Hinkle Ch. 40- Musculoskeletal

The nurse is conducting a musculoskeletal assessment of a patient in a nursing home. The patient is unable to dorsiflex his right foot or extend his toes. The nurse evaluates this finding as an injury to which of the following nerves? a) Femoral b) Achilles c) Sciatic d) Peroneal

d) Peroneal Explanation: Injury to the peroneal nerve as a result of pressure may cause foot drop or the inability to dorsiflex the foot and extend the toes.

Which is a risk-lowering strategy for osteoporosis? a) Diet low in calcium and vitamin D b) Increased age c) Low initial bone mass d) Smoking cessation

d) Smoking cessation Explanation: Risk-lowering strategies include increased dietary calcium and vitamin D intake, smoking cessation, alcohol and caffeine consumption in moderation, and outdoor activity. Individual risk factors include low initial bone mass and increased age. A lifestyle risk factor is a diet low in calcium and vitamin D.

A patient is being discharged home with a long arm cast. What education should the nurse include to prevent disuse syndrome in the arm? a) Repositioning the arm in the cast b) Proper use of a sling c) Abduction and adduction of the shoulder d) Use of isometric exercises

d) Use of isometric exercises Explanation: Isometric exercises allow for use of the muscle without moving the bone. Doing isometric exercises every hour while the patient is awake will help prevent disuse syndrome. Proper use of a sling does not prevent disuse syndrome. The patient should not attempt to reposition the arm in the cast. Abduction and adduction of the shoulder will help the shoulder joint but does not require the use of muscles in the lower arm.

Which hormone inhibits bone reabsorption and increases calcium deposit in the bone? a) Calcitonin b) Growth hormone c) Sex hormones d) Vitamin D

a) Calcitonin Explanation: Calcitonin, secreted by the thyroid gland in response to elevated blood calcium levels, inhibits bone reabsorption and increases the deposit of calcium in the bone. The other answers do not apply.

Which of the following refers to a blunt force injury to soft tissue? a) Fracture b) Contusion c) Strain d) Dislocation

b) Contusion Explanation: A contusion is blunt force injury to the soft tissue. A dislocation is a separation of joint surfaces. A strain is a musculotendinous injury. A fracture is a break in the continuity of the bone.

Which nerve is assessed when the nurse asks the patient to spread all fingers? a) Median b) Peroneal c) Ulnar d) Radial

c) Ulnar Explanation: Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation, while pricking the fat pad at the top of the small finger allows assessment of the sensory function affected by the ulnar nerve. The peroneal nerve is assessed by asking the patient to dorsiflex the ankle and to extend the toes. The radial nerve is assessed by asking the patient to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. The median nerve is assessed by asking the patient to touch the thumb to the little finger.

Mr. Johnston is admitted to the orthopedic unit and is scheduled for emergency ORIF (open reduction with internal fixation) of the fractured neck of the femur. His medical history reveals hypertension, atrial fibrillation, and congestive heart failure (CHF). He has denied allergies. Home medications are metoprolol (Lopressor) 25 mg BID, digoxin (Lanoxin) 125 mcg daily, and furosemide (Lasix) 20 mg daily. He has taken all of his medications with breakfast this morning at 7 am. The IV infusion has been changed to D5NS with 20 mEq KCl, infusing at 80 mL/hour. He is positioned supine with Buck's extension traction with a 7-pound weight on his left leg. The head of bed is elevated to 30 degrees. A Foley catheter, inserted in the ED, is draining 35 mL per hour.

The nursing activities and nursing management needed for this patient prior to surgery are as follows: The nurse should check vital signs and pulse oximetry, lung and cardiac sounds, and do a pain assessment frequently. The nurse should also check basic lab work results such as hemoglobin and hematocrit, platelets, white blood cell count, glucose and electrolyte levels. It is important to check that a chest x-ray, ECG, and history and physical exam have been done pre-operatively. The consent must be signed and witnessed; this may need to be done by the wife if the patient has received pain medications. The nurse may need to consult hospital policies and procedures or the risk manager in this instance. The best case scenario is that the patient signs before the pre-operative medication or pain medication is administered. A check of allergy status should be repeated, along with the presence of advance directives, including code status, living will and healthcare power of attorney. These documents should be brought to the hospital and put on the patient's chart. The patient must be maintained on complete bed rest and NPO status. Circulation, movement, and sensation of both legs must be assessed at least every 2 hours, and a baseline established. IV antibiotics will be ordered and administered along with PRN pain medications. The nurse should begin patient teaching by asking the patient to return-demonstrate deep breathing, gluteal setting exercises, along with the use of incentive spirometry and trapeze equipment. Dentures and valuables must be removed and stored safely.

Which medication directly inhibits osteoclasts thereby reducing bone loss and increasing bone mass density (BMD)? a) Calcitonin (Miacalcin) b) Teriparatide (Forteo) c) Vitamin D d) Raloxifene (Evista)

a) Calcitonin (Miacalcin) Explanation: Miacalcin directly inhibits osteoclasts, thereby reducing bone loss and increased BMD. Evista reduces the risk of osteoporosis by preserving BMD without estrogenic effects on the uterus. Forteo has been recently approved by the FDA for the treatment of osteoporosis. Vitamin D increases the absorption of calcium.

Colles' fracture occurs in which of the following areas? a) Distal radius b) Clavicle c) Elbow d) Humeral shaft

a) Distal radius Explanation: A Colles' fracture is a fracture of the distal radius (wrist). It is usually the result of a fall on an open, dorsiflexed hand.

Pulselessness, a very late sign of compartment syndrome, may signify which of the following? a) Lack of distal tissue perfusion b) Nerve involvement c) Venous congestion d) Diminished arterial perfusion

a) Lack of distal tissue perfusion Explanation: Pulselessness is a very late sign that may signify lack of distal tissue perfusion. The other answers do not apply

The nurse reading a patient's chart notices that the patient is documented to have paresthesia. The nurse plans care for a patient with which of the following? a) Absence of muscle tone b) Abnormal sensations c) Involuntary twitch of muscle fibers d) Absence of muscle movement suggesting nerve damage

b) Abnormal sensations Explanation: Abnormal sensations, such as burning, tingling, and numbness, are referred to as paresthesias. The absence of muscle tone suggesting nerve damage is referred to as paralysis. A fasciculation is the involuntary twitch of muscle fibers. A muscle that holds no tone is termed flaccid.

The nurse is assessing the muscle tone of a patient with cerebral palsy. Which of the following descriptions does the nurse determine to be an expected assessment of this patient's muscle tone? a) Flaccid b) Hypertonic c) Atonic d) Atrophied

b) Hypertonic Explanation: In patients with conditions characterized by upper motor neuron destruction, such as in cerebral palsy, the muscles are often hypertonic. However, in conditions with lower motor neuron destruction, the muscles become atonic and/or atrophied and/or flaccid.

Which of the following describes an osteon? a) A bone resorption cell b) A bone-forming cell c) A microscopic functional bone unit d) A mature bone cell

c) A microscopic functional bone unit Explanation: The center of an osteon contains a capillary, a microscopic functional bone unit. An osteoblast is a bone-forming cell. An osteoclast is a bone resorption cell. An osteocyte is a mature bone cell.

When is it advisable for the nurse to apply heat to a sprain or a contusion? a) Immediately b) Do not apply at all c) After 2 days d) Only after a week

c) After 2 days Explanation: It is advisable to apply heat on a sprain or a contusion 2 days after a sprain or a contusion has occurred. This is because after 2 days, swelling is not likely to increase and as a result heat application reduces pain and relieves local edema by improving circulation. Delaying the application of heat prolongs the pain and increases the risk of local edema.

What is the term for a rhythmic contraction of a muscle? a) Crepitus b) Hypertrophy c) Clonus d) Atrophy

c) Clonus Explanation: Clonus is a rhythmic contraction of the muscle. Atrophy is a shrinkagelike decrease in the size of a muscle. Hypertrophy is an increase in the size of a muscle. Crepitus is a grating or crackling sound or sensation that may occur with movement of ends of a broken bone or irregular joint surface.

The nurse is conducting a community education program on hip fracture risk. The nurse evaluates that the participants understand the program when the program determines that the person at highest risk for a hip fracture is which of the following? a) High school football player b) 30-year-old pregnant woman c) Toddler just starting to walk d) 80-year-old widow

d) 80-year-old widow Explanation: Hip fracture occurs with greater incidence in elderly people and is often a life-altering event that has a negative impact on the person's mobility and quality of life.

Which of the following terms refers to muscle tension being unchanged with muscle shortening and joint motion? a) Contracture b) Fasciculation c) Isometric contraction d) Isotonic contraction

d) Isotonic contraction Explanation: Exercises such as swimming and bicycling are isotonic. Isometric contraction is characterized by increased muscle tension, unchanged muscle length, and no joint motion. Contracture refers to abnormal shortening of muscle, joint, or both. Fasciculation refers to the involuntary twitch of muscle fibers.

Which of the following terms refers to mature compact bone structures that form concentric rings of bone matrix? a) Cancellous bone b) Endosteum c) Trabecula d) Lamellae

d) Lamellae Explanation: Lamellae are mineralized bone matrices. Endosteum refers to the marrow cavity lining of hollow bone. Trabecula refers to latticelike bone structure. Cancellous bone refers to spongy, latticelike bone structure.

The nurse is educating a patient with lower back pain on proper lifting techniques. The nurse would document what behavior as evidence the education was effective? a) The patient used a narrow base of support. b) The patient bent at the hips and tightened the abdominal muscles. c) The patient reached over head with arms fully extended. d) The patient placed the load close to the body.

d) The patient placed the load close to the body. Explanation: Instructions for the patient with low back pain should include that when lifting, the patient should avoid overreaching. The patient should also keep the load close to the body, bend the knees and tighten the abdominal muscles, use a wide base of support, and use a back brace to protect the back. Bending at the hips increases the strain on the back muscles when lifting.

Why is it important for Mr. Johnston to cough and use his incentive spirometer?

Atelectasis and pneumonia are risks for older patients after surgery. The risk is amplified if they do not take deep breaths and cough adequately to reinflate their lungs. Nosocomial pneumonia has a high mortality rate.

The nurse is giving discharge teaching to Mr. Leung on his fourth post-operative day. He will be coming two times per week for outpatient therapy to the hospital rehab area. List the important concepts that should be discussed before the patient is discharged.

Maintain careful handling of the residual limb. If the ace wrap or outer wrapping comes off, make sure it is rewrapped as soon as possible to prevent edema. If edema develops, the prosthesis may not fit. The patient should notify his physician immediately. The nurse may ask for a return demonstration of the leg wrapping procedure by the wife or caretaker to ensure that it is done correctly. Adjustments will be made to his prosthesis to accommodate the changes in residual limb size that are expected within the first six months to a year after the amputation. Discuss phantom pain and ways to minimize it. Suggest activity, distraction, and kneading/massage of the residual limb. The patient's doctor may prescribe local anesthetics such as Lidocaine patches or TENS (transcutaneous electrical nerve stimulation). It is important to stress that the phantom sensations will eventually decrease. Emphasize that any antibiotics ordered at discharge must be completely finished.Sometimes patients try to cut costs or forget to finish their prescriptions. This can set the stage for resistant infections and potentially jeopardize the capability for the residual limb to support a prosthesis. Reinforce that he should not sit for long periods as this can lead to flexion contracture of the affected leg. Also, he should continue his hip and knee exercises to strengthen his muscles and develop the necessary endurance involved in ambulation with a prosthesis. Help the patient and family to identify any hazards or obstacles in their home, which may be problematic when he is moving within that environment. They should be modified or removed before the patient returns home. Identify support groups within the community that the patient may find helpful and wish to attend. This might be the American Diabetic Association and/or an amputee support group.

Here are some more lab and testing parameters that may indicate bleeding: Skin color, Diaphoresis, SOB (shortness of breath) and Urine ouput. State their significance.

Pallor and diaphoresis may be present as well. Pallor and cyanosis indicate less oxygen. Diaphoresis may indicate shock that may be caused by bleeding. A drop in the pulse oximetry reading to less than 91%, and an increase in respiratory rate accompanied by SOB, may also indicate an inability of the blood to adequately carry oxygen. Urine output and color should be checked frequently. Output of less than 30cc per hour may indicate fluid conservation by the kidneys to combat blood loss. Also, the presence of blood in the urine (hematuria) may indicate Foley insertion trauma or bladder injury from the fall.

Which interventions should a nurse implement as part of initial pain relief measure for the patient with a cast? Select all that apply. a) Administration of analgesics b) Application of cold packs c) Application of a new cast d) Provide passive range-of-motion e) Elevation of the involved part

a) Administration of analgesics, b) Application of cold packs, e) Elevation of the involved part Explanation: Most pain can be relieved by elevating the casted part of the body, and by applying cold packs as prescribed and administering analgesics. The application of a new cast and providing passive range-of-motion would not assist in decreasing initial pain for a patient with a cast.

A patient is transported to the ED for a femur fracture following a motor vehicle crash. What action by the nurse is the highest priority? a) Assess vital signs and level of consciousness. b) Assess pedal pulses. c) Assess the diameter of the thigh every 15 minutes. d) Administer pain medication per orders.

a) Assess vital signs and level of consciousness. Explanation: Femur fractures can lead to hypovolemic shock due to blood loss in the tissue. By assessing the vital signs and level of consciousness, the nurse can assess for shock. Assessing the pedal pulses and measuring the diameter of the thigh are appropriate interventions for someone with a femur fracture, but assessing for hypovolemic shock would be a priority. Pain medication should be safely administered per orders to help control pain. Many pain medications lower BP. If the patient is in shock, BP may be too low to administer the pain medication safely.

Which common problem of the upper extremity results from entrapment of the median nerve at the wrist? a) Carpal tunnel syndrome b) Ganglion c) Dupuytren's contracture d) Impingement syndrome

a) Carpal tunnel syndrome Explanation: Carpal tunnel syndrome is commonly due to repetitive hand activities. A ganglion is a collection of gelatinous material near the tendon sheaths and joints that appears as a round, firm, cystic swelling, usually on the dorsum of the wrist. Dupuytren's contracture is a slowly progressive contracture of the palmar fascia. Impingement syndrome is associated with the shoulder and may progress to a rotator cuff tear.

The nurse is evaluating a patient's peripheral neurovascular status. Which of the following should the nurse report to the health care provider as a circulatory indicator of peripheral neurovascular dysfunction? a) Cool skin b) Paralysis c) Weakness d) Paresthesia

a) Cool skin Explanation: Indicators of peripheral neurovascular dysfunction related to circulation include pale, cyanotic, or mottled skin with a cool temperature. The capillary refill is more than 3 seconds. Weakness and paralysis are related to motion. Paresthesia is related to sensation.

Which is a flexion deformity caused by a slowly progressive contracture of the palmar fascia? a) Dupuytren's contracture b) Callus c) Hallux valgus d) Hammertoe

a) Dupuytren's contracture Explanation: Dupuytren's disease results in a slowly progressive contracture of the palmar fascia, called Dupuytren's contracture. A callus is a discretely thickened area of skin that has been exposed to persistent pressure or friction. A hammertoe is a flexion deformity of the interphalangeal joint, which may involve several toes. Hallux valgus is a deformity in which the great toe deviates laterally.

Which is a deformity in which the great toe deviates laterally? a) Hallux valgus b) Plantar fasciitis c) Pes cavus d) Hammertoe

a) Hallux valgus Explanation: Hallux valgus is a deformity in which the great toe deviates laterally. A hammertoe is a flexion deformity of the interphalangeal joint, which may involve several toes. Pes cavus refers to a foot with an abnormally high arch and a fixed equines deformity of the forefoot. Plantar fasciitis is an inflammation of the foot-supporting fascia.

Which of the following is a factor that inhibits fracture healing? a) History of diabetes b) Increased vitamin D and calcium in the diet c) Immobilization of the fracture d) Patient age of 35

a) History of diabetes Explanation: Factors that inhibit fracture healing include diabetes, smoking, local malignancy, bone loss, extensive local trauma, age greater than 40, and infection. Factors that enhance fracture healing include proper nutrition, vitamin D and calcium, exercise, maximum bone fragment contact, proper alignment, and immobilization of the fracture.

Which of the following is a metabolic bone disease that is characterized by inadequate mineralization of bone? a) Osteomalacia b) Osteomyelitis c) Osteoporosis d) Osteoarthritis

a) Osteomalacia Explanation: Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. Osteoporosis is characterized by reduction of total bone mass and a change in bone structure that increases susceptibility to fracture. Osteomyelitis is an infection of bone that comes from extension of soft tissue infection, direct bone contamination, or hematogenous spread. Osteoarthritis (OA), also known as degenerative joint disease, is the most common and frequently disabling of the joint disorders. OA affects the articular cartilage, subchondral bone, and synovium.

A patient with a short arm cast is suspected to have compartment syndrome. What actions should the nurse include in the plan of care? Select all that apply. a) Provide support to the injured extremity. b) Assess neurovascular status every 8 hours. c) Elevate the arm above the heart. d) Apply ice to extremity. e) Prepare for cast removal.

a) Provide support to the injured extremity., e) Prepare for cast removal. Explanation: The nurse should anticipate immediate removal of the cast and provide support to the injured extremity. Neurovascular status should be assessed more frequently than every 8 hours. If the patient is not showing improvement in the neurovascular status, then a fasciotomy may be needed. Waiting 8 hours to assess neurovascular status may cause permanent damage to the extremity. To promote arterial blood flow, the arm should be elevated to the heart level, not above. Ice should not be used as it could further decrease blood flow to the extremity.

There are reasons for and against the addition of potassium to the IV solution administered to Mr. Johnston. For the statement below, choose "For" or "Against": Cell death related to bone and tissue injury may cause potassium to be released from cells, causing hyperkalemia. a) For b) Against

b) Against Explanation: Although it is not a nursing task to make the decision for or against the addition of potassium to the patient's medication orders, it is important to understand the rationales involved in order to watch for the presence of unwanted reactions.

The homecare nurse is evaluating the musculoskeletal system of a geriatric patient whose previous assessment was within normal limits. The nurse initiates a call to the health care provider and/or emergency services when which of the following changes are found? a) Increased joint stiffness b) Decreased right-sided muscle strength c) Decreased flexibility d) Decreased agility

b) Decreased right-sided muscle strength Explanation: Although symmetrical decreases in muscle strength can be a part of the aging process, asymmetrical decreases are not. The nurse should contact the health care provider when decreased right-sided muscle strength is found, as this could indicate a stroke or transient ischemic attack. Decreased flexibility, decreased agility, and increased joint stiffness are all part of the aging process and therefore do not require the nurse to contact the health care provider.

The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects which complication? a) Hypovolemic shock b) Fat embolism syndrome c) Reflex sympathetic dystrophy syndrome d) Compartment syndrome

b) Fat embolism syndrome Explanation: Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion. With compartment syndrome, the patient complains of deep, throbbing, unrelenting pain. With hypovolemic shock, the patient would have decreased BP and increased pulse rate. Clinical manifestations of reflex sympathetic dystrophy syndrome include severe, burning pain, local edema, hyperesthesia, muscle spasms, and vasomotor skin changes.

A patient who was in a motor vehicle crash is diagnosed with a stable T7 spinal fracture with no neurologic deficits. Which of the following nursing interventions should the nurse implement? a) Sit patient upright in a padded chair for meals. b) Maintain bed rest with head of bed at 20 degrees. c) Withhold opioid pain medication to prevent ileus. d) Maintain NPO status (nothing by mouth) for surgical repair.

b) Maintain bed rest with head of bed at 20 degrees. Explanation: The patient should maintain limited bed rest with the head of the bed lower than 30 degrees. If the patient's pain is not controlled with a lower form of pain medication, then an opioid may be used to treat the pain. The nurse should monitor for an ileus. Stable spinal fractures are treated conservatively and not with surgical repair. The patient should avoid sitting until the pain eases.

Which of the following terms refers to failure of fragments of a fractured bone to heal together? a) Dislocation b) Nonunion c) Subluxation d) Malunion

b) Nonunion Explanation: When nonunion occurs, the patient complains of persistent discomfort and movement at the fracture site. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation or dislocation of joint surfaces. Malunion refers to growth of the fragments of a fractured bone in a faulty position, forming an imperfect union.

Which of the following orthopedic surgeries is done to correct and align a fracture after surgical dissection and exposure of the fracture? a) Arthrodesis b) Open reduction c) Joint arthroplasty d) Total joint arthroplasty

b) Open reduction Explanation: An open reduction is the correction and alignment of the fracture after surgical dissection and exposure of the fracture. Arthrodesis is immobilizing fusion of a joint. A joint arthroplasty or replacement is the replacement of joint surfaces with metal or synthetic materials. A total joint arthroplasty is the replacement of both the articular surfaces within a joint with metal or synthetic materials.

What assessment findings of the leg are consistent with a fracture of the femoral neck? a) Adducted and internally rotated b) Shortened, adducted, and externally rotated c) Shortened, abducted, and internally rotated d) Abducted and externally rotated

b) Shortened, adducted, and externally rotated Explanation: With fractures of the femoral neck, the leg is shortened, adducted, and externally rotated.

Which device is designed specifically to support and immobilize a body part in a desired position? a) Brace b) Splint c) Traction d) Sling

b) Splint Explanation: A splint may be applied to a fractured extremity initially until swelling subsides. A brace is an externally applied device to support a body part, control movement, and prevent injury. A sling is used to support an arm and traction is the use of a pulling force on a body part.

The nurse is educating a patient on home care following a ganglion cyst removal of the right wrist. Which of the following statements made by the patient demonstrates that the nurse's teaching has been effective? a) "If my hand becomes numb and cool I will elevate it above my heart." b) "If my pain is not relieved I will use a heat pack and take some more medication." c) "I will leave the dressing on until I follow up with my doctor as scheduled." d) "I will notify my doctor if I develop redness and purulent drainage for 2 days."

c) "I will leave the dressing on until I follow up with my doctor as scheduled." Explanation: The first dressing change is done by the surgeon at a scheduled follow-up appointment. If the hand becomes cool and numb, the patient needs to call the surgeon as soon as possible. The surgeon should be notified immediately if redness and purulent drainage develop. Medication should only be used as prescribed. The use of heat may increase swelling, which may increase pain.

A nurse is educating a patient diagnosed with osteomalacia. Which of the following statements by the nurse is appropriate? a) "You will need to decrease the amount of dairy products consumed." b) "You will need to avoid foods high in phosphorus, and vitamin D." c) "You may need to be evaluated for an underlying cause, such as renal failure." d) "You will need to engage in vigorous exercise three times a week for 30 minutes."

c) "You may need to be evaluated for an underlying cause, such as renal failure." Explanation: The patient may need to be evaluated for an underlying cause. If an underlying cause is discovered, that will guide the medical treatment. The patient needs to maintain an adequate to increased supply of calcium, phosphorus, and vitamin D. Dairy products are a good source of calcium. The patient is at risk for pathological fractures and therefore should not engage in vigorous exercise.

Which would be consistent as a component of self-care activities for the patient with a cast? a) Place the casted extremity in a dependent position frequently. b) Use plastic hanger wrapped in gauze to scratch under the cast. c) Cushioning rough edges of the cast with tape d) Cover the cast with plastic to insulate it.

c) Cushioning rough edges of the cast with tape Explanation: The patient can cushion rough edges with tape to prevent skin irritation. The cast should be kept dry, but do not cover it with plastic or rubber because this causes condensation, which dampens the cast and skin. The casted extremity is to be elevated to heart level frequently; a dependent position will increase swelling. A patient should not use any object to scratch under the cast.

Which of the following terms refers to a fracture in which one side of a bone is broken and the other side is bent? a) Oblique b) Avulsion c) Greenstick d) Spiral

c) Greenstick Explanation: A greenstick fracture is a fracture in which one side of a bone is broken and the other side is bent. A spiral fracture is a fracture twisting around the shaft of the bone. An avulsion is the pulling away of a fragment of bone by a ligament or tendon and its attachment. An oblique fracture is a fracture occurring at an angle across the bone

Which type of cast encloses the trunk and a lower extremity? a) Long-leg b) Short-leg c) Hip spica d) Body cast

c) Hip spica Explanation: A hip spica cast encloses the trunk and a lower extremity. A body cast encloses the trunk. A long-leg cast extends from the junction of the upper and middle third of the thigh to the base of the toes. A short-leg cast extends from below the knee to the base of the toes.

Which should be included in the teaching plan for a patient diagnosed with plantar fasciitis? a) Complications of plantar fasciitis include neuromuscular damage and decreased ankle range of motion. b) Plantar fasciitis presents as an acute onset of pain localized to the ball of the foot. c) Management of plantar fasciitis includes stretching exercises. d) The pain of plantar fasciitis diminishes with warm water soaks.

c) Management of plantar fasciitis includes stretching exercises. Explanation: Management also includes wearing shoes with support and cushioning to relieve pain, orthotic devices (e.g., heel cups, arch supports), and the use of nonsteroidal anti-inflammatory drugs (NSAIDs). Plantar fasciitis, an inflammation of the foot-supporting fascia, presents as an acute onset of heel pain experienced with taking the first steps in the morning. The pain is localized to the anterior medial aspect of the heel and diminishes with gentle stretching of the foot and Achilles tendon. Unresolved plantar fasciitis may progress to fascial tears at the heel and eventual development of heel spurs.

Localized rapid bone turnover, most commonly affecting the skull, femur, tibia, pelvic bones, and vertebrae, is characterized by which of the following bone disorders? a) Osteomyelitis b) Ganglion c) Paget's disease d) Osteomalacia

c) Paget's disease Explanation: Paget's disease results in bone that is highly vascularized and structurally weak, predisposing to pathologic fractures. Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. A ganglion is a collection of neurological gelatinous material. Osteomyelitis is an infection of bone that comes from the extension of a soft tissue infection, direct bone contamination, or hematogenous spread.

After a fracture, during which stage or phase of bone healing is devitalized tissue removed and new bone reorganized into its former structural arrangement? a) Reparative b) Inflammation c) Remodeling d) Revascularization

c) Remodeling Explanation: Remodeling is the final stage of fracture repair. During inflammation, macrophages invade and débride the fracture area. Revascularization occurs within about 5 days after the fracture. Callus formation occurs during the reparative stage, but is disrupted by excessive motion at the fracture site.

The nurse working in the orthopedic surgeon's office is asked to schedule a shoulder arthrography. The nurse determines that the surgeon suspects which of the following findings? a) Decreased bone density b) Fracture of the clavicle c) Tear in the joint capsule d) Injury to the radial nerve

c) Tear in the joint capsule Explanation: Arthrography is useful in identifying acute or chronic tears of the joint capsule or supporting ligaments of the knee, shoulder, ankle, hip, or waist. X-rays are used to diagnose bone fractures. Bone densitometry is used to estimate bone mineral density. An electromyogram (EMG) provides information about the electrical potential of the muscles and nerves leading to them.

Which of the following statements is accurate regarding care of a plaster cast? a) A dry plaster cast is dull and gray. b) The cast will dry in about 12 hours. c) The cast can be dented while it is damp. d) The cast must be covered with a blanket to keep it moist during the first 24 hours.

c) The cast can be dented while it is damp. Explanation: The cast can be dented while it is damp. A dry plaster case is white and shiny. The cast will dry in 24 to 72 hours. A freshly applied cast should be exposed to circulating air to dry and should not be covered with clothing or bed linens or placed on plastic-coated mats or bedding

Which of the following nursing actions would help prevent deep vein thrombosis in a patient who has had an orthopedic surgery? a) Instructing about using patient-controlled analgesia, if prescribed b) Instructing about exercise, as prescribed c) Applying cold packs d) Applying antiembolism stockings

d) Applying antiembolism stockings Explanation: Applying antiembolism stockings helps prevent deep vein thrombosis (DVT) in a patient who is immobilized due to orthopedic surgery. Regular administration of analgesics controls and prevents escalation of pain while ROM exercises help in maintaining muscle strength and tone and prevent contractions. On the other hand, cold packs are applied to help reduce swelling and this does not prevent deep vein thrombosis.

A patient who has extremity right wrist fracture complains of severe burning pain, frequent changes in the skin from hot and dry to cold and feeling clammy shiny skin that is growing more hair in the injured extremity. The nurse should anticipate providing care for what complication? a) Heterotrophic ossification b) Avascular necrosis of bone c) Reaction to an internal fixation device d) Complex regional pain syndrome (CRPS)

d) Complex regional pain syndrome (CRPS) Explanation: The symptoms reported by the patient are consistent with CRPS. Avascular necrosis is manifested by pain and limited movement. Pain and decreased function are the prime indicators of reaction to an internal fixation device. Heterotrophic ossification causes muscular pain and limited muscular contraction and movement.

The nurse is reading the admission note of a patient with a bone fracture that requires surgery. The note indicates the presence of crepitus. The nurse interprets this as being which of the following? a) Closed fracture b) Ecchymosis c) Bleeding d) Crackling sound

d) Crackling sound Explanation: Crepitus is a sound or sensation elicited by the rubbing together of fragments of bone, as in a fracture, or in irregular joint surfaces. The sound/sensation can be described as "grating" or "crackling."

The nurse working in the ER receives a call from the x-ray department communicating that the patient the nurse is caring for has a fracture in the shaft of the tibia. The nurse tells the physician that the patient's fracture is which of the following? a) Epiphysis b) Scoliosis c) Lordosis d) Diaphysis

d) Diaphysis Explanation: The diaphysis is primarily cortical bone. An epiphysis is an end of a long bone. Lordosis refers to an increase in lumbar curvature of spine. Scoliosis refers to lateral curving of the spine.

Dupuytren's contracture causes flexion of which area(s)? a) Ring finger b) Thumb c) Index and middle fingers d) Fourth and fifth fingers

d) Fourth and fifth fingers Explanation: Dupuytren's contracture causes flexion of the fourth and fifth fingers, and frequently the middle finger.

Which factor may contribute to compartment syndrome? a) Macular lesion b) Venous thromboemboli c) Disuse syndrome d) Hemorrhage

d) Hemorrhage Explanation: The normal pressure of a compartment can be altered in cases of fracture by the force of the injury itself or by development of edema or hemorrhage at the site of the injury. Venous thromboemboli are some of the other early complications of fracture, but they are not related to compartment syndrome. Macular lesion is caused by the accumulation of blood under the skin, as occurs with trauma such as bone fracture. Disuse syndrome mostly occurs in hip fracture.

What was the rationale for the addition of protein, vitamins, and minerals to Mr. Leung's diet? a) Protein will take the place of carbohydrate to decrease cholesterol. b) Zinc helps to reverse his anemia. c) Vitamin C lowers BP, thereby increasing cardiac output. d) Protein, vitamin C, and zinc aid healing.

d) Protein, vitamin C, and zinc aid healing. Explanation: A diet with added protein, vitamin C, multivitamins, and extra minerals (such as iron and zinc) can promote healing. If the anemia is related to iron deficiency, the addition of FeSO4 is warranted. A look at the patient's lab work to check albumin is important too. Added protein may raise albumin levels. This may exert a positive colloid osmotic pressure on the fluids outside the blood stream, pulling fluid from outside to inside the vessels. This cuts down on edema, which inhibits healing.

Which of the following principles apply to the patient in traction? a) Knots in the ropes should touch the pulley. b) Weights are removed routinely. c) Weights should rest on the bed. d) Skeletal traction is never interrupted.

d) Skeletal traction is never interrupted. Explanation: Skeletal traction is applied directly to the bone and is never interrupted. In order to be effective, the weights must hang freely and not rest on the bed or floor. Knots in the rope or the footplate must not touch the pulley or the foot of the bed. Traction must be continuous to be effective in reducing and immobilizing fractures.

The nurse is conducting a musculoskeletal assessment on a patient documented to have rheumatoid arthritis. Which of the following would the nurse anticipate finding when inspecting the patient's fingers? a) Hard nodules adjacent to the joints b) Hard nodules of bony overgrowth c) Soft nodules along the palmar surface d) Soft, subcutaneous nodules along the tendons

d) Soft, subcutaneous nodules along the tendons Explanation: The subcutaneous nodules of rheumatoid arthritis are soft and occur within and along tendons that provide extensor function to the joints. The nodules of gout are hard and lie within and immediately adjacent to the joint capsule itself. Osteoarthritic nodules are hard and painless and represent bony overgrowth that has resulted from destruction of the cartilaginous surface of bone within the joint capsule.

Most cases of osteomyelitis are caused by which of the following microorganisms? a) Pseudomonas species b) Proteus species c) Escherichia coli d) Staphylococcus

d) Staphylococcus Explanation: Staphylococcus aureus causes 70% to 80% of bone infections. Proteus species are frequently found in osteomyelitis, but they do not cause the majority of bone infections. Pseudomonas species are frequently found in osteomyelitis, but they do not cause most bone infections. While E. coli is frequently found in osteomyelitis, it does not cause the majority of bone infections.

A patient complains of pain in the right knee, stating, "My knee got twisted when I was going down the stairs." The patient was diagnosed with an injury to the ligaments and tendons of the right knee. Which terminology, documented by the nurse, best reflects the injury? a) Sprain b) Subluxation c) Dislocation d) Strain

d) Strain Explanation: A sprain is an injury to the ligaments and tendons surrounding a joint, usually caused by a wrenching or twisting motion. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation or dislocation of joint surfaces. Strain refers to a muscle pull or tear.

Here are some lab and testing parameters that may indicate bleeding: Hemoglobin and Hematocrit, Platelets, Pulse Oximetry, and Respiratory Rate. State their significance.

Before fluid administration, hemoglobin and hematocrit may actually be elevated, caused by hemoconcentration. After rehydration, they will decrease, indicating blood loss. If the platelets are low, less than 100,000 (when the norm is 150,000-400,000) there is additional risk for bleeding. This platelet situation is unlikely with Mr. Johnston unless he has some type of undetected cancer or bone marrow abnormality. A drop in the pulse oximetry reading to less than 91%, and an increase in respiratory rate accompanied by SOB, may also indicate an inability of the blood to adequately carry oxygen.

14 of 20 Case Study - Part III The nurse notes that Mr. Johnston is alert, is oriented, and has return-demonstrated the use of incentive spirometry. Although initially his pain was rated as a 7, it was relieved with IV administration of morphine 2 to 3 mg every 3 to 4 hours. Vital signs, pulse oximetry, and urine output have remained within normal limits. Lungs remain clear and heart rate is 80 and irregular. He is afebrile. Peripheral pulses are good quality and equal. Left thigh girth has not increased. Mr. Johnston is taken to surgery, where his displaced femoral neck fracture is treated with ORIF with the insertion of a compression screw and side plate for added stability. He tolerates the procedure well and has returned to the orthopedic unit at 9 pm. Post-Op Orders: Medications Cipro 400 mg IVPB every 12 hours Morphine sulfate 2 mg every 3 hours around the clock overnight until 7 am to maintain pain-free status Resume home medications (Lopressor, digoxin, and Lasix) Ferrous sulfate 325 mg BID PO Pantoprazole (Protonix) 40 mg, enoxaparin (Lovenox) 30 mg, and docusate (Colace) 100 mg daily PO PRN: hydrocodone/acetaminophen (Vicodin) 5/500, 1 or 2 tabs every 6 hours for severe pain Acetaminophen (Tylenol) 500 mg every 6 hours for weak pain Magnesium hydroxide (MOM) 30 mL PO Bisacodyl (Dulcolax) 10 mg PO Fleets enema Ondansetron (Zofran) 4 mg IV over 2 to 5 minutes

Treatments: Bilateral plexi-pulses to feet, TED hose to right leg Turn every 2 hours to 30 degrees with pillow support between legs Reinforce dressing PRN Ice chips to clear liquids as tolerated; resume soft, low sodium diet in am IV fluids: D5.45 NS at 60 mL per hour Maintain pulse oximetry greater than 92% Incentive spirometry, 10x per hour while awake Vital signs and CMS every 2 hours until 7 am; then resume every 4 hours Physical therapy and occupational therapy evaluation in am

There are reasons for and against the addition of potassium to the IV solution administered to Mr. Johnston. For the statement below, choose "For" or "Against": Mr. Johnston takes digoxin. Hypokalemia may promote digoxin toxicity. a) For b) Against

a) For Explanation: Although it is not a nursing task to make the decision for or against the addition of potassium to the patient's medication orders, it is important to understand the rationales involved in order to watch for the presence of unwanted reactions.

Which of the following is the most effective cleansing solution to complete pin site care? a) Alcohol b) Chlorhexidine c) Betadine d) Hydrogen peroxide

b) Chlorhexidine Explanation: Chlorhexidine solution is recommended as the most effective cleansing solution; however, water and saline are alternate choices. Hydrogen peroxide and Betadine solutions have been used, but they are believed to be cytotoxic to osteoblasts and may actually damage healthy tissue.

The nurse notes that the patient's left great toe deviates laterally. This finding would be recognized as which of the following? a) Flatfoot b) Hammertoe c) Hallux valgus d) Pes cavus

c) Hallux valgus Explanation: Hallux valgus is commonly referred to as a bunion. Hammertoes are usually pulled upward. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

An x-ray demonstrates a fracture in which a bone has splintered into several pieces. Which type of fracture is this? a) Compound b) Depressed c) Impacted d) Comminuted

d) Comminuted Explanation: A comminuted fracture may require open reduction and internal fixation. A compound fracture is one in which damage also involves the skin or mucous membranes. A depressed fracture is one in which fragments are driven inward. An impacted fracture is one in which a bone fragment is driven into another bone fragment.

Which of the following terms refers to disease of a nerve root? a) Contracture b) Involucrum c) Sequestrum d) Radiculopathy

d) Radiculopathy Explanation: When the patient reports radiating pain down the leg, he or she is describing radiculopathy. Involucrum refers to new bone growth around the sequestrum. Sequestrum refers to dead bone in an abscess cavity. Contracture refers to abnormal shortening of muscle or fibrosis of joint structures.

The nurse is caring for patient scheduled to have magnetic resonance imaging (MRI). The nurse contacts the health care provider to cancel the MRI when the nurse reads which of the following in the patient's medical history? a) Cochlear implant b) Tumor removal c) Colostomy d) Skin graft

a) Cochlear implant Explanation: Nonremovable cochlear devices can become inoperable when exposed to MRI. Therefore, it is contraindicated for a patient with a cochlear implant to have an MRI. Also, transdermal patches (e.g., nicotine patch [NicoDerm], nitroglycerin transdermal [Transderm-Nitro], scopolamine transdermal [Transderm Scop], clonidine transdermal [Catapres-TTS]) that have a thin layer of aluminized backing must be removed before MRI because they can cause burns. The primary provider should be notified before the patches are removed. Additionally, the patient should remove all jewelry, hair clips, hearing aids, credit cards with magnetic strips, and other metal-containing objects; otherwise, these objects can become dangerous projectiles or cause burns.

Which actions by the nurse demonstrate an understanding of caring for a patient in traction? Select all that apply. a) Placing a trapeze on the bed b) Removing skeletal traction to turn and reposition the patient c) Ensuring that the weights are hanging freely d) Assessing pain level frequently e) Assessing patient's alignment in the bed

a) Placing a trapeze on the bed, c) Ensuring that the weights are hanging freely, d) Assessing pain level frequently, e) Assessing patient's alignment in the bed Explanation: The weights must hang freely with the patient in good alignment in the center of the bed. The nurse should frequently monitor pain, as uncontrolled pain may be a sign of a complication. The patient will be able to assist with alignment and bed mobility if a trapeze is placed on the bed. Skeletal traction should never be interrupted.

A patient with a fractured ankle is having a fiberglass cast applied. The patient starts yelling, "My leg is burning, take it off." What action by the nurse is most appropriate? a) Administer antianxiety and pain medication. b) Remove the cast immediately, notifying the physician. c) Call for assistance to hold the patient is the required position until the cast has dried. d) Explain that the sensation being felt is normal and will not cause burns to the patient.

d) Explain that the sensation being felt is normal and will not cause burns to the patient. Explanation: A fiberglass cast when applied will give off heat. The reaction is a normal, temporary sensation. Heat given off during the application phase of the cast does not cause burns to the skin. By explaining these principles to the patient, the nurse can alleviate any anxiety associated with the application of the cast. Because this is a known reaction to the application of the fiberglass cast, it is not necessary to remove the cast. Holding the patient may cause more harm to the injury. Antianxiety medications are generally not needed when applying a cast.

Which term describes a surgical procedure to release constricting muscle fascia so as to relieve muscle tissue pressure? a) Osteotomy b) Arthroplasty c) Arthrodesis d) Fasciotomy

d) Fasciotomy Explanation: A fasciotomy is a surgical procedure to release constricting muscle fascia so as to relieve muscle tissue pressure. An osteotomy is a surgical cutting of bone. An arthroplasty is a surgical repair of a joint. Arthrodesis is a surgical fusion of a joint.

A patient with a long arm cast continues to complain of unrelieved throbbing pain even after receiving opioid pain medication. Which of the following is the priority action by the nurse? a) Assess for complications. b) Assess for previous opioid drug use. c) Reposition the patient for comfort. d) Teach relaxation techniques.

a) Assess for complications. Explanation: Unrelieved pain can be an indicator of a complication, such as, compartment syndrome. Previous opioid drug use should not influence a complete and thorough assessment. Repositioning the patient for comfort may be appropriate once all indications of a complication are ruled out. It is appropriate to teach relaxation techniques to help ease the pain, but assessing for a complication remains the highest priority.

The nurse is caring for patient with a hip fracture. The physician orders the patient to start on a bisphosphonate. Which medication would the nurse document as given? a) Raloxifene (Evista) b) Alendronate (Fosamax) c) Teriparatide (Forteo) d) Denosumab (Prolia)

b) Alendronate (Fosamax) Explanation: Alendronate (Fosamax) is a bisphosphonate medication. Raloxifene (Evista) is a selective estrogen receptor modulator. Terparatide (Forteo) is an anabolic agent, and denosumab (Prolia) is a monoclonal antibody agent.

A patient who had hospitalized with acute osteomyelitis is being discharged home. The patient states, "I'm not sure I will be able to manage the IV at home." a) "We will be removing the IV before we send you home." b) "I will make sure you have a home health nurse to care for the IV." c) "I'm not sure I will be able to manage the IV at home." d) "What concerns you the most about caring for the IV?"

d) "What concerns you the most about caring for the IV?" Explanation: Osteomyelitis is treated with long-term IV antibiotics. For this reason, patients usually require IV therapy in the home environment. By saying, "don't worry," the nurse is dismissing the patient's concerns and providing nontherapeutic communication. The patient will require home IV therapy, so it is inappropriate to state that the IV will be removed. Not all patients will need or can afford a home health nurse to administer the IV therapy. The concern the patient has might be a small concern that education by the nurse may solve or it may be the need for emotional support. The nurse needs to assess the patient's concerns related to caring for the IV.

In a patient with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which of the following complications do the assessments help the nurse to monitor in the patient? a) Compartment syndrome b) Disseminated intravascular coagulation c) Fat embolism syndrome d) Carpal tunnel syndrome

a) Compartment syndrome Explanation: The nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable in a patient with a dislocation to assess for compartment syndrome. It is a complication associated with dislocation. A patient with a dislocation does not experience an increased risk of complications such as disseminated intravascular coagulation, carpal tunnel syndrome, or fat embolism syndrome.

There are reasons for and against the addition of potassium to the IV solution administered to Mr. Johnston. For the statement below, choose "For" or "Against": Mr. Johnston received extra fluids in the ED, which may increase urine output and potassium loss. a) For b) Against

a) For Explanation: Although it is not a nursing task to make the decision for or against the addition of potassium to the patient's medication orders, it is important to understand the rationales involved in order to watch for the presence of unwanted reactions.

There are reasons for and against the addition of potassium to the IV solution administered to Mr. Johnston. For the statement below, choose "For" or "Against": Mr. Johnston took his diuretic this morning, which may cause hypokalemia. a) Against b) For

b) For Explanation: Although it is not a nursing task to make the decision for or against the addition of potassium to the patient's medication orders, it is important to understand the rationales involved in order to watch for the presence of unwanted reactions.

Morton's neuroma is exhibited by which clinical manifestations? a) Inflammation of the foot-supporting fascia b) Swelling of the third (lateral) branch of the median plantar nerve c) Diminishment of the longitudinal arch of the foot d) High arm and a fixed equinus deformity

b) Swelling of the third (lateral) branch of the median plantar nerve Explanation: Morton's neuroma is swelling of the third branch of the median plantar nerve. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. Flatfoot is a common disorder in which the longitudinal arch of the foot is diminished. Plantar fasciitis is an inflammation of the foot-supporting fascia.

The nurse is assessing a young girl during her school's annual sports physical. The assessment reveals that the girl has lateral curving of the spine. The nurse reports to the health care professional that the assessment revealed which of the following? a) Scoliosis b) Diaphysis c) Lordosis d) Epiphysis

a) Scoliosis Explanation: Scoliosis is a lateral curving of the spine. Lordosis is an increase in the lumbar curvature of the spine. Diaphysis is the shaft of a long bone. Epiphysis is the end of a long bone.

A patient with chronic osteomyelitis has undergone 6 weeks of antibiotic therapy. There is no improvement in the wound appearance. What action would the nurse anticipate to promote healing? a) Vitamin supplements b) Surgical debridement c) Wound irrigation d) Wound packing

b) Surgical debridement Explanation: In chronic osteomyelitis, surgical debridement is used when the wound fails to respond to antibiotic therapy. Wound packing, vitamin supplements, and wound irrigation are not the standard of care when treating chronic osteomyelitis.

Which nerve is being assessed when the nurses asks the patient to dorsiflex his ankle and extend his toes? a) Radial b) Median c) Peroneal d) Ulnar

c) Peroneal Explanation: The motor function of the peroneal nerve is assessed by asking the patient to dorsiflex the ankle and to extend the toes, while pricking the skin between the great toe and center toe assesses the sensory function. The radial nerve is assessed by asking the patient to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. The median nerve is assessed by asking the patient to touch the thumb to the little finger. Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation.

The patient is scheduled for a meniscectomy of the right knee. The nurse would plan postoperative care based on what surgical procedure? a) Replacement of one of the articular surfaces of a joint b) Incision and diversion of the muscle fascia c) Replacement of knee with artificial joint d) Excision of damaged joint fibrocartilage

d) Excision of damaged joint fibrocartilage Explanation: The most common site for meniscectomy is the knee; the procedure refers to the excision of damaged joint fibrocartilage. Fasciotomy refers to the incision and diversion of the muscle fascia to relieve muscle constriction. Hemiarthroplasty refers to the replacement of one of the articular surfaces of a joint. Total joint arthroscopy is the replacement of a joint with synthetic material

The nurse is educating a group of women on the prevention of osteoporosis. The nurse recognizes the education as being effective when the group members make which of the following statements? a) We need to increase aerobic exercise. b) We need to consume a low-calcium, high-phosphorus diet c) We need an adequate amount of exposure to sunshine. d) Estrogen deficiency increases bone density.

c) We need an adequate amount of exposure to sunshine. Explanation: The only accurate statement is related to getting an adequate amount of exposure to sunshine. Aerobic exercise, such as swimming, does not prevent osteoporosis. The exercise needs to be weight bearing. A diet low in calcium and high in phosphorus will increase the risk of osteoporosis. Estrogen deficiency is linked to decreased bone mass.

A patient with a musculoskeletal injury is instructed to increase dietary calcium. Which of the following statements by the nurse is appropriate? a) "You need to increase the amount of noncitrus fruits in your diet." b) "You need to increase the amount of vitamin D in your diet." c) "You need to increase the amount of red meat in your diet." d) "You need to increase the amount of phosphorus in your diet."

b) "You need to increase the amount of vitamin D in your diet." Explanation: Vitamin D is needed for the absorption of calcium. Although fruits containing vitamin C will assist in the absorption of calcium, noncitrus fruits are of little benefit for calcium absorption. Increasing phosphorus s in the diet can cause calcium to be lost from the bone, decreasing bone density. Red meat does not facilitate calcium absorption.

Which of the following is a benefit of a continuous passive motion (CPM) device when applied after knee surgery? a) It promotes healing by immobilizing the knee joint. b) It promotes healing by increasing circulation and movement of the knee joint. c) It provides active range of motion. d) It prevents infection and controls edema and bleeding.

b) It promotes healing by increasing circulation and movement of the knee joint. Explanation: A CPM device applied after knee surgery promotes healing by increasing circulation and movement of the knee joint.

A patient is placed in traction for a femur facture. The nurse would document what as the expected outcomes of traction? Select all that apply. a) Full range of motion to extremity b) Realignment of a fracture c) Increased ability to bear weight d) Minimization of muscle spasms e) Decreased pedal pulse f) Reduction of deformity

b) Realignment of a fracture, d) Minimization of muscle spasms, f) Reduction of deformity Explanation: Traction is used to minimize muscle spasms, to reduce, align, and immobilize fractures, and to reduce deformity. Traction does not allow for full range of motion or an increased ability to bear weight. The patient is confined to the bed while in traction. A decreased pulse is a sign of circulatory compromise and should be investigated and reported.

The ED nurse teaches patients with sports injuries to remember the acronym RICE. This acronym stands for which of the following combinations of treatment? a) Rest, ice, circulation, and examination b) Rest, ice, compression, elevation c) Rotation, ice, compression, and examination d) Rotation, immersion, compression, and elevation

b) Rest, ice, compression, elevation Explanation: RICE is used for the treatment of contusions, sprains, and strains. While circulation problems must be examined, the RICE treatment does not refer to circulation and examination. Rotation of a joint is contraindicated when injury is suspected, and immersion of the area may be anatomically difficult. Examination, while indicated, does not provide treatment.

A patient with a recent left above-the-knee amputation states, "I can feel pain in my left toes." Which of the following is the best response by the nurse? a) "Your left toes have been amputated." b) "The pain is really from the nerves in the upper leg." c) "Pain medication usually does not help this type of pain." d) "Describe the pain and rate it on the pain scale."

d) "Describe the pain and rate it on the pain scale." Explanation: The nurse should recognize phantom pain as real and complete a pain assessment as if the limb were attached. The patient's pain should be address and treated appropriately. By telling the patient that the toes have been amputated or the pain is really from the nerves in the upper leg, the nurse is negating the patient's pain. Opioid pain medication can be effective with phantom pain.

Which of the following is an indicator of neurovascular compromise? a) Pain on active stretch b) Diminished pain c) Warm skin temperature d) Capillary refill of more than 3 seconds

d) Capillary refill of more than 3 seconds Explanation: Capillary refill of more than 3 seconds is an indicator of neurovascular compromise. Other indicators include cool skin temperature, pale or cyanotic color, weakness, paralysis, paresthesia, unrelenting pain, pain on passive stretch, and absence of feeling. Cool skin temperature is an indicator of neurovascular compromise. Unrelenting pain is an indicator of neurovascular compromise. Pain on passive stretch is an indicator of neurovascular compromise.

A patient asks the nurse why his residual limb cannot be elevated on a pillow. What is the best response by the nurse? a) "Elevating the leg might lead to a flexion contracture." b) "I am sorry. We ran out of pillows. I can elevate it on a few blankets." c) "You need to turn yourself side to side. If your leg is on a pillow, you would not be able to do that." d) "Elevating the extremity may increase your chances of compartment syndrome."

a) "Elevating the leg might lead to a flexion contracture." Explanation: Elevating the residual limb on a pillow may lead to a flexion contracture; this could jeopardize the patient's ability to use a prosthesis. The patient does need to turn to both sides, but might still be able to do it with his extremity elevated. Elevating the extremity would not increase the risk for compartment syndrome. The limb should not be elevated on pillows or blankets.

The patient asks what the Lovenox is for and why he needs it every day. What do you think the nurse should tell the patient? a) "Enoxaprin (Lovenox) is like synthetic heparin, which will prevent blood clots from developing in your legs." b) "Lovenox is given every day into your abdomen to prevent ulcer formation." c) "This drug increases your platelets, which are important in helping your body fight infection." d) "Lovenox prevents red blood cell formation, which could cause clots in your veins."

a) "Enoxaprin (Lovenox) is like synthetic heparin, which will prevent blood clots from developing in your legs." Explanation: DVT (deep vein thrombosis) is the most common complication after hip fractures and hip repair. Lovenox is a synthetic, low-molecular-weight heparin that prevents leg clots in post-surgical patients. The patient will also be prescribed oral warfarin (Coumadin). The Lovenox is given in the abdomen to facilitate absorption. An air bubble in the syringes of 30 and 40 mg doses must not be expelled prior to injection. The bubble acts as an airlock to prevent the medication from leaking out. The nurse must also encourage oral fluids and remind the patient to do foot and ankle exercises. The nurse should check the patient's circulation every 4 hours for signs of DVT, such as swelling, pain, redness, and warmth. DVT increases the risk of pulmonary embolism, a lethal complication.

A 75-year-old patient had surgery for a left hip fracture yesterday. When completing the plan of care, the nurse should include assessment for which of the following complications? Select all that apply. a) Sepsis b) Necrosis of the humerus c) Pneumonia d) Skin breakdown e) Delirium

a) Sepsis, c) Pneumonia, d) Skin breakdown, e) Delirium Explanation: Complications in patients with hip fractures are often related to the age of the patient. During the first 24 to 48 hours following surgery for hip fracture, atelectasis or pneumonia from the anesthesia can develop. Thromboemboli are possible, as is sepsis. Elderly patients are also at risk for delirium in hospital settings because of the stress of the trauma, unfamiliar surroundings, sleep deprivation, and medications. An elderly patient with decreased mobility is at risk for skin breakdown. Necrosis is a potential complication of the surgery, but the complication would be with the femur, not the humerus

A patient diagnosed with a right ulnar fracture asks why the cast needs to go all the way up the arm. What is the best response by the nurse? a) "This will allow for the strength in the arm to remain consistent." b) "The joint above the fracture and below the fracture must be immobilized." c) "When a spica cast is ordered, the arm must be immobilized." d) "The method will allow for the fastest healing time and the greatest mobility."

b) "The joint above the fracture and below the fracture must be immobilized." Explanation: Generally, the joints proximal and distal to the fracture are immobilized to promote healing. The purpose is not for the strength to remain consistent, most patients will lose strength. A spica cast would not be ordered for an ulnar fracture. Although immobilizing the joints above and below fractures may aide in healing time, it does not allow for increased mobility.

During which stage or phase of bone healing after fracture does callus formation occur? a) Reparative b) Inflammation c) Remodeling d) Revascularization

a) Reparative Explanation: Callus formation occurs during the reparative stage, but is disrupted by excessive motion at the fracture site. Remodeling is the final stage of fracture repair during which the new bone is reorganized into the bone's former structural arrangement. During inflammation, macrophages invade and débride the fracture area. Revascularization occurs within about 5 days after the fracture.

Nursing interventions for Mr. Johnston prior to surgery include monitoring for shock and bleeding. Which parameters should the nurse check? Select all that apply. a) Peripheral sensation b) Blood pressure c) Respiratory rate d) Heart rate e) Thigh girth

b) Blood pressure, d) Heart rate, e) Thigh girth Explanation: It is necessary to check all of these parameters to prevent management complications prior to surgery. However, blood pressure, thigh girth, and heart rate are parameters that relate to shock and bleeding. Since the patient had low blood pressure in the ER and needed extra IV fluids to increase it, the nurse should be alert to the possibility of shock related to continued bleeding within the fractured hip. Establishing a baseline of peripheral pulses and circulatory status is important. Measuring the thigh girths for comparison may reveal an enlargement on the left side related to continued bleeding. The nurse also needs to monitor the blood pressure and heart rate for signs of shock. A narrowing pulse pressure with decreased systolic pressure as in 100/86 could be indicative of blood loss into the leg tissue. Because the patient took digoxin and metoprolol this morning, the typical tachycardia associated with shock may be absent. They both decrease heart rate.

The nurse teaching the patient with a cast about home care includes which of the following instructions? a) Dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems b) Cover the cast with plastic or rubber c) Keep the cast below heart level d) Fix a broken cast by applying tape

a) Dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems Explanation: Instruct the patient to keep the cast dry and to dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems, and do not cover it with plastic or rubber. A cast should be kept dry but do not cover it with plastic or rubber because this causes condensation, which dampens the cast and skin. A casted extremity should be elevated frequently to heart level to prevent swelling. A broken cast should be reported to the physician and the patient should not attempt to fix it.

The nurse teaches the patient which of the following interventions in order to avoid hip dislocation after replacement surgery? a) Never cross the affected leg when seated. b) Avoid placing a pillow between the legs when sleeping. c) Bend forward only when seated in a chair. d) Keep the knees together at all times.

a) Never cross the affected leg when seated. Explanation: Crossing the affected leg may result in dislocation of the hip joint after total hip replacement. The patient should be taught to keep the knees apart at all times. The patient should be taught to put a pillow between the legs when sleeping. The patient should be taught to avoid bending forward when seated in a chair.

A patient diagnosed with osteoporosis is being discharged home. Which of the following is the priority education the nurse should provide? a) Removing all small rugs from the home b) Classifying medications c) Increasing calcium and vitamin D in the diet d) Participating in weight-bearing exercises

a) Removing all small rugs from the home Explanation: A patient with osteoporosis is at risk for fractures related to falls. The home environment needs to be evaluated for safety issues, such as rugs and other objects that could cause a fall. All other education is important in educating the patient, but the risk for injury with a fall and potential for a fracture makes safety in the home environment a priority.

The nurse is performing a musculoskeletal assessment of a patient in a nursing home who had a stroke 2 years ago and who has right-sided hemiplegia. The nurse notes that the girth of the patient's right calf is 2 inches less in diameter than the left calf. The nurse attributes the decreased girth to which of the following? a) Increased use of left calf muscle b) Atrophy of right calf muscle c) Edema in left lower extremity d) Bruising in right lower extremity

b) Atrophy of right calf muscle Explanation: Girth of an extremity may increase due to exercise, edema, or bleeding into the muscle. However, a patient with right-sided hemiplegia is unable to use the right lower extremity. This patient may experience atrophy of the muscles from lack of use, which will result in a subsequent decrease in the girth of the calf muscle.

A patient suffered an open fracture to the left femur during a horseback riding accident. For which of the following complications is this patient at highest risk? a) Complex regional pain syndrome b) Infection c) Malunion d) Depression

b) Infection Explanation: This patient is at the highest risk for infection because of the open fracture that was obtained while horseback riding. Infection that enters the body and affects the bone can lead to osteomyelitis. The treatment may involve long-term antibiotics and may even result in fatality. The patient is still at risk for malunion, but this is a slight risk because the bone can be visualized (either through the wound or surgical intervention) and returned to anatomical position. The other options are possible consequences of this type of injury, but do not represent the most serious complication.

What is the best action by the nurse to achieve the optimal outcomes when caring for a patient with a musculoskeletal disorder that is using a cast? a) Preparing the patient for cast application b) Assessing for neurovascular compromise c) Educating the patient on cast care and complications d) Providing effective pain control

c) Educating the patient on cast care and complications Explanation: Educating the patient is essential to achieve optimal outcomes. Although the nurse should prepare the patient for cast applications, assess for neurovascular compromise, and provide effective pain control, these interventions are centered on the care provided by the nurse. The patient is more likely to be in the home setting while a cast is in place, requiring the patient to have the education to properly care for the cast and have the knowledge of the complications so that early interventions can happen.

A physician prescribes raloxifene (Evista) to a hospitalized patient. The patient's history includes a right hip fracture, hysterectomy, deep vein thrombosis, and hypertension. Which of the following actions by the nurse demonstrates safe nursing care? a) Administering the raloxifene (Evista) with food or milk b) Administering the raloxifene (Evista) in the evening c) Holding the raloxifene (Evista) and notifying the physician d) Having the patient sit upright for 30-60 minutes following administration

c) Holding the raloxifene (Evista) and notifying the physician Explanation: Raloxifene (Evista) is contraindicated in patients with a history of deep vein thrombosis. The nurse should hold the medication and notify the physician. Raloxifene (Evista) can be given without regard to food or time of day. Raloxifene (Evista) is a selective estrogen receptor modulation (SERM) medication. Sitting upright for 30-60 minutes is for the classification of bisphosphonates.

A patient with a tibia fracture was placed in an external fixator 24 hours ago. The nurse is completing pin care and notices redness at the pin site and a small amount of serous drainage. What action by the nurse is appropriate? a) Prepare for surgical removal of the fixator. b) Document the findings. c) Notify the physician. d) Assess patient's hemoglobin and hematocrit.

b) Document the findings. Explanation: Serous drainage and redness at the pin site is an expected finding for 24-48 hours postinsertion. The nurse should document the findings and continue to monitor the site. The physician does not need to be notified unless other signs and symptoms are present. The fixator does not need to be removed at this time. The greatest concern is for infection; assessing the hemoglobin and hematocrit are not relevant to assessing for infection

A patient has been prescribed alendronate (Fosamax) for the prevention of osteoporosis. Which of the following is the highest priority nursing intervention associated with the administration of the medication? a) Ensure adequate intake of vitamin D in the diet b) Have patient sit upright for 60 minutes following administration c) Encourage patient to get yearly dental exams d) Assess for the use of corticosteroids

b) Have patient sit upright for 60 minutes following administration Explanation: While all interventions are appropriate, the highest priority is having the patient sit upright for 60 minutes following the administration of the medication. This will prevent irritation and potential ulceration of the esophagus. The patient should have adequate intake of vitamin D and obtain yearly dental exams. The concurrent use of corticosteroids and Fosamax is link to a complication of osteonecrosis.

Which patient(s) is most likely to have compartment syndrome after sustaining a fracture? Select all that apply. a) The patient using ice for pain control in the extremity b) The patient with elevated pressure level within the muscles c) The patient with hemorrhage in the site of injury d) The patient with a plaster cast applied immediately after injury e) The patient who sustained a clavicle fracture

b) The patient with elevated pressure level within the muscles, c) The patient with hemorrhage in the site of injury, d) The patient with a plaster cast applied immediately after injury Explanation: Compartment syndrome occurs when the normal pressure of a compartment is altered in cases of fracture by the force of the injury itself, by development of edema, or by hemorrhaging at the site of the injury, which increases the contents of the compartment, or from outside pressure caused by constriction from a dressing or cast. A patient with elevated muscle pressure is at risk for compartment syndrome. The application of a plaster cast immediately after the injury places the patient at risk for compartment syndrome because the cast will not allow for edema and therefore will compress the tissue. Clavicle fractures are not a risk factor for compartment syndrome due to the location of the fracture. Ice will assist in decreasing the edema and may help prevent compartment syndrome.

The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following actions? a) Increase fiber in the diet b) Walk or perform weight-bearing exercises c) Decrease the intake of vitamin A and D d) Reduce stre

b) Walk or perform weight-bearing exercises Explanation: Risk-lowering strategies for osteoporosis include walking or exercising outdoors, performing a regular weight-bearing exercise regimen, increasing dietary calcium and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation.

List the major post-operative complications associated with amputation in the following categories: Infection, Hemorrhage, and Hazards of immobility.

Infection: Since the wound was infected prior to surgery and it had begun to spread to the rest of the body, it is very important for the nurse to monitor the incision site as well as vital signs and lab reports which might indicate infection. Besides the WBC count, an increase in bands on the differential is very important to note. Hemorrhage: Bleeding from the wound may occur suddenly as the result of a loosened suture. Often, this can be a massive bleed and a tourniquet is prominently displayed at the bedside for use in this situation. The dressing and incision site should be monitored for oozing and increased sero-sanguineous drainage. Hazards of immobility: 1. Respiratory: any older, post-surgical patient is at risk for atelectasis and pneumonia. Mr. Leung has appropriately utilized his incentive spirometer, coughing, and deep breathing activities to avoid these complications. Pulse oximetry and vital signs have been monitored so that any respiratory problems can be assessed and managed before they become dangerous. 2. Circulatory problems can cause peripheral clots which could result in a pulmonary embolus. Mr. Leung has continued his movement exercises. The physician has also ordered anti-coagulant medications to decrease the viscosity of his blood and prevent the development of clots. 3. Skin breakdown is a risk over any bony prominence as well as over the residual limb. Mr. Leung has been instructed and helped to move from side-to-side at least every two hours. He should wash and dry the prosthesis articulation area of his residual limb daily, and monitor it for any suspicious skin abnormalities. Usually, some sort of absorbent sock will be applied between the skin and the prosthesis.

The nurse is creating a teaching plan for a 65-year-old woman on prevention of osteoporosis. The nurse should include which of the following on the teaching plan? Select all that apply. a) Increased consumption of low-fat milk b) Increased consumption of fish c) Daily intake of 800 mg of calcium d) Daily intake of 1,000 IU of vitamin D

a) Increased consumption of low-fat milk, b) Increased consumption of fish, d) Daily intake of 1, 000 IU of vitamin D Explanation: Diet is an essential component of maintaining adult bone mass and preventing osteoporosis. Recommended daily intake of calcium is 1,000-1,200 mg. Good sources of calcium include low-fat milk, yogurt, and cheese and calcium-fortified foods. To ensure absorption of calcium, vitamin D intake should range from 800-1,000 IU for adults over the age of 50. Good sources of vitamin D include vitamin D-fortified milk and cereals, egg yolks, saltwater fish, and liver.

A patient is exhibiting diminished range of motion, loss of flexibility, stiffness, and loss of height. The history and physical findings are associated with age-related changes of which area? a) Joints b) Muscles c) Ligaments d) Bones

a) Joints Explanation: History and physical findings associated with age-related changes of the joints include diminished range of motion, loss of flexibility, stiffness, and loss of height. History and physical findings associated with age-related changes of bones include loss of height, posture changes, kyphosis, flexion of hips and knees, back pain, osteoporosis, and fracture. History and physical findings associated with age-related changes of muscles include loss of strength, diminished agility, decreased endurance, prolonged response time (diminished reaction time), diminished tone, a broad base of support, and a history of falls. History and physical findings associated with age-related changes of ligaments include joint pain on motion that resolves with rest, crepitus, joint swelling/enlargement, and degenerative joint disease (osteoarthritis).

A patient with a traumatic amputation of the right lower leg is refusing to look at the leg. Which of the following actions by the nurse is most appropriate? a) Provide feedback on the patient's strengths and available resources. b) Encourage the patient to perform range-of-motion (ROM) exercises to the right leg. c) Request a referral to occupational therapy. d) Provide wound care without discussing the amputation.

a) Provide feedback on the patient's strengths and available resources. Explanation: The nurse should encourage the patient to look at, and assist with, care of the residual limb. Providing feedback on the patient's strengths and resources may allow the patient to start to adapt to the body image and lifestyle change. The nurse should also allow time for the patient to discuss his or her feelings related to the amputation. Requesting a referral to occupational therapy and encouraging the patient to perform ROM exercises are appropriate, but do not address the emotional aspect of losing an extremity.

A patient in the emergency department is being treated for a wrist fracture. The patient asks why a splint is being applied instead of a cast. What is the best response by the nurse? a) "It is best if an orthopedic doctor applies the cast." b) "A splint is applied when more swelling is expected at the site of injury." c) "You would have to stay here much longer because it takes a cast longer to dry." d) "Not all fractures require a cast."

b) "A splint is applied when more swelling is expected at the site of injury." Explanation: Splints are noncircumferential and will not compromise circulation when swelling is expected. A splint is applied to support and immobilize the injured joint. A fracture will experience swelling as part of the inflammation process. The patient would not have to stay longer if a fiberglass cast is applied. Fiberglass cast dry in approximately 30 minutes. An orthopedic doctor is not needed to apply the cast. Many nurses and technicians are trained in proper application of a cast. Some fractures may not be treated with a cast but it would not be appropriate to answer with this response because it does not reflect the actual reason for a splint being applied.

Which nursing intervention is appropriate for a patient with a closed reduction extremity fracture? a) Promoting intake of omega-3 fatty acids b) Encouraging participation in ADLs c) Administering prescribed enema to prevent constipation d) Using frequent dependent positioning to prevent edema

b) Encouraging participation in ADLs Explanation: General nursing measures for a patient with a fracture reduction include administering analgesics, providing comfort measures, encouraging participation with ADLs, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing the patient for self-care. Omega-3 fatty acids have no implications on the diet of a patient with a fracture reduction. Dependent positioning may increase edema since the extremity is below the level of the heart. While some pain medications may contribute to constipation, this intervention would be reserved for a patient experiencing constipation and not as a preventative measure.

A patient with a right below-the-knee amputation is being transferred from the postanesthesia care unit to a medical-surgical unit. What is the highest priority nursing intervention by the receiving nurse? a) Review the physician orders for type and frequency of ordered pain medication. b) Ensure that a large tourniquet is in the room. c) Document the receiving report from the transferring nurse. d) Delegate the gathering of enough pillows for proper positioning and comfort.

b) Ensure that a large tourniquet is in the room. Explanation: The patient with an amputation is at risk for hemorrhage. A tourniquet should be placed in plain sight for use if the patient hemorrhages. Documenting the receiving report is important, but is not the highest priority. The nurse may delegate to unlicensed assistive personnel (UAP) the job of gathering more pillows for positioning, but this is not the highest priority. The nurse will need to review the physician's orders for pain medication but, again, this is not the highest priority because any patient is hemorrhaging by the patient needs to be addressed first.

What is the safest initial management of a person with a suspected hip fracture? a) Put a pressure dressing over the bleeding area and splint legs together with tape. b) Roll victim on to unaffected side and pull shoulders to move. c) Call for ambulance assistance and do not attempt to move the person. d) Move victim by grabbing shoulders and legs and lifting as a unit.

c) Call for ambulance assistance and do not attempt to move the person. Explanation: After assessment of the ABCs -- airway, breathing, and circulation (pulse) -- the victim should be left in the position in which he was found and covered with a blanket. 911 should be called immediately. Moving this type of victim could cause more internal bleeding and increased damage to interior structures, especially nerves. The hip should be stabilized and supported by emergency personnel. With an open fracture, there is a risk for osteomyelitis, tetanus and gas gangrene. The tetanus, and antibiotic prophylaxis begun in the emergency department will help prevent these complications. Splinting the legs together could put greater stress on the already fractured hip. More bleeding could result.

Which of the following is a risk for an older patient who is taking Vicodin and plain Tylenol frequently? a) The patient should not need so much pain medication. b) The codeine will cause diarrhea. c) It is recommended that Tylenol not exceed 4 grams in 24 hours or liver problems may occur. d) Pain medication such as Tylenol is more effective than Vicodin.

c) It is recommended that Tylenol not exceed 4 grams in 24 hours or liver problems may occur. Explanation: Although the Vicodin (5 mg hydrocodone and 500 mg Tylenol) contains codeine which may aggravate the patient's constipation problem, it is important to believe how the patient rates his pain. Even if the patient takes two Vicodin (a total of 1000 mg of Tylenol) every 6 hours, that will total 4000 mg or 4 grams. An older person or someone with liver problems should aim not to exceed 2 grams of Tylenol over a 24 hour period or perhaps not take Tylenol at all.

An unresponsive patient had a plaster cast applied 8 hours ago to the right lower leg. When moving the patient, the nurse notices an indentation on the posterior lower portion of the cast. What is the best action by the nurse? a) Remove the cast immediately. b) Assess for pedal pulse and mobility of toes. c) Notify the physician. d) Document the findings.

c) Notify the physician. Explanation: Indentations in the cast can cause skin irritations and breakdown. The physician needs to be notified to assess the need for a new cast or manipulation of the current cast to prevent the skin breakdown. The nurse will need to document the findings and actions taken to resolve the issue but cannot document actions without completing an action, such as notifying the physician. The cast does not need immediate removal. Pedal pulse will indicate if a circulatory issue is present but with the patient being unresponsive, mobility of the toes cannot be assessed.

Mr. Leung mentions that his doctor has often ordered a hemoglobin A1C test and he does not really understand what hemoglobin has to do with his diabetes. What is the most accurate answer that the nurse can provide? a) Hemoglobin goes down when your glucose goes up, so it is a way of checking your red blood cells without actually having to do that test. b) It measures how your kidneys are doing. Sometimes low glucose can cause kidney problems over time. c) The hemoglobin A1C is a long-term measure of how well you are controlling your diabetes. d) Now that your toes have been amputated, that test will not be necessary any more.

c) The hemoglobin A1C is a long-term measure of how well you are controlling your diabetes. Explanation: The hemoglobin A1C is also known as glycosylated hemoglobin. It is an indication of how much glucose is in the blood over the life of the hemoglobin molecule, about 120 days. Normal is usually about 4% to 6% for a non-diabetic patient. The physician uses it as an indication of how well the diabetic patient controls his blood glucose level. It is measured about every 3 months; the physician would like it to remain as close to normal as possible. Maintaining a near-normal A1C helps the diabetic patient prevent long-term complications such as retinopathy, nephropathy, and neuropathy. It also helps prevent short-term complications such as hypoglycemia and hyperglycemia.

What is the rationale for the doctor's order for ferrous sulfate? a) The iron that it contains will help to relieve constipation. b) The iron augments the effects of morphine. c) The medication provides iron, an essential component in the formation of hemoglobin. d) Normally, digoxin depletes the body of iron; the patient should have been taking this medication before admission.

c) The medication provides iron, an essential component in the formation of hemoglobin. Explanation: Iron supplements are usually ordered after surgery with anticipated blood loss to help the body rebuild RBCs and oxygen-carrying capacity. It is best absorbed when given between meals with orange juice. Vitamin C seems to increase its absorption. Patient teaching also involves telling the patient that his stool may turn black while he is taking iron. In this patient with pre-existing constipation, stool frequency must be assessed, as constipation is a common side effect after surgery and also with Vicodin, because of the codeine it contains. Since proton pump inhibitors may decrease absorption, it is important to separate the iron supplement from the Protonix when administering them. All the other options are false. In fact, iron may cause constipation.

The nurse is witnessing Mr. Leung's signature of the consent form for a "below-the-knee amputation." He asks: "Why can't they just take off my foot at the ankle; that's where the infection is?" What is the best response that the nurse can give? a) "I need you to sign the consent now. You can ask your doctor about that right before surgery." b) "You should have asked your doctors about that when they were here." c) "I can't explain anything about that to you. I am only the nurse." d) "The amputation is usually performed at the lowest spot possible on the leg that will heal the best. Perhaps we should call your doctor to explain it to you again before you sign the consent."

d) "The amputation is usually performed at the lowest spot possible on the leg that will heal the best. Perhaps we should call your doctor to explain it to you again before you sign the consent." Explanation: The site of amputation is determined by two factors: circulation in the part and whether it meets the criteria for the use of a prosthesis. Preserving the knee joint will make for easier ambulation with less energy expenditure than if the amputation is above the knee. If the amputation is performed right above the area of discoloration and infection, there is a danger that the residual limb or stump will still have poor circulation. This will make using a prosthesis difficult or ultimately impossible. An informed consent mandates that the patient realizes the extent of the surgery; any other information concerning the procedure or preoperative questions must also be fully understood. The nurse is witnessing a signature and verifying that the patient is satisfied with the explanation given by the physician. The nurse can teach the patient within established parameters and use therapeutic communication techniques designed to elicit whether the patient understands what the physician has said. The nurse should not belittle or berate the paitent for "forgetting" to ask all of the questions when the doctor was present. Often, the physician has verbally explained all of the pertinent information to the patient, but presurgical anxiety may make the patient forget what was discussed. The nurse should not force the patient to sign the consent because it is convenient. A consent signed under duress would not be legal.

On the second post-operative day, Mr. Leung puts on his call light and complains of pain in his right foot, which he rates as 7 out of 10. His PCA pump has been discontinued and Vicodin is still ordered for his pain PRN. What is the most appropriate response by the nurse? a) "The pain you are feeling is called phantom pain and does not need any pain medication." b) "Since the phantom pain is not real, I will give you Tylenol instead of the Vicodin." c) "You must be mistaken. You cannot feel any pain in that foot. It was amputated." d) "You may have Vicodin for the pain. Would you prefer one or two tablets?"

d) "You may have Vicodin for the pain. Would you prefer one or two tablets?" Explanation: Phantom pain is a frequent complaint of the patient with an amputation. The patient's assessment must be believed as the pain is real to him. The prescribed medication must be administered. The pain is real to the patient and he must be medicated in order to relieve it. Other mechanisms may also be tried, such as distraction and position changes. It is not advisable to put heat or cold on the extremity, especially with a diabetic, as the patient may not be able to assess whether it is excessively hot or cold. Arguing with the patient and acting as if he is lying is not therapeutic. The pain is real to him. If the nurse does not believe the patient, the trust between them may be jeopardized. The patient may withhold information in the future. The nurse should not change the medication that is given for severe pain. Vicodin should be given and relief should be assessed within 30 minutes.

Why is it important to auscultate Mr. Johnston's lung sounds frequently? a) Because of the history of hypertension, he is at risk for a heart attack. b) Older hip fracture patients are at risk for osteoporosis. c) He may be at risk for infection. d) He has a history of CHF.

d) He has a history of CHF. Explanation: Mr. Johnston is receiving D5NS with 20 mEq of KCl at 80 mL per hour. Although he had a low BP in the ED, he does have a history of CHF and hypertension. This situation may have caused cardiac enlargement; with the extra fluids, his left ventricle may fail and cause back-up of fluid and pressure into the lungs. Atrial fibrillation involves decreased atrial contraction ability because of quivering ineffective atrial muscle activity. Because Mr. Johnston has been NPO prior to surgery, he needs extra IV fluids to maintain circulation and prevent dehydration. Although Mr. Johnston may be at risk for infection and the lungs could eventually be involved, presently the greatest risk for infection lies in his wound. The history of hypertension may eventually put him at higher risk for a heart attack; however, if the BP is not controlled, he may be at greater risk for a stroke. Although distractor #3 is true, monitoring the lung sounds will not have an effect on the risk for osteoporosis.