitation is a normal change that affects all people to some extent. b. Joint pain that develops with age is usually related to previous trauma or infection of the joints. c. This is a symptom of a systemic arthritis that eventually affects all joints as the disease progresses. d. Changes in the cartilage and bones of joints may cause symptoms of pain and loss of function in some people as they age.

d. Cartilage destruction in the joints affects the majority of those affected by the age of 40 and when the destruction becomes symptomatic, osteoarthritis (OA) is said to be present. Degenerative changes cause symptoms after age 50 or 60 but more than half over age 65 have x- ray evidence of OA. Joint pain and functional disability should not be considered a normal finding in aging persons. OA is not a systemic disease but may be caused by a known event or condition that directly damages cartilage or causes joint instability (e.g., menopause, obesity).

After teaching a patient with RA to use heat and cold therapy to relieve symptoms, the nurse determines that teaching has been effective when what is said by the patient? a. "Heat treatments should not be used if muscle spasms are present." b. "Cold applications can be applied for 25 to 30 minutes to relieve joint stiffness." c. "I should use heat applications for 25 minutes to relieve the symptoms of an acute flare." d. "When my joints are painful, I can use a bag of frozen corn for 10 to 15 minutes to relieve the pain."

d. Cold therapy is indicated to relieve pain during an acute inflammation, can be applied with frozen packages of vegetables, and should last only 10 to 15 minutes at a time. Heat in the form of heating pads, moist warm packs, paraffin baths, or warm baths or showers is indicated to relieve stiffness and muscle spasm. Heat should not be applied for more than 20 minutes at a time.

A young patient with a fractured femur has a hip spica cast applied. While the cast is drying, what is most important for the nurse to do? a. Elevate the legs above the level of the heart for 24 hours. b. Turn the patient to both sides and prone to supine every 2 hours. c. Cover the cast with a light blanket to avoid chilling from evaporation. d. Assess the patient frequently for abdominal pain, nausea, and vomiting.

d. Complaints of abdominal pain or pressure, nausea, and vomiting are signs of cast syndrome that occur when hip spica casts or body jacket braces are applied too tightly, causing compression of the superior mesenteric artery against the duodenum. The cast may have to be split or removed, and the HCP should be notified. Elevation is not indicated for a spica cast, and the patient with a spica cast should not be placed in the prone position during the initial drying stage because the cast is so large and heavy it may break. A cast should never be covered with a blanket because heat builds up in the cast and may increase edema.

What best describes the manifestations of OA? a. Smaller joints are typically affected first. b. There is joint stiffness after periods of inactivity. c. Joint stiffness is accompanied by fatigue, anorexia, and weight loss. d. Pain and immobility may be aggravated by falling barometric pressure.

d. Pain and immobility of OA may be aggravated by falling barometric pressure. OA affects weight-bearing joints of knees and hips. Stiffness occurs on arising but usually subsides after 30 minutes. Pain during the day is relieved with rest. Fatigue, anorexia, and weight loss are nonspecific manifestations of the onset of RA.

A patient has fallen in the bathroom of the hospital room and reports pain in the upper right arm and elbow. Before splinting the injury, the nurse knows that the priority management of a possible fracture should include which action? a. Elevation of the arm b. Application of ice to the site c. Notification of the health care provider d. Neurovascular checks below the site of the injury

d. Sensation, motor function, and pain distal to the injury should be checked before and after splinting to assess for nerve damage and documented to avoid doubts about whether a problem discovered later was missed during the original examination or was caused by the treatment. Peripheral vascular assessment is also needed. Then the HCP is notified. Elevation of the limb and application of ice should be instituted after the extremity is splinted.

Laboratory findings that the nurse would expect to be present in the patient with RA include a. polycythemia. b. increased immunoglobulin G (IgG). c. decreased white blood cell (WBC) count. d. antibodies to citrullinated peptide (anti-CCP).

d. The antibody to citrullinated peptide (anti-CCP) is more specific than RF for RA and may allow for earlier and more accurate diagnosis. Other tests include C-reactive protein (CRP) that is elevated from inflammatory reactions of RA, a finding that is useful in monitoring the response to therapy. Anemia, rather than polycythemia, is common, and immunoglobulin G (IgG) levels are normal. The white blood cell (WBC) count may be increased in response to inflammation and is also elevated in synovial fluid.

What is most likely to cause the pain experienced in the later stages of OA? a. Crepitation b. Bouchard's nodes c. Heberden's nodes d. Bone surfaces rubbing together

d. The pain in later OA is caused by bone surfaces rubbing together after the articular cartilage has deteriorated. Crepitation occurs earlier in the disease with loose particles of cartilage in the joint cavity. Bouchard's nodes and Heberden's nodes are tender but occur as joint space decreases and as early as 40 years of age.