Muskulo Prob 1

A client with a short-leg plaster cast complains of an intense itching under the cast. The nurse provides instructions to the client regarding relief measures for the itching. Which client statement indicates an understanding of appropriate measures to relieve the itching?

"I can use a hair dryer on the low setting and allow the cool air to blow into the cast." Therefore, the best way to relieve itching is with a forceful injection of air inside the cast.

A client has been experiencing muscle weakness over a period of several months. The primary health care provider suspects polymyositis. Which client statement correctly identifies a confirmation of test results and this diagnosis?

"I will know I have polymyositis if the muscle fibers are inflamed." Rationale: In polymyositis, necrosis and inflammation are seen in muscle fibers and myocardial fibers.

The client with a crush injury to the leg has a highly positive urine myoglobin level. The nurse would assess this client carefully for signs and symptoms of which problem?

Acute tubular necrosis. When a large amount of myoglobin is being cleared from the body, there is a risk of the renal tubules being clogged with myoglobin, causing acute tubular necrosis.

A client with a femur fracture develops fat embolus and is experiencing respiratory distress. The nurse plans to assist with which therapies?

Administration of oxygen, intubation, and mechanical ventilation with positive end-expiratory pressure. Rationale: Respiratory failure is the most common cause of death after fat embolus

A client is treated in a primary health care provider's office for a sprained ankle after a fall. Radiographic examination has ruled out a fracture. Before sending the client home, the nurse plans to teach the client to avoid which activity in the next 24 hours?

Applying a heating pad. Rationale: Soft tissue injuries such as sprains are treated by RICE (rest, ice, compression, and elevation) for the first 24 hours after the injury. Ice is applied intermittently for 20 to 30 minutes at a time. Heat is not used in the first 24 hours because it could increase venous congestion, which would increase edema and pain.

The nurse is teaching a client who had a lumbar laminectomy how to perform activities of daily living without causing strain on the back. Which action performed by the client indicates a need for further instruction?

Bends over to tie shoes. Rationale: To prevent strain on the lower back, it is important to use proper body mechanics. This includes bending at the knees, and not at the waist, when picking things up or lifting.

The nurse is caring for a client diagnosed with osteitis deformans (Paget's disease). Which does the nurse identify as the cause of the client's stooped posture and bowing of lower extremities?

Bone resorption and regeneration. Rationale: Paget's disease is characterized by skeletal deformities resulting from abnormal bone resorp‐ tion followed by abnormal regeneration.

The nurse is performing a musculoskeletal assessment of an immobile client for disuse osteoporosis. Which would the nurse assess to obtain the best information about the bone remodeling process?

Calcitonin. Bone remodeling is the result of osteoblastic and osteoclastic activities, calcitonin (which antagonizes parathyroid hormone and inhibits bone resorption)

A client is admitted to the emergency department with an open fracture of the right tibia. What intervention is most appropriate for this client?

Check the neurovascular status of the area distal to the extremity. Rationale: To prevent further damage, the neurovascular status must be assessed for temperature, color, sensation, movement, and capillary refill.

A client has been diagnosed with gout, and the nurse provides dietary instructions. The nurse determines that the client needs additional teaching if the client states that it is acceptable to eat which food?

Chicken liver. Rationale: Liver and other organ meats would be omitted from the diet of a client who has gout because of their high purine content.

A client with a left arm fracture supported in a cast complains of loss of sensation in the left fingers. The nursing assessment identifies pallor in the distal portion of the arm, poor capillary refill, and a diminished left radial pulse. On the basis of these findings, the nurse would take which as a priority action?

Contact the primary health care provider (PHCP). These signs also can occur with constriction from a tight cast. Regardless of the cause, the nurse notifies the PHCP immediately. Emergency intervention is needed, which could entail removal of the constricting cast, fracture reduction, or surgery to repair the area.

The nurse is caring for a client who had surgery to repair a fractured left-sided hip using a posterior approach. In implementing hip precautions, which action would the nurse teach the client to avoid?

Crossing legs at the ankle. ​

The nurse is caring for a client diagnosed with osteomyelitis from a skeletal injury. Which mechanism of the disease process can result in necrosis of the bone?

Devascularization. A microorganism gains entry into the blood and grows, causing increased pressure on the bone, leading to ischemia and ultimately necrosis as a result of devascularization.

The occupational health nurse is called to care for an employee who experienced a traumatic amputation of a finger. Which actions would the nurse take to provide emergency care and prepare the client for transport to the hospital? Select all that apply.

Elevate the extremity above heart level. Assess the employee for airway or breathing problems. Examine the amputation site and apply direct pressure to the site using layers of gauze.The gauze that is applied is a pressure dressing and is not removed because of the risk of dislodgment of a clot that may be forming; the pressure dressing will be removed at the hospital. The extremity is elevated above the victim's heart level to decrease the bleeding. The severed finger needs to be wrapped in dry, sterile gauze (if available) or a clean cloth. It is placed in a watertight, sealed plastic bag.

The nurse is gathering subjective and objective data from a client with a diagnosis of suspected rheumatoid arthritis (RA). The nurse would expect to note which early signs and symptoms of RA? Select all that apply.

Fatigue. Morning stiffness. Rationale: Early signs and symptoms of RA include fatigue, weight loss, fever, malaise, morning stiffness, pain at rest and with movement, and complaints of night pain. The involved joints appear edematous.

The nurse provides instructions to a client diagnosed with osteoporosis. Education about prevention of which complication is the most important?

Fractures. Rationale: bone disease characterized by low bone mass and structural deterioration of bone tissue, leading to increased bone fragility. The client is most likely to suffer fractures as a result of this disorder.

A client who sustained a severe sprain of the ankle is told by the primary health care provider that the pain experienced is caused by muscle spasm and swelling in the area of the injury. Which interventions would the nurse anticipate will be included in the client's initial plan of care? Select all that apply.

Ice bags. Elevation. Compression bandage. Rationale: Reflex spasm of local muscles and swelling caused by rupture of local capillary beds can best be treated initially by remembering the acronym RICE, which stands for rest, ice, compression, and elevation.

Which teaching point is the priority when the nurse is teaching the client about caring for a plaster cast?

Immediately report any increase in drainage or interruption in cast integrity. ​

The nurse is caring for a client with a hip fracture who has just been placed in Buck's traction. What intervention is most important for the nurse to perform?

Inspect the skin at least every 8 hours for signs of irritation or inflammation. Rationale: It is important for the skin to be assessed at least every 8 hours. Weights need to be no more than 5 to 10 lb (2.3 to 4.5 kg) to prevent injury to the skin and would always be freely hanging.

A client has Buck's extension traction applied to the right leg. Which intervention would the nurse plan to prevent complications of the device?

Inspect the skin on the right leg. Rationale: Buck's extension traction is a type of skin traction. The nurse inspects the skin of the limb in traction at least once every 8 hours for irritation or inflammation.

The nurse is assigned to care for a client who is in Buck's traction. The nurse prepares a plan of care for the client and includes which nursing action in the plan?

Inspect the skin under the boot at least every 8 hours.

A client has been diagnosed with subluxation of the shoulder. The nurse explains to the client that which injury has occurred to the joint?

It has incompletely dislocated. A dislocation is the disruption of a joint to the extent that the articulating surfaces are no longer in contac

A client who suffered a contusion after being hit on the thigh with a racquetball has been told that it is acceptable to apply heat to the area 72 hours after the injury. The nurse explains the rationale for this treatment to the client, stating that which is the physiological benefit of heat in this case?

It promotes reabsorption of blood from the injured tissue. ​

The nurse is preparing a client for an arthroscopy of the knee. When providing teaching, which information is essential for the nurse to include?

It will identify whether there is a joint injury and provide a route for surgical repair if indicated.

The nurse is caring for a client with osteoarthritis. The nurse performs an assessment knowing that which clinical manifestations are associated with the disorder? Select all that apply.

Joint pain that diminishes after rest. Joint pain that intensifies with activity. Rationale: The stiffness and joint pain that occur in osteoarthritis diminish after rest and intensify with activity.

The nurse is creating a plan of care for a client scheduled for a left total hip arthroplasty. Which interventions would the nurse include in the plan to prevent complications of the surgery? Select all that apply.

Keep the leg slightly abducted. Teach leg exercises to the client. Use aseptic technique for wound care. To prevent dislocation, the nurse needs to position the client correctly with the leg slightly abducted and prevent hip flexion beyond 90 degrees.

The nurse is lecturing to a group of clients who are at high risk for osteoporosis. The nurse would inform the clients about which most important measure?

Limit caffeine intake. Rationale: Excessive caffeine intake can increase calcium loss in the urine.

A client is seen in the primary health care provider's office for complaints of wrist pain. A diagnosis of carpal tunnel syndrome is made. In explaining this disorder to the client, the nurse states that it is caused by compression of which nerve?

Median. Rationale: Carpal tunnel syndrome is caused by excessive pressure on the median nerve as a result of in‐ jury, overuse, or disease.

The nurse is planning discharge teaching for a client admitted with a fracture of the leg that does not extend all the way through the bone. The nurse would include information about which types of fractures?

Open. An open (or compound) fracture is one in which the fractured bone protrudes through the skin, disrupting soft tis‐ sue.

The nurse is caring for a client who sustained an open fracture and is diagnosed with acute osteomyelitis of the right lower extremity. Which intervention would the nurse plan to perform?

Perform sterile dressing changes. treatment of os‐ teomyelitis often includes surgical debridement and requires sterile dressing changes.

The client is complaining of skin irritation from the edges of a cast applied the previous day. Which action would the nurse take?

Petal the cast edges with adhesive tape. Rationale: The nurse petals the edges of the cast with tape to minimize skin irritation. If a client has a cast applied and returns home, the client can be taught to do the same.

The nurse is caring for a client who sustained multiple fractures in a motor vehicle crash 12 hours earlier. The client now exhibits severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. Which is the initial nursing action?

Position the client in a Fowler's position. Rationale: Clients with fractures are at risk for fat embolism. With suspected fat embolism, the nurse would position the client in a sitting (Fowler's) position to relieve dyspnea.

The nurse is caring for a client on postoperative day 1 following left above-knee amputation. Which is the priority nursing action at this time?

Position the residual limb flat on the bed. after the first 24 hours, the residual limb is placed flat on the bed to reduce hip and knee contracture.

The nurse is caring for a client diagnosed with osteomyelitis. Which data noted in the client's record are supportive of this diagnosis? Select all that apply.

Pyrexia. Elevated white blood cell count. Elevated erythrocyte sedimentation rate. Bone scan impression indicative of infection. Rationale: Osteomyelitis is an infection of the bone, bone marrow, and surrounding tissue

A client with a muscle injury has difficulty with the ability to flex the hips. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item?

Raised toilet seat. Rationale: A raised toilet seat is useful if the client does not have the mobility or ability to flex the hips.

At the beginning of the work shift, the nurse assesses the status of a client wearing a halo device. The nurse determines that which assessment finding requires intervention?

Red skin areas under the jacket. Rationale: Red skin areas under the jacket indicate that the jacket is too tight. The resulting pressure could lead to altered skin integrity and needs to be relieved by loosening the jacket.

Which tests can be used to diagnose gout? Select all that apply.

Serum uric acid level. Synovial fluid aspiration. 24-hour urine uric acid level. ​

The nurse is creating a plan of care for a client in skin traction. Which frequent assessment would the nurse include in the plan as a priority intervention?

Signs of skin breakdown. .pTraction is maintained with 5 to 8 lb (2.3 to 3.6 kg) of weight, and this type of traction can cause skin breakdown.

The nurse has given activity guidelines to a client with chronic low back pain. The nurse determines that the client understands the instructions if the client states to do which activities? Select all that apply.

Sitting using a lumbar roll or pillow. Standing with one foot on a step or stool. Standing with one foot on a step or stool. ​

The nurse is caring for a client with a swollen left ankle who has difficulty bearing weight on this leg and states the ankle was twisted. Based on these findings, which condition does the nurse determine the client has most likely experienced?

Sprain. Rationale: A sprain is an injury to a ligament caused by a wrenching or twisting motion. Signs and symptoms include pain, swelling, and inability to use the joint or bear weight normally.

A client was admitted to the hospital 2 hours ago following multiple fractures to the pelvis and soft tissue injury to the abdomen. Diagnostic studies have ruled out perforation of abdominal organs. The nurse places highest priority on monitoring this client for which changes in vital signs?

Tachycardia, hypotension Feedback: Rationale: Clients who experience fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Signs of hypovolemic shock include tachycardia and hypotension.

Which intervention would the nurse include in a postoperative teaching plan for a client who underwent a spinal fusion and will be wearing a brace?

Tell the client to inspect the environment for safety hazards.

The nurse is caring for a client diagnosed with a rotator cuff lesion. The nurse assesses the client knowing that the client most likely has which structure affected?

Tendon. Lesions of the rotator cuff often involve the supraspinatus tendon of the shoulder. Usually the problem involves one or more of the tendons and muscles in the musculotendinous cuff.

The nurse has developed a plan of care for a client in traction and documents a problem of inability to perform self-care independently. The nurse evaluates the plan of care and determines that which observation indicates a successful outcome?

The client assists in self-care as much as possible. Rationale: A successful outcome for the problem of self-care is for the client to do as much of the self- care as possible. The nurse needs to promote independence ​

he nurse is caring for a client admitted for a torn meniscus. What is the focus of the nurse's immediate assessment?

The knee. The knee is a common area for meniscal tears because it is frequently injured as a result of falls and sports injuries.

The nurse is providing care for a client admitted 3 days ago with a severe left ankle contusion. The nurse determines that heat application to the area has been effective if which has occurred?

There is reabsorption of blood noted at the injured site. Rationale: The primary benefit from applying heat to a contusion is to speed up the rate of absorption of blood that has hemorrhaged into the affected soft tissue.

The nurse is collecting data related to a client's risk factors associated with osteoporosis. Which data would the nurse include? Select all that apply.

Thin body build. Smoking history. Postmenopausal age. Chronic corticosteroid use. Family history of osteoporosis. ​

The nurse is providing dietary instructions to a client with osteoporosis and is discussing appropriate food items to include in the diet. Which food items would the nurse recommend as being high in calcium? Select all that apply.

Tofu. Salmon. Spinach Rationale: Foods high in calcium include milk and milk products, dark green leafy vegetables, tofu and other soy products, sardines, salmon with bones, and hard water.

The nurse determines that a client's skeletal traction needs correction if which observation is made?

Traction ropes rest against the footboard. Rationale: Traction ropes must hang free of the bed. The remaining options are observations that indicate correct use of the traction setup

The nurse is caring for a client with acute back pain. Which are the most likely causes of this problem? Select all that apply.

Twisting of the spine. Hyperflexion of the spine. Herniation of an intervertebral disk. Scoliosis (curvature), sciatica, and degenerative vertebral changes are more likely to cause chronic back pain.