Musculoskeletal system NCLEX
The nurse is caring for a client recently diagnosed with Parkinson disease (PD). The nurse is assessing the client and knows that PD is characterized by what cardinal signs/symptoms? Select all that apply. 1.Tremor 2.Dry skin 3.Muscle rigidity 4.Postural instability 5.Orthostatic hypertension 6.Bradykinesia or akinesia (slow movement/no movement)
1.Tremor 3.Muscle rigidity 4.Postural instability 6.Bradykinesia or akinesia (slow movement/no movement)
The nurse is evaluating the client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performed which action? 1.Holds the cane on the right side 2.Moves the cane when the right leg is moved 3.Leans on the cane when the right leg swings through 4.Keeps the cane 6 inches out to the side of the right foot
2.Moves the cane when the right leg is moved
The nurse is teaching a client about foods in the diet that could minimize the risk of osteoporosis. The nurse should encourage the client to increase intake of which food? 1.Fish 2.Turkey 3.Cheese 4.Sweet potatoes
3.Cheese
The nurse is caring for a client who had a total knee replacement. Postoperatively, the nurse monitors for which highest priority assessment? 1.Calf pain 2.Heel breakdown 3.Bladder distention 4.Extremity shortening
1. Calf pain
The nurse is caring for a client with a tibial fracture who was just diagnosed with acute compartment syndrome (ACS). Which procedure does the nurse anticipate the surgeon will perform? 1.Fasciotomy 2.Arteriotomy 3.Venous thromboectomy 4.External compartment removal
1.Fasciotomy
A client is admitted to the nursing unit after a left below-knee amputation following a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How does the nurse correctly interpret the client's statement? 1."It is a normal response and indicates the presence of phantom limb pain." 2."It is a normal response and indicates the presence of phantom limb sensation." 3."It is an abnormal response and indicates that the client is in denial about the limb loss." 4."It is an abnormal response and indicates that the client needs more psychological support."
2."It is a normal response and indicates the presence of phantom limb sensation."
The nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. The client has been prescribed hip precautions. The nurse plans to implement which activities in the care of the client? Select all that apply. 1.Ensure the client doesn't bend the hips beyond 120 degrees. 2.Ensure the client doesn't sit or stand for long periods of time. 3.Ensure the client engages in rigorous exercise to maintain strength. 4.Ensure the client doesn't cross the legs past the midline of the body. 5.Ensure the client uses assistive/adaptive devices with activities of daily living.
2.Ensure the client doesn't sit or stand for long periods of time. 4.Ensure the client doesn't cross the legs past the midline of the body. 5.Ensure the client uses assistive/adaptive devices with activities of daily living.
A postoperative client received a spinal anesthetic. The client has not experienced pain because the anesthetic has not yet worn off. The nurse should monitor the client closely for pain and provide the client with which instruction? 1."I will be bringing your pain medication at 10:00 pm." 2."You will not feel pain because of the spinal anesthesia." 3."You will need to let me know when you start to get feeling back in your legs." 4."You will not be able to take pain medication until you have been up to the bathroom."
3."You will need to let me know when you start to get feeling back in your legs."
A client is treated in the primary health care provider's office for a sprained ankle. Before sending the client home, the nurse plans to reinforce instructions to the client about which item to avoid in the next 24 hours? 1.Resting the foot 2.Applying an Ace wrap 3.Applying a heating pad 4.Elevating the ankle on a pillow while sitting or lying down
3.Applying a heating pad
The nurse has reinforced instructions with the client with a nonplaster (fiberglass) leg cast about cast care at home. The nurse determines that the client needs further teaching if the client makes which statement? 1."I should avoid walking on wet, slippery floors." 2."I'm not supposed to scratch the skin underneath the cast." 3."It's all right to wipe dirt off the top of the cast with a damp cloth." 4."If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting."
4."If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting."
The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest to minimize the pain. The nurse plans to put the bed in which position? 1.Flat with the knee gatch raised 2.In semi-Fowler's position with the foot of the bed flat 3.In high-Fowler's position with the foot of the bed flat 4.In semi-Fowler's position with the knee gatch slightly raised
4.In semi-Fowler's position with the knee gatch slightly raised
The nurse is caring for a client who sustained multiple fractures in a motor vehicle accident 12 hours ago. The client develops severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. Which is the nurse's initial action? 1.Reassess the vital signs. 2.Perform a neurological assessment. 3.Place the client in a supine position. 4.Place the client in a Fowler's position.
4.Place the client in a Fowler's position.
The nurse is reinforcing instructions to a client with osteoporosis regarding appropriate food items to include in the diet. The nurse tells the client that which food item would provide the least amount of calcium? 1.Pork 2.Seafood 3.Sardines 4.Plain yogurt
2. Seafood
The nurse in the emergency department is caring for a client with a fractured arm. The nurse understands that which item is least likely needed before reduction of the fracture in the casting room? 1.Anesthesia consent 2.Consent for the procedure 3.Administration of an analgesic 4.Explanation of the procedure to the client
1. Anesthesia consent
The nurse has reinforced client instructions regarding crutch safety. Which comment by the client would indicate a need for further teaching? 1."Crutch tips will not slip, even when wet." 2."Use of someone else's crutches is a bad idea." 3."Crutch tips should be inspected periodically for wear." 4."I need to have spare crutches and tips available."
1."Crutch tips will not slip, even when wet."
The nurse is teaching a client about crutch walking. Which comment by the client indicates a need for further teaching? 1."I know I need strong arm muscles to walk with crutches." 2."My crutches must rest up underneath my arm for extra support." 3."I need to make sure that there are rubber tips on the ends of my crutches so I won't slip." 4."I'm going to use the three-point gait, because it allows little weight bearing on my affected leg."
1."I know I need strong arm muscles to walk with crutches."
A client is complaining of pain underneath a cast in the area of a bony prominence. Which should the nurse anticipate? 1.The cast will be bivalved. 2.A window will be cut in the cast. 3.The cast will be replaced with an air splint. 4.Extra padding will be put over this area of the cast
2. A window will be cut in the cast
A client with skeletal traction applied to the right leg complains to the nurse about severe right leg pain in spite of being medicated with a prescribed analgesic. Which action should the nurse take? 1. Provide pin care. 2.Notify the registered nurse. 3.Remove some of the traction weights. 4.Find out when the next dose of the prescribed analgesic can be given.
2. Notify the registered nurse
The nurse is caring for a client diagnosed with Paget's disease. What abnormal laboratory values would the nurse specifically monitor in a client with Paget's disease? Select all that apply. 1.Decreased potassium 2.Elevated serum calcium 3.Elevated serum amylase 4.Increased creatine kinase (CK-MM) 5.Elevated serum alkaline phosphatase (ALP) 6.Elevated 24-hour urinary hydroxyproline level
2. Elevated serum calcium 5. Elevated serum alkaline phosphate 6. Elevated 24-hour urinary hydroxyproline level
A client with a left arm fracture exhibits loss of sensation in the left fingers, pallor, slow refill, and diminished left radial pulse. The licensed practical nurse (LPN) should take which action? 1.Administer an analgesic. 2.Notify the registered nurse. 3.Check the circulation again in 30 minutes. 4.Provide range-of-motion exercises to the fingers of the left hand.
2. Notify the registered nurse
A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if which action is noted? 1.The client holds the walker using the handgrips. 2.The client advances the walker with reciprocal motion. 3.The client leans forward slightly when advancing the walker. 4.The client supports body weight on the hands while advancing the weaker leg.
2. The client advances the walker with reciprocal motion
The nurse is caring for a client with a long bone fracture who is at risk for fat embolism. The nurse specifically monitors for the early signs of this complication by checking which criteria? Select all that apply. 1.The client's renal system 2.The client's mental status 3.The client's mobility status 4.The client's respiratory function 5.The client's cardiovascular system
2.The client's mental status 4.The client's respiratory function
A client is experiencing an acute exacerbation of bursitis. The nurse encourages the client to avoid which least likely helpful measure until the current episode is resolved? 1.Resting the joint 2.Applying moist heat 3.Elevation of the joint 4.Active intermittent range of motion
4.Active intermittent range of motion
The home care nurse is caring for a client who had a below-the-knee amputation of the right leg. What are some teaching points the nurse gives to the client and family? Select all that apply 1.Apply the bandage in a top-down manner. 2.Use a shrinker stocking or sock to cover the wrapped stump. 3.Rewrap the residual limb once a day with an elastic bandage. 4.Begin residual limb care when sutures or staples are removed. 5.After the limb is healed, it is cleaned each day with the rest of the body during bathing with soap and water. 6.When the staples or sutures are removed, inspect the end of the residual limb every day for signs of inflammation or skin breakdown.
2.Use a shrinker stocking or sock to cover the wrapped stump. 3.Rewrap the residual limb once a day with an elastic bandage. 6.When the staples or sutures are removed, inspect the end of the residual limb every day for signs of inflammation or skin breakdown.
A client has several fractures of the lower leg and has been placed in an external fixation device. The client is upset about the appearance of the leg, which is very edematous. The nurse determines that the client is experiencing which problem? 1.Feelings of isolation 2.Inability to tolerate activity 3.Concerns about body image 4.Inability to physically move about
3. Concerns about body image
A client with type 1 diabetes mellitus has had a left above-the-knee amputation. The nurse carefully inspects the residual limb for which complication because of the history of diabetes? 1.Pain 2.Hemorrhage 3.Edema of the stump 4.Separation of wound edges
3. Edema of the stump
A client has been placed in Buck's extension traction. Which technique provided by the nurse will provide countertraction? 1.Using a footboard 2.Providing an overhead trapeze 3.Slightly elevating the foot of the bed 4.Slightly elevating the head of the bed
3. Slightly elevating the foot of the bed
he nurse is discharging a client who had conventional open back surgery. Which comment by the client indicates a need for further teaching? 1."I plan to restrict or limit my driving." 2."I will avoid bending and twisting at the waist." 3."I'll go for a walk every day, but I won't take the dog." 4."I'll be careful not to lift anything heavier than 20 pounds."
4. I'll be careful not to lift anything heavier than 20 lbs
This morning a client sustained a right proximal fibula and tibia fracture that was casted in a long leg plaster cast. During evening rounds, the nurse notes that the right lower extremity capillary refill is greater than 3 seconds and the toes are edematous and dusky. The client states that the pain medication is not working anymore and that the right foot feels like it is asleep. The nurse analyzes the data and determines that the client's signs/symptoms are indicative of which complication? 1.Fat embolism 2.Venous thrombosis 3.Volkmann's thrombosis 4.Compartment syndrome
4. compartment syndrome
The nurse is reinforcing discharge instructions to a client following surgical treatment for carpal tunnel syndrome. Which statement by the client would indicate a need for further teaching? 1."I should elevate my arm to reduce the swelling." 2."I should use a sling to limit movement and keep my arm elevated." 3."I should return to the primary health care provider in about 10 days to have the sutures removed." 4."I should perform pronation and supination exercises of my wrist starting 24 hours after surgery."
4."I should perform pronation and supination exercises of my wrist starting 24 hours after surgery."
The nurse has given a client instructions on how to do active range-of-motion exercises on her contracted right hand. The nurse determines that the client understands the rationale for this procedure when the client makes which statement? 1."I'm doing this, so I can go home soon." 2."It hurts, but things always have to hurt at my age." 3."If I don't do this, that therapist gets really angry at me." 4."I'm doing these exercises so I can begin to fasten my buttons and dress myself again."
4."I'm doing these exercises so I can begin to fasten my buttons and dress myself again."
The nurse is caring for a client who has had a spinal fusion with insertion of hardware. The nurse should be especially concerned with which finding? 1.An oral temperature of 101° F orally 2.Complaints of discomfort during repositioning 3.Old bloody drainage outlined on the surgical dressing 4.Discomfort during coughing and deep breathing exercises
1. An oral temperature of 101° F orally
The nurse stops at the scene of an automobile accident to assist a victim. The victim complains of severe leg pain, is unable to get out of the automobile, and is frightened. Which is the appropriate nursing action? 1.Stay with the victim. 2.Assist the victim out of the automobile. 3.Leave the victim to call an ambulance. 4.Tell the victim to keep moving the leg to maintain circulation.
1.Stay with the victim.
A client with a herniated intervertebral lumbar disk complains of a knifelike, stabbing pain in the lower back, as well as pain radiating into the right buttock. The nurse interprets that the sharp, stabbing pain is probably a result of which reason? 1.Pressure on the spinal cord 2.Pressure on the spinal nerve root 3.Muscle spasm in the area of the herniated disk 4.Excess cerebrospinal fluid production in the area
2. Pressure on the spinal nerve root
The nurse is providing care for a client following a bone biopsy. Which action by the nurse is unnecessary in the care of this client? 1.Elevating the limb for 24 hours 2.Monitoring vital signs every 4 hours 3.Administering intramuscular opioid analgesics 4.Monitoring the site for swelling, bleeding, hematoma
3. Administering intramuscular opioid analgesics
A nursing instructor asks a nursing student about the risk factors associated with osteoporosis. The instructor determines that the student needs further teaching if the student states that which is an associated risk factor? 1.Postmenopausal age 2.Family history of osteoporosis 3.High-calcium diet consumption 4.Long-term use of corticosteroids
3. High-calcium diet consumption
The nurse is providing care to a client with this type of cast. (Refer to figure.) The nurse documents that the client has which type of cast? 1.A long leg cast 2.A short leg cast 3.A hip spica cast 4.A body jacket cast
3. a hip spica cast
The nurse is checking the casted extremity of a client. The nurse should check for which sign indicative of infection? 1.Dependent edema 2.Diminished distal pulse 3.Presence of a "hot spot" on the cast 4.Coolness and pallor of the extremity
3.Presence of a "hot spot" on the cast
A client has sustained multiple fractures in the left leg and is in skeletal traction. The nurse has obtained an overhead trapeze for the client's use to aid in bed mobility. The nurse should monitor for which high-risk area for pressure and breakdown? 1.Left heel 2.Scapulae 3.Right heel 4.Back of the head
3.Right heel
The nurse prepares to care for a client with inflamed joints and plans to use which item to maintain proper positioning for the inflamed joints? 1.Footboards 2.Large pillows 3.Small pillows 4.Soft mattress
3.Small pillows
The nurse reinforces cast application instructions to a client who is going to have a plaster cast applied. The nurse determines that the client needs further teaching if the client makes which statement about the casting? 1.The cast will give off heat as it dries. 2.The cast edges may be trimmed with a cast knife. 3.The client may bear weight on the cast in 30 minutes. 4.A stockinette will be placed over the leg area to be casted.
3.The client may bear weight on the cast in 30 minutes.
A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention? 1.Massaging the skin at the rim of the cast 2.Petaling the cast edges with adhesive tape 3.Using a rough file to smooth the cast edges 4.Applying lotion to the skin at the rim of the cast
2.Petaling the cast edges with adhesive tape
The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. How should the nurse plan to position the client? 1.Trochanter roll to prevent abduction while turning 2.Pillow to keep the right leg abducted during turning 3.Pillow to keep the right leg adducted during turning 4.Trochanter roll to prevent external rotation while turning
2.Pillow to keep the right leg abducted during turning
The nurse is preparing to reinforce instructions to a client regarding how to safely use crutches. Before initiating the teaching, the nurse collects data on the client. Which priority data should be included? 1.The client's fear related to the use of the crutches 2.The client's feelings about the restricted mobility 3.The client's understanding of the need for increased mobility 4.The client's vital signs, muscle strength, and previous activity level
4. The clients vital signs, muscle strength, and previous activity level
The nurse is caring for a client who was admitted to the hospital with a fractured right femur sustained from a fall 5 hours ago. The client's plan of care includes interventions related to monitoring for signs/symptoms of fat embolism. The nurse provides appropriate care by performing which action? 1.Monitoring for signs of dyspnea 2.Monitoring the client's temperature regularly 3.Maintaining external rotation of the right leg 4.Educating the client to report paresthesia of the right lower leg
1. monitoring for signs of dyspnea
A client is being discharged after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement? 1."I need to avoid getting the cast wet." 2."I will use my fingertips to lift and move the leg." 3."I need to cover the casted leg with warm blankets." 4."I can use a padded coat hanger end to scratch under the cast."
1."I need to avoid getting the cast wet."
A client has just had a cast removed and the underlying skin is yellow-brown and crusted. The nurse determines that further instructions are needed about skin care if the client makes which statement? 1."I will soak the skin and then wash it gently." 2."I need to scrub the skin vigorously with soap and water." 3."I need to apply an emollient lotion to enhance softening." 4."I need to use a sunscreen on the skin if it will be directly exposed to the sun."
1."I will soak the skin and then wash it gently.
The nurse is caring for a client with a fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment syndrome by which action? 1.Elevating the limb and applying ice to the affected leg 2.Elevating the limb and covering it with bath blankets 3.Keeping the leg horizontal and applying ice to the affected leg 4.Placing the leg in a slightly dependent position and applying ice
1.Elevating the limb and applying ice to the affected leg
The nurse has reviewed activity restrictions with a client who is being discharged following hip surgery and insertion of a femoral head prosthesis. The nurse determines that the client understands the material presented if the client makes which statement? 1."I will use a raised toilet seat." 2."I will bend carefully to put on socks and shoes." 3."I will sit in chairs without arms for better mobility." 4."I will exercise the leg past the point of 90-degree flexion."
1. I will use a raised toilet seat
An older client with advanced Alzheimer's disease is placed in balanced suspension traction, and the primary health care provider expects to internally fixate the client's femur in 1 week. Based on this information, the nurse determines that the priority relates to addressing which client problem? 1.Risk for constipation 2.Impaired tissue integrity 3.Risk for activity intolerance 4.Disturbed thought processes
1. Risk for constipation
A client who has had a total knee replacement tells the nurse that there is pain with extension of the knee. Which action should the nurse implement? 1.Administer an analgesic. 2.Immobilize the knee temporarily. 3.Notify the primary health care provider immediately. 4.Put the client's knee through full passive range of motion.
1. administer an analgesic
The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position? 1.3 inches to the front and side of the client's toes 2.8 inches to the front and side of the client's toes 3.15 inches to the front and side of the client's toes 4.20 inches to the front and side of the client's toes
2.8 inches to the front and side of the client's toes
During admission data collection the nurse asks the client to run the heel of one foot down the lower anterior surface of the other leg. The nurse notices rhythmic tremors of the leg being tested and concludes that the client has interference in which area? 1.Sensation and reflexes 2.Balance and coordination 3.Bowel and bladder control 4.Muscle strength and flexibility
2.Balance and coordination
The nurse is caring for a client admitted with fat embolism syndrome (FES). Which are some of the early manifestations of this syndrome? Select all that apply. 1.Fever 2.Dyspnea 3.Petechiae 4.Hypoxemia 5.Tachypnea 6.Decreased level of consciousness
2.Dyspnea 4.Hypoxemia 5.Tachypnea
A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which area as a high-risk area for pressure and breakdown? 1.Scapulae 2.Left heel 3.Right heel 4.Back of the head
2. Left heel
The nurse is planning to teach a client with a left arm cast about measures to keep the left shoulder from becoming stiff. Which suggestion should the nurse include in the teaching plan? 1."Use a sling on the left arm." 2."Lift the left arm up over the head." 3."Lift the right arm up over the head." 4."Make a fist with the hand of the casted arm."
2."Lift the left arm up over the head."
The nurse is planning to reinforce instructions to the client about proper use of a thoracolumbosacral orthosis (TLSO) after spinal fusion with instrumentation. The nurse plans to include which teaching points in discussion with the client? 1.The brace should be applied directly next to the skin. 2.The device is applied before getting out of bed in the morning. 3.The Velcro closures should be fairly loose to avoid constriction. 4.Areas of skin redness at the edges of the brace indicate a good, snug fit.
2.The device is applied before getting out of bed in the morning.
A client has undergone fasciotomy to treat compartment syndrome of the leg. Which type of wound care should the nurse anticipate will be prescribed for the fasciotomy site? 1.Dry, sterile dressings 2.Hydrocolloid dressings 3.Moist, sterile saline dressings 4.Half-strength povidone-iodine dressings
3.Moist, sterile saline dressings
A client has just had skeletal traction applied following insertion of pins. The nurse should place highest priority on performing which action? 1.Performing pin site care 2.Explaining to the client the upcoming pin care procedure 3.Ensuring that the weights on the traction setup are hanging free 4.Providing for diversion such as watching television or reading a newspaper
3. ensuring that the weights on the traction setup are hanging free
Which statement by the client who has received home care instruction following an arthroscopy of the knee indicates a need for further teaching? 1."I should elevate my knee while sitting." 2."I should avoid excessive use of the joint for several days." 3."I can apply heat to my knee if it becomes uncomfortable." 4."I should return to the primary health care provider in about 7 days for follow-up."
3."I can apply heat to my knee if it becomes uncomfortable."
A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when he will be able to walk on the cast. How should the nurse correctly respond to this question? 1.In 24 hours 2.In 48 hours 3.In approximately 8 hours 4.Within 20 to 30 minutes of application
4 within 20 to 30 minutes of application
The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action? 1.Try to manually reduce the fracture. 2.Assist the person with getting up and walking to the sidewalk. 3.Leave the person for a few moments to call an ambulance. 4.Stay with the person and encourage the person to remain still.
4. Stay with the person and encourage the person to remain still
The nurse is caring for a client who had a total knee replacement and was put on a continuous passive motion (CPM) machine in the postanesthesia care unit (PACU). What are some of the actions the nurse needs to monitor to operate this machine? Select all that apply. 1.Ensure that the machine is well padded. 2.Assess the client's response to the machine. 3.When the machine is not in use, store it on the floor. 4.Check the cycle and range-of-motion settings once a day. 5.Turn off the machine while the client is having a meal in bed. 6.Make sure that the joint being moved is properly positioned on the machine.
1.Ensure that the machine is well padded. 2.Assess the client's response to the machine. 5.Turn off the machine while the client is having a meal in bed. 6.Make sure that the joint being moved is properly positioned on the machine.
The nurse is caring for a client diagnosed with Paget's disease. The nurse plans care knowing that this condition usually affects which bones? Select all that apply. 1.Femur 2.Skull 3.Tibia 4.Sternum 5.Shoulder 6.Vertebrae
1.Femur 2.Skull 3.Tibia 6.Vertebrae
The nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? Select all that apply. 1.Keep the cast and extremity elevated. 2.The cast needs to be kept clean and dry. 3.Allow the wet cast 24 to 72 hours to dry. 4.Expect tingling and numbness in the extremity. 5.Use a hair dryer set on a warm to hot setting to dry the cast. 6.Use a soft-padded object that will fit under the cast to scratch the skin under the cast.
1.Keep the cast and extremity elevated. 2.The cast needs to be kept clean and dry. 3.Allow the wet cast 24 to 72 hours to dry.
A client with right-sided weakness needs to learn how to use a cane. How should the nurse teach the client to position the cane? 1.Left hand, and 6 inches lateral to the left foot 2.Right hand, and 6 inches lateral to the right foot 3.Left hand, placing the cane in front of the left foot 4.Right hand, placing the cane in front of the right foot
1.Left hand, and 6 inches lateral to the left foot
The nurse is caring for a client recently diagnosed with secondary gout. Secondary gout involves hyperuricemia (excessive uric acid in the blood) caused by another disease or factor. Which diseases or factors make clients more at risk for acquiring this condition? Select all that apply. 1.Older clients 2.Obese people 3.Client with liver disease 4.Postmenopausal women 5.Clients from poor economic communities 6.Clients with cardiovascular health problems
1.Older clients 2.Obese people 3.Client with liver disease
An elderly client is brought to the emergency department via ambulance after sustaining a fall. An x-ray indicates that the client sustained a femoral neck fracture. The nurse is collecting data from the client and knows that which disease processes increase the older adult's risk for hip fractures? Select all that apply 1.Osteoporosis 2.Foot disorders 3.Bony metastases 4.Carpal tunnel syndrome 5.Diminished visual acuity 6.Changes in cardiac function
1.Osteoporosis 2.Foot disorders 5.Diminished visual acuity
The nurse is collecting data from a client who is being seen in the health care clinic. The client is complaining of unrelieved back pain that has persisted over the past 3 months. The nurse determines that which harmful effect can occur as a result of uncontrolled muscle pain? 1.Anorexia 2.Weakness 3.Weight loss 4.Hypertension
2. Weakness
A client has had surgery to repair a fractured left hip. The nurse plans to use which important item when repositioning the client from side to side in the bed? 1.Bed pillow 2.Abductor splint 3.Adductor splint 4.Overhead trapeze
2. abductor splint
A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. The nurse avoids using which intervention in an effort to relieve the spasm? 1.Heat 2.Cold 3.Analgesics 4.Prescribed intermittent traction
2. cold
A client has just undergone spinal fusion after suffering a herniated lumbar disk. The nurse should avoid which action to maintain client safety after this procedure? 1.Keeping the head of bed flat 2.Having the client use an overhead trapeze 3.Having the client use a logrolling technique for repositioning 4.Placing pillows under the length of the legs
2. having the client use an overhead trapeze
The nurse has provided instructions to a client in an arm cast about the signs/symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states to report which early symptom of compartment syndrome? 1.Cold, bluish fingers 2.Numbness and tingling in the fingers 3.Pain that increases when the arm is dependent 4.Pain that is relieved only by an opioid analgesic
2. numbness and tingling in the fingers
The nurse is caring for a client who has a cast applied to the left lower leg. On data collection, the nurse notes the presence of skin irritation from the edges of a cast. Which nursing intervention is appropriate? 1.Contact the primary health care provider. 2.Petal the cast edges with adhesive tape. 3.Massage the skin at the edges of the cast. 4.Place a small face cloth in the cast around the edges of the cast.
2.Petal the cast edges with adhesive tape.
A client with a fractured femur is placed in skeletal traction. The nurse should do which to monitor for nerve injury? 1.Check the blood pressure. 2.Check the pin sites for drainage. 3.Check the neurovascular status of the affected extremity. 4.Monitor the client's ability to perform active range of motion to the affected extremity.
3.Check the neurovascular status of the affected extremity.
The nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed to touch down the affected leg. How should the nurse teach the client to use the crutches? 1.Crutches and then both legs simultaneously 2.Crutches and the right leg, then advance the left leg 3.Crutches and the left leg, then advance the right leg 4.Left leg and right crutch, then right leg and left crutch
3.Crutches and the left leg, then advance the right leg
The nurse is caring for a client who has just had rotator cuff repair. The client asks the nurse how soon he can resume his tai chi classes. The nurse should make which statement to the client? 1."You will never be able to do tai chi again!" 2."Tai chi is good for you, so you can start any time." 3."Tai chi uses only your leg muscles, so it would be all right." 4."You shouldn't be doing any exercises that require the use of your upper arms until you have been cleared to do so by the primary health care provider."
3."Tai chi uses only your leg muscles, so it would be all right."
A client who is scheduled for surgery and who is to be placed in skeletal traction says to the nurse, "I'm not sure if I want to have this skeletal traction or if the skin traction would be best to stabilize my fracture." Based on the client's statement, the nurse should make which response to the client? 1."There is no reason to be concerned. I have seen lots of these procedures." 2."Skeletal traction is much more effective than skin traction in your situation." 3."You have concerns about skeletal versus skin traction for your type of fracture?" 4."Your fracture is very unstable. You will die if you don't have this surgery performed."
3."You have concerns about skeletal versus skin traction for your type of fracture?"
The nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. How should the nurse explain compartment syndrome? 1.A bone fragment has injured the nerve supply in the area. 2.An injured artery causes impaired arterial perfusion through the compartment. 3.Bleeding and swelling cause increased pressure in an area that cannot expand. 4.The fascia expands with injury, causing pressure on underlying nerves and muscles.
3.Bleeding and swelling cause increased pressure in an area that cannot expand.
The nurse is preparing to collect data from a client who has sustained a pelvic fracture following a motor vehicle crash. The nurse reviews the primary health care provider's (PHCP) prescriptions and notes that the PHCP has prescribed a pelvic (skin) sling. The nurse prepares to place the client in which device? Refer to figure. 1.A 2.B 3.C 4.D
3.C
The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the priority? 1.Take a set of vital signs. 2.Call the radiology department. 3.Immobilize the leg before moving the client. 4.Reassure the client that everything will be fine.
3.Immobilize the leg before moving the client.
A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by which condition? 1.Infection under the cast 2.The anxiety of the client 3.Impaired tissue perfusion 4.The newness of the fracture
3.Impaired tissue perfusion
The nurse is caring for a comatose client at risk for fat embolism because of a fractured femur and pelvis sustained in a fall. Which finding does the nurse identify as early signs/symptoms of possible fat embolism? 1.Decreased heart rate and increased restlessness 2.Decreased heart rate and decreased respiratory rate 3.Increased heart rate and adventitious breath sounds 4.Increased heart rate and increased oxygen saturation
3.Increased heart rate and adventitious breath sounds
A client has Buck's extension traction applied to the right leg. The nurse should plan which intervention to prevent complications of the device? 1.Giving pin care once a shift 2.Massaging the skin of the right leg with lotion every 8 hours 3.Inspecting the skin on the right leg at least once every 8 hours 4.Releasing the weights on the right leg for range-of-motion exercises daily
3.Inspecting the skin on the right leg at least once every 8 hours
The nurse is teaching a client how to walk with a cane. Which information should the nurse include? Select all that apply. 1.The cane is placed on the affected side. 2.A quad-cane provides a narrower base for the cane. 3.The cane should create no more than 30 degrees of flexion of the elbow. 4.The top of the cane should be parallel to the greater trochanter of the femur. 5.A straight leg cane is used if the client only needs minimal support for an affected leg.
3.The cane should create no more than 30 degrees of flexion of the elbow. 4.The top of the cane should be parallel to the greater trochanter of the femur. 5.A straight leg cane is used if the client only needs minimal support for an affected leg.
The nurse is caring for a client with a diagnosis of osteoarthritis. Which actions would be least helpful for the client? 1.Gentle regular exercise 2.A warm bath or shower early in the day 3.increasingly vigorous and high-impact exercise 4. An individualized program of pain medication.
3.increasingly vigorous and high-impact exercise
The nurse is teaching a male client with osteomalacia about this disorder. Which comment by the client indicates a need for further teaching? 1."I need to take high doses of vitamin D." 2."Calcification does not occur to harden my bones." 3."Vitamin D helps calcium to be absorbed in my small intestines." 4."This condition is primarily due to my lack of calcium and testosterone."
4."This condition is primarily due to my lack of calcium and testosterone."
The nurse is caring for a client with osteoarthritis. The nurse collects data, knowing that which is a sign/symptom associated with this disorder? 1.Morning stiffness 2.Positive rheumatoid factor 3.An elevated sedimentation rate 4.Dull aching pain in the affected joints
4.Dull aching pain in the affected joints
The nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the casted leg, the nurse should perform which intervention? 1.Keep the leg in a level position. 2.Elevate the leg for 3 hours, and put it flat for 1 hour. 3.Keep the leg level for 3 hours, and elevate it for 1 hour. 4.Elevate the leg on pillows continuously for 24 to 48 hours.
4.Elevate the leg on pillows continuously for 24 to 48 hours.
A client has just had an application of a nonplaster cast. What are some of the synthetic materials used for nonplaster casts? Select all that apply. 1.Rayon 2.Nylon 3.Neoprene 4.Fiberglass 5.Polyester-cotton knit
4.Fiberglass 5.Polyester-cotton knit
The nurse has provided instructions to a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that the client needs further teaching if the client verbalizes which action should be done? 1.Increase fiber and fluids in the diet. 2.Bend at the knees to pick up objects. 3.Strengthen the back muscles by swimming or walking .4.Get out of bed by sitting straight up and swinging the legs over the side of the bed.
4.Get out of bed by sitting straight up and swinging the legs over the side of the bed.
The nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which is a primary prevention measure? 1.Selecting shoes that have firm nonskid soles 2.Applying nonskid strips on areas that get wet 3.Installing telephones in several rooms of the house 4.Maintaining body weight at or above minimum recommended levels
4.Maintaining body weight at or above minimum recommended levels
A client has undergone total hip replacement of the right hip, which was damaged by osteoarthritis. Which action should be included in the postoperative plan of care? 1.Ensure the client receives the daily tablet of enoxaparin. 2.Assist the client in keeping the legs as close together as possible. 3.Remind the client to use a handrail when lowering the hips into a 120-degree flexion. 4.Partial weight bearing on the operative leg is usually permitted 72 hours postoperatively; check surgeon's prescription.
4.Partial weight bearing on the operative leg is usually permitted 72 hours postoperatively; check surgeon's prescription.
The nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further teaching if the nurse observes the client doing which activity? 1.Pulling up on the trapeze 2.Flexing and extending the feet 3.Doing quadriceps-setting and gluteal-setting exercises 4.Performing active range of motion (ROM) to the right ankle and knee
4.Performing active range of motion (ROM) to the right ankle and knee
The nurse is providing postprocedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should reinforce which client instruction? 1.Resume regular full activity the following day. 2.Do not eat or drink anything until the following morning. 3.Keep the shoulder completely immobilized for the rest of the day. 4.Report to the registered nurse the development of fever or redness and heat at the site.
4.Report to the registered nurse the development of fever or redness and heat at the site.
The nurse is caring for a client who had an above-the-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage that has fallen off. The nurse should immediately perform which action? 1.Apply ice to the site. 2.Call the primary health care provider. 3.Apply a dry sterile dressing and elevates it on one pillow. 4.Rewrap the residual limb with an elastic compression bandage.
4.Rewrap the residual limb with an elastic compression bandage.
A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful? 1.Telling the client that the saw makes a frightening noise 2.Reassuring the client that no one has had an arm lacerated yet 3.Stating that the hot cutting blades cause burns only very rarely 4.Showing the client the cast cutter and explaining how it works
4.Showing the client the cast cutter and explaining how it works
A primary health care provider has given a prescription for dietary iron supplements to the client with osteoporosis who has an iron deficiency anemia. The nurse suggests that the client do which to enhance compliance with therapy? 1.Decrease fluid intake. 2.Decrease dietary fiber. 3.Chew the tablet thoroughly. 4.Take the medication following a meal
4.Take the medication following a meal
A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. What should the nurse tell the client to provide greater reassurance? 1.Canes prevent falls, not cause them. 2.The physical therapist will determine if the cane is inadequate. 3.The cane would help break a fall, even if the client does slip. 4.The cane has a flared tip with concentric rings to provide stability.
4.The cane has a flared tip with concentric rings to provide stability.