NCLEX Musculoskeletal Disorder 3
A client seeks tx in er department for a lower leg injury. There is visible deformity to the lower aspect of the leg and injured leg appears shorte than the other. The area is painful, swollen, and beginnin to become ecchymotic. The nurse interprets that this cliet has experienced a
fracture
A nurse is checking the casted extremity of a client. The nurse would check for which of the following signs and symptoms indicative of infection 1.edema 2. no distal pulses 3.hot spot on the cast
hot spot on the cast which are areas of the cast that are warmer than others
If a nonplaster (fiberglass) gets wet the client can dry it how
if the cast gets wet, it can be dried with a hair dryer set to a COOL setting to prevent skin breakdown.
A nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured . Which action is the priority
immobilize the leg before moving the client
The edges of a cast can be petaled with tape to do what
minimize skin iritation
A clietn has had a bone scan procedure. What is the after care
no specific aftercare. Encourage client to drink large amounts of water for 24-48 hours to flush the radiosotope from the system. There are no hazards to the clietn or staff from the minimal amount of radioactivity of the isotope
Morning stiffness occurs in
osteoarthritis
A client with a sprain but not fracture should be told to do what before being sent home
patien should be taughts to rest, ice, compress, and elevate SPRIAN=RICE
Food high in calcium include what
plain yougurt, diary products, seafood, sardines, green vegetables, calcium-fortified orange juics, and cereal
Bivalving a cast involves what
splitting the cast along both sides to allow space for swelling, facilitate taking x rays, or make a half cast usae as intermittent splint
A client has slight weakness in the right leg. Based on this information, teh nurse determines that the client would benifit most from the use of a
straight-leg cane is useful for the client with slight weakness in one leg
Elevated sedimention rate, morning stiffness occure in
RA
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. The nurse replies that the client will be able to bear weight on the cast when?
The client can bear weight within 20 to 30 minutes of application
A nurse is planning to teach the client with a left arm cast about measures to keep the left shoulder from becoming stiff. Which suggestion would the nurse include in the teaching plan
the shoulder of a casted arm should be lifeted over the head perodically as a prevenetive meausre.
A client is admitted to the nursing unit after a l BKA following a crush injury to the foot and lower leg. The client says "I feel my left foot itching". The nurse interprets this how?
a normal response, and indicates the presence of phantom limb sensation.
A client is complaining of pain underneath a cast in the area of a bony prominence. The nurse interprets that this client may need to have what?
a window cut in the cast. A window may be cut in a dried cast to relieve pressure, monitor pulses, relieve discomfort, or remove drains
Risk factors associated with osteoporosis
diet low in calcium sedentary lifestyle cigarette smoking long term alcohol assumption chronic illness longe term use of anticonvulsants and furosemide (Lasix)
A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which the followin as a high-risk area for pressure and breakdown
elbows if they are used for repositioning instead of trapeze, heel of good leg whih is used as a brace when pushing up in bed. ischial tuberosity, popliteal space, and schilles tendon
A nurse is assigned to care for a client with multiple trauma who is admitted to the hospital. The client has a leg fracture, and a plaster cast had been applied. In positioning the casted leg , the nurse should do what
elevate the leg on pillow continuously for 24-48 hours
A nurse is caring for a client with fresh application of a plaster leg cast. THe nurse plans to prevent the development of compartment syndrom by doing what?
elevating the limb and applying ice to the affected leg. Compartment syndrom is prevented by controlling edema. This is acheived most optimally with elevation and application of ice
What is a fasciculation
fine muscle twitches that are not normally present
A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse s response is based on the understand that this could result in
injury to the brachial plexus nerves
A nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Include what instructions for patien
keep cast and extremity elevate the cast needs to be kept clean and dry allow the wet cast 24 hours to 72 hours to dry
What is nursing care after bone biopsy
mointoy site for swelling, bleeding, and hematoma formation elevate site for 24 hours to reduce edem monitor vitals every four hourse for 24 hours. The client usually requires mild analgesics, more sever pain usually indicates that complication are arising
A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension tractions is primarily:
provides comfort by reducing muscle spasms and provides fracture immobilization
A client with diabetes mellitus has had a R BKA (right below knee amputation). The nurse should monitor for what?
separtion of wound edges. Client's with diabetes mellitus are more prone to wound infection and delayed healing because of the disease
A nurse is evaluating the pin sites of a client in skeletal traction. THe nurse is least concerned with 1. inflammation 2.serous drainage 3.pain at pin site 4.purulent drainage
serous drainage. A small amount of serous oozing is expected at pin insertion sites.
What is a gallium scan
similar to a bone scan, but with an injection of gallium isotope instead of technetium-99m. Gallium is injected 2-3 hours before the procedure, which takes 30-60 minutes to perform. The client must lie still during procedure and there is no special aftercare
For the patient in Buck's extension traction which is applied to a leg, the nurse can provide counteraction by:
slighltly elevating the foot of the bed
A client who is learning to use a can if afraid it will slip with ambulations causing a fall. the nurse provides the client with the greatest reassurance by telling the client that:
the cane has a flared tip with concentric rings to provide stability
A client with right sided weakness needs to learn how to use a cane. The nurse plans to teach the client to position the can by holding it with the
the client is taught to hold the cane on the opposite side of the weakness. This will be the patient's left hand. The cane is placed 6 inches lateral to the fithe toe
A nurse is planning to provide instructions to the client how to stand on crutches. In the written instructions, the nurse plans to tell the client to place the crutches:
6-10 inches in front and to the side of the client depending on the body size. This provides a base of support to the client and improves balance
A nurse is evaluating the client's use of a cane for left sided weakness. The nurse would interven if the client moves the cane with witch side as the right leg is moved?
the nurse would interven and correct if the patient moves the cane when the righ leg is moved. The cane is held 6 inches lateral to the fifth great tow. The cane is moved forward with the affected leg. The client leans on the cane for added support while the stronger side swings through
