Musculoskeletal (Level 3)
The nurse is evaluating the outcome of therapy for a client with osteoarthritis. Which indicates goals of therapy have been met? a. The client's joint degeneration has been arrested. b. The client is able to self-administer gold compound safely. c. The client feels better than on hospital admission. d. The client's joint range of motion has improved.
Correct answer: D One outcome criterion for the client with osteoarthritis is improved joint mobility.It is probably not possible to arrest the disease.Gold compound is administered to clients with rheumatoid arthritis not osteoarthritis. Outcome criteria should be specific; feeling better is too general to be useful
A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first? a. Administer an opioid analgesic. b. Obtain a prescription to adjust the weight amount. c. Offer a muscle relaxant to the client. d. Realign the client's position.
Correct answer: D The nurse should administer opioid analgesics to relieve pain that cannot be controlled with other measures; however, another action is the priority. The nurse should contact the provider to obtain a prescription to adjust the weight amount to relieve pain that cannot be controlled with other measures; however, another action is the priority. The nurse should offer the client a muscle relaxant to relieve pain that cannot be controlled with other measures; however, another action is the priority. The greatest risk to this client is injury form circulatory compromise and tissue damage; therefore, the first action the nurse should take is to realign the client's position
Which is an appropriate outcome for a client with rheumatoid arthritis? a. The client will manage joint pain and fatigue to perform activities of daily living b. The client will maintain full range of motion in joints c. The client will prevent the development of further pain and joint deformity d. The client will take anti-inflammatory medications as indicated by the presence of disease symptoms
Correct answer: A An appropriate outcome for the client with rheumatoid arthritis is that the client adopt self-care behaviors to manage joint pain, stiffness, and fatigue and be able to perform activities of daily living.Range-of-motion (ROM) exercises can help maintain mobility, but it may not be realistic to expect the client to maintain full ROM.Depending on the disease progression, there may be further development of pain and joint deformity, even with appropriate therapy.It is important for the client to understand the importance of taking the prescribed drug therapy even if symptoms have abated
A nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. To assist in meeting this goal, which of the following nursing interventions is the highest priority? a. Maintain immobilization and alignment. b. Provide optimal nutrition and hydration. c. Promote independence in activities of daily living. d. Provide relief from pain and discomfort.
Correct answer: A Maintaining the prescribed immobilization and body alignment will keep the fracture fragments in close anatomical proximity, thereby promoting functional fracture healing. According to the safety and risk reduction priority setting framework, this goal should receive the highest priority. While important for the care of a client who has a fracture, this intervention is not the highest priority according to the safety and risk reduction priority setting framework. While appropriate for the care of a client who has a fracture, this intervention is not the highest priority according to the safety and risk reduction priority setting framework. While necessary for the care of a client who has a fracture, this intervention is not the highest priority according to the safety and risk reduction priority setting framework
A male client underwent a lumbar spinal fusion yesterday. Which nursing assessment should alert the nurse to the development of a possible complication? a. Moderate pain in lower back b. Clear yellowish fluid on the dressing c. Lateral rotation of head and neck d. Nonproductive cough
Correct answer: B Clear yellowish drainage on the dressing could be the sign of a CSF leak which is a serious complication following back surgery.The rest of the options are normal or are not concerning of a complication of back surgery
A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first? a. Change in temperature of the toes. b. Pallor of the toes. c. Edema of the toes. d. Inability to move toes.
Correct answer: B If a cast is too tight it will increase pressure on the blood vessels, impairing circulation. When this occurs, the temperature of the toes will become cool to the touch. However, this is not the initial finding. If a cast is too tight it will increase pressure on the blood vessels, impairing circulation. When this occurs, pallor of the toes is the initial finding. The nurse should immediately report this finding to the provider. If a cast is too tight it will increase pressure on the blood vessels, impairing circulation. When this occurs, edema will become present in the toes. However, this is not the initial finding. If a cast is too tight it will increase pressure on the blood vessels, impairing circulation and nerve transmission. When this occurs, the client will lose the ability to move the toes. However, this is not the initial finding
1The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which is the priority nursing action? a. Provide pin care b. Medicate the client c. Call the healthcare provider d. Remove 2 pounds
Correct answer: C Severe pain in a client in skeletal traction may indicate a need for realignment, or the traction weights applied to the limb may be too heavy. The nurse realigns the client. If this measure is ineffective, the nurse then calls the health care provider. Severe leg pain once traction has been established indicates a problem. Providing pin care is unrelated to the problem as described. Medicating the client should be done after trying to determine and treat the cause. The nurse should never remove the weights from the traction system without a specific prescription to do so
A nurse is preparing discharge instruction for a client with a below-the-knee amputation. Which instruction would be a priority? a. Sterile wound management b. Elevation of the residual limb c. Performing prescribed exercises d. Reporting occurrences of phantom limb pain immediately
Correct answer: C The nurse should advise the client to exercise as prescribed to prevent contracture formation.Aseptic wound management is acceptable.Elevation of the residual limb should be avoided to prevent contracture formation.As phantom limb pain is common, reporting on an imminent basis is unnecessary
When admitting a client with a fractured extremity, the nurse should FIRST assess: a. The area proximal to the fracture b. The actual fracture site c. The area distal to the fracture d. The opposite extremity for baseline comparison
Correct answer: C While assessing the fracture site is important- it is most important to assess for neurovascular status distal to the fracture site to get a baseline and know how well the peripheral limb is getting blood flow
