RN- MOBILITY NCLEX QUESTIONS

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A client with a diagnosis of schizophrenia is admitted to the psychiatric hospital in a catatonic state. During the physical examination, the client's arm remains outstretched after the nurse obtains his pulse and blood pressure readings, and the nurse must reposition his arm. This client is exhibiting:

waxy flexibility. Explanation: Waxy flexibility, the ability to assume and maintain awkward or uncomfortable positions for long periods, is characteristic of catatonic schizophrenia. Clients commonly remain in these awkward positions until someone repositions them. Clients with dependency problems may demonstrate suggestibility, a response pattern in which one easily agrees to the ideas and suggestions of others rather than making independent judgments. Catatonic clients may also exhibit negativity (for example, resistance to being moved or being asked to cooperate) and retardation (slowed movement).

Using the Morse Fall Scale (see chart), order the following clients from lowest to highest fall risk. All options must be used.

27-year-old client with acute pancreatitis receiving morphine sulfate IV every 2 hours as needed for pain; has no significant medical history, smokes two packs of cigarettes per day, may be up independently and has steady gait. 48-year-old who is quadriplegic admitted for wound care of a stage IV pressure ulcer, receiving IV antibiotics per a peripherally inserted central catheter (PICC); the client is alert and oriented. 84-year-old client with non-insulin-dependent diabetes admitted with new-onset confusion, and forgets about limitations of activity. The client reportedly fell at home last week, is currently on bed rest, and has normal saline infusing per saline lock. 62-year-old client with Parkinson's disease, admitted for pneumonia and receiving IV antibiotics. The client reports falling at home but continues to ambulate with a cane. During this hospitalization, the client has gotten out of bed without calling for assistance. Explanation: The client with pancreatitis is at a low risk for falls (has IV = 20 points). The nurse should continue to assess for any factors that may develop to increase this client's fall risk, perhaps a change due to pain or the use of pain medication. The client who is quadriplegic and has an IV is at medium risk (35 points); the nurse should continue to assure the client's safety while in bed. The elderly client with new-onset confusion has multiple factors that make the client a high fall risk (fall history, ambulatory aid, IV, impaired gait, confusion, 75 points), and the nurse should institute fall precautions. The client with Parkinson's disease and a history of falling has the highest fall risk according to the Morse Fall Scale: fall history, secondary diagnosis, ambulatory aid, IV, impaired gait, confusion (100 points); the nurse should institute fall precautions.

After surgery and insertion of a total hip prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse interprets these findings as indicating:

joint dislocation. Explanation: The joint has dislocated when the client with a total joint prosthesis develops severe sudden pain and an inability to move the extremity. Clinical manifestations of an infection would include inflammation, redness, erythema, and possibly drainage and separation of the wound. Bleeding could be external (e.g., blood visible from the wound or on the dressing) or internal and manifested by signs of shock (e.g., pallor, coolness, hypotension, tachycardia). The seepage of glue into soft tissue would have occurred in the operating room, when the glue is still in the liquid form. The glue dries into the hard, fixed form before the wound is closed.

When assessing a client who reports a back injury, it is critical for the nurse to question the client about:

mechanism of injury. Explanation: The mechanism of injury is always the most critical information to obtain from a client with a musculoskeletal injury. In the event of a back injury, the mechanism of injury provides the greatest clue as to the extent of injury and the proper treatment plan. The other questions are important but will not give the critical information needed related to this specific problem and injury.

The nurse is observing a client who is recovering from back strain lift a box as shown in the accompanying image. What should the nurse do?

Praise the client for using correct body mechanics. Explanation: The client is using correct body mechanics for lifting because she is keeping her back as straight as possible and is holding the box close to her body. She is using her large leg muscles to lift the box. She is using a broad base of support by placing her feet as wide apart as possible. The other suggestions would cause the client to put a strain on her back.

When performing an assessment, the nurse identifies the following signs and symptoms: discoordination, decreased muscle strength, limited range of motion, and reluctance to move. These signs and symptoms indicate which nursing diagnosis?

Impaired physical mobility Explanation: This client demonstrates the limitation of physical movement defined as Impaired physical mobility. Health-seeking behavior is a state in which a client in stable health actively seeks ways to alter personal health habits or his environment in order to move toward optimal health. Disturbed sensory perception indicates changes in the characteristics of incoming stimuli. Deficient knowledge exists when the client requires further teaching.

When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the client to prevent:

contractures. Explanation: Typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory infections. Nursing care should be directed toward the goal of preventing these complications. Ascites, fluid overload, and dry mouth are not associated with multiple sclerosis.

A nurse is educating a client with chronic back pain about the use of the fentanyl patch. Which statement by the nurse is appropriate?

"The desired effect may take up to 24 hours."

A male client underwent a lumbar spinal fusion yesterday. Which nursing assessment should alert the nurse to the development of a possible complication?

clear yellowish fluid on the dressing Explanation: Clear yellowish fluid on the dressing may be cerebrospinal fluid (CSF). This fluid must be tested for glucose to determine whether it is CSF. If so, the client is at great risk for an infection of the central nervous system, which has a high mortality rate. The client should be able to laterally rotate the head and neck, which is above the surgical site in the spinal column. During the nursing postoperative neuromuscular-vascular assessment of movement of the head and neck, the nurse should find results consistent with the preoperative baseline status. Using the standing position to void is normal for a male client. Coughing is the body's defense mechanism to help clear the lungs of the anesthetic agents and to ventilate the lungs in response to a sustained deep inspiration for ventilation of the lower lobes of the lungs. A frequent cough could place a strain on the incision site and should be avoided. Also, a productive cough of thick, yellow sputum would indicate the complication of a respiratory infection.

Passive range-of-motion (ROM) exercises for the legs and assisted ROM exercises for the arms are part of the care regimen for a client with a spinal cord injury. Which observation by the nurse would indicate a successful outcome of this treatment?

free, easy movement of the joints Explanation: ROM exercises help preserve joint motion and stimulate circulation. Contractures develop rapidly in clients with spinal cord injuries, and the absence of this complication indicates treatment success. Range of motion will keep the ankle joints freely mobile. Footdrop, however, is prevented by proper positioning of the ankle and foot, which is usually accomplished with high-top sneakers or splints. External rotation of the hips is prevented by using trochanter rolls. Local ischemia over bony prominences is prevented by following a regular turning schedule.

The nurse is caring for an adult with a grade III compound fracture of the right femur; the client has been placed in skeletal traction. The intended outcome of the traction is to:

reduce and immobilize the fracture. Explanation: Skeletal traction is often used to regain normal length of the bone, but in this situation the main purpose of the traction is to reduce and immobilize the fracture. This type of traction allows the client to move in bed without dislocating the fracture. This client has an open fracture, but skeletal traction will not prevent further skin breakdown.

A client is scheduled to undergo transurethral resection of the prostate. The procedure is to be done under spinal anesthesia. Postoperatively, the nurse should assess the client for:

respiratory paralysis. Explanation: If paralysis of vasomotor nerves in the upper spinal cord occurs when spinal anesthesia is used, the client is likely to develop respiratory paralysis. Artificial ventilation is required until the effects of the anesthesia subside. Seizures, cardiac arrest, and renal shutdown are not likely results of spinal anesthesia.

When the nurse is conducting a preoperative interview with a client who is having a vaginal hysterectomy, the client states that she forgot to tell her surgeon that she had a total hip replacement 3 years ago. The nurse communicates this information to the perioperative nurse because:

the client should not have her hip externally rotated when she is positioned for the procedure. Explanation: The nurse should notify the surgery department and document the past surgery in the medical record in the preoperative notes so that the client's hip is not externally rotated and the hip dislocated while she is in the lithotomy position. The prosthesis should not be a problem as long as the perioperative nurse places the return electrode away from the prosthesis site. The perioperative nurse will inform the rest of the team, but the primary reason to inform the perioperative nurse is related to safe positioning of the client. The surgeon should enter this information on the client's medical record at this time.

The nurse is caring for a client who is experiencing an exacerbation of gout. When providing instruction, which dietary modifications are stressed? Select all that apply.

• Eat a low-purine diet. • Limit alcohol intake. Explanation: Gout is characterized by an abnormal metabolism of uric acid. Individuals either produce too much uric acid or their body is unable to metabolize and excrete it. Purines are metabolized into uric acid. The client who suffers from gout would be placed on a low-purine diet with foods such as peanut butter, cherries, rice, pasta, fruits, and vegetables. Fluids do not have to be limited. Alcohol intake would be limited as it is thought to trigger an exacerbation.

A client with multiple sclerosis (MS) is receiving discharge instructions from the nurse. Which of the following statements by the clien indicates that more instruction is required?

"I will walk with my feet close together." Explanation: Clients with multiple sclerosis should walk with their feet wider apart, not close together to facilitate balance and reduce the risk of falls. The other options are correct statements as watching one's feet while walking is beneficial to clients with MS. A voiding time schedule helps to prevent any episodes of incontinence. Dysphagia is a potentially serious complication and should be reported to the client's primary healthcare provider.

A client has been receiving radiation therapy for 3 weeks to treat cancer and has fatigue. The nurse should consider which factor when planning to help the client cope with the fatigue?

A balance of activity and rest will help manage the fatigue. Explanation: The plan of care to treat fatigue associated with radiation therapy should include encouraging the client to remain active and to plan scheduled rest periods as necessary before activity. Engaging in activities, such as walking, has been shown to decrease the cycle of fatigue, anxiety, and depression that can occur during treatment. Fatigue is a very common side effect of radiation therapy that typically begins during the third or fourth week of treatment and persists until after treatment ends. The presence of fatigue does not mean that the cancer is not responding to treatment or that the client has developed another health problem.

A client is being discharged following an open reduction and internal fixation of the left ankle, and is to wear a non-weight-bearing cast for 2 weeks. What should the nurse teach the client to do when using crutches?

Maintain two to three finger widths between the axillary fold and underarm piece grip. Explanation: The nurse instructs the client to maintain two finger widths between the axillary fold and the underarm piece grip of the crutches to prevent pressure on the brachial plexus. The client is advised to use the three-point gait; in the four-point and two point-gait there is partial weight bearing of both feet. The client is also advised to keep the affected leg elevated when sitting to prevent swelling, and to use the arms, not the axillae, to maintain balance and support.

To help minimize calcium loss from a hospitalized client's bones, the nurse should:

encourage the client to walk in the hall. Explanation: Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore, encouraging the client to increase physical activity, such as by walking in the hall, helps minimize calcium loss. Turning or repositioning the client every 2 hours wouldn't increase activity sufficiently to minimize bone loss. Providing dairy products and supplemental feedings wouldn't lessen calcium loss — even if the dairy products and feedings contained extra calcium — because the additional calcium doesn't increase bone stimulation or osteoblast activity.

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. The nurse should:

explain how to overcome a freezing gait by telling the client to march in place. Explanation: Clients with Parkinson's disease may experience a freezing gait when they are unable to move forward. Instructing the client to march in place, step over lines in the flooring, or visualize stepping over a log allows them to move forward. It is important to ambulate the client and not keep them on bed rest. A muscle relaxant is not indicated.

A nurse is assessing a client for neurologic impairment after a total hip replacement. Which finding would indicate impairment in the affected extremity?

inability to move Explanation: Being unable to move the affected leg suggests neurologic impairment. A decrease in the distal pulse, diminished capillary refill, and coolness to touch of the affected extremity suggest vascular compromise.

A nurse notes that a client has kyphosis and generalized muscle atrophy. Which problem is a priority when the nurse develops a nursing plan of care?

ineffective coughing and deep breathing Explanation: In kyphosis, the thoracic spine bends forward with convexity of the curve in a posterior direction, making effective coughing and deep breathing difficult. Although the client may develop other problems because respiratory status deteriorates when pulmonary secretions are not adequately cleared from airways, ineffective coughing and deep breathing should receive priority attention.

Which indicates that performing passive range-of-motion (ROM) exercises on an unconscious client has been successful?

maintenance of joint mobility Explanation: The goal of performing passive ROM exercises is to maintain joint mobility. Active exercise is needed to preserve bone and muscle mass. Passive ROM movements do not prevent bone demineralization or have a positive effect on the client's muscle tone.

A client is scheduled to have a graded exercise test. The nurse explains to the client that the test will determine how:

well the body reacts to controlled exercise stress. Explanation: Graded exercise testing is a diagnostic and prognostic tool used to determine the physiologic responses to controlled exercise stress. Information gained from a graded exercise test can achieve diagnostic, functional, and therapeutic objectives for the client. Graded exercise tests involve the use of a treadmill, stationary bicycle, or arm ergometry. The information obtained from this test is not used to set the incline on the treadmill, and measuring the distance walked and the duration of the walk are not the purpose of a graded exercise test.

The nurse is instructing a client following right-knee replacement on how to use crutches. Which instructions are included? Select all that apply.

• Have your elbows bent when holding the crutch handles • Place crutches one foot in front of you • Pivot on your left leg • Swing your left leg forward Explanation: It is very important to instruct a client to safely use crutches. Additional damage to the injured knee may result with improper crutch use. When using crutches, instruct the client to, "place the crutches about 1 foot (0.3 meters) in front of your feet, slightly wider apart than your body. Next, lean on the handles of your crutches (not armpit) and move your body forward. Use the crutches for support. Do not step forward on the weak leg. Finish the step by swinging your left leg forward. Repeat steps to move forward. Turn by pivoting on the strong left leg, not the right leg. The armpits should not support your body weight."

A 20-year-old seeks treatment at a local emergency care center after spraining his ankle while playing football with friends. The ankle is painful and swollen. Which actions should the nurse perform, as ordered by the physician? Select all that apply.

• Initially apply cold pack. • Instruct the client to elevate the ankle for 48 to 72 hours. • Provide crutch-gait training. • If needed, apply an elastic bandage from the toes to midcalf. Explanation: Pain caused by an injury is best treated initially with cold applications. Cold reduces localized swelling and decreases vasodilation. Decreasing vasodilation prevents pain-producing chemicals from entering the circulation. The client should be instructed to call the physician if pain worsens or persists. Additional radiographs may be necessary to detect a fracture that might have originally been missed. The client should also be instructed to elevate the joint for 48 to 72 hours after the injury. If an elastic bandage is needed, the nurse should wrap the bandage from toes to midcalf, forming a figure eight, and teach the client how to reapply it. The nurse should ensure that the client also receives crutch-gait training.

When preparing a client for discharge from the hospital after a total knee replacement, the nurse should include which information in the discharge plan? Select all that apply.

• Report signs of infection to health care provider (HCP). • The physical therapist will encourage progressive ambulation with use of assistive devices. Explanation: After a total knee replacement, efforts are directed at preventing complications, such as thromboembolism, infection, limited range of motion, and peroneal nerve palsy. The nurse should instruct the client to report signs of infection, such as an increased temperature. To prevent edema, the affected leg must remain elevated when the client sits in a chair. The client will wear antiembolism stockings at all times, including when sleeping. After discharge, the client may undergo physical therapy on an outpatient basis per HCP prescription. The client should leave the dressing in place until the follow-up visit with the surgeon.

A client is admitted to the trauma center with a spinal cord transection at T4. Which of the physical limitations does the nurse anticipate when planning care? Select all that apply.

• The client will be unable to independently ambulate. • The client will have no control of the bladder. Explanation: The client with a spinal cord transection (complete tear) at the thoracic 4 location will be a paraplegic with no control of the body below mid chest. The client will need assistance to ambulate (wheelchair) and assistance with urination. The client will be able to breathe independently, speak, feed themselves and have normal cognitive function

A nurse should perform passive range-of-motion (ROM) exercises on which clients? Select all that apply.

• a client who has temporary loss of sensation • a client who is unconscious Explanation: Passive ROM exercises are used to move the client's joints through as full a ROM as possible. Passive ROM exercises improve or maintain joint mobility and help prevent contractures. These exercises are indicated for the client with temporary or permanent loss of mobility, sensation, or consciousness. Exercises help with joint mobility, strength, and endurance. Plantar flexion of the foot and supination of the hand may be normal joint movements if the client can do active ROM. Septic joints have infection that may be spread either hematogenously or through trauma.

Four days after surgery for internal fixation of a C3-C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which features of the wheelchair are appropriate for the needs of this client?

• back and head that are high • seat that is lower than normal • chair controlled by the client's breath Explanation: The client with a C3-C4 fracture has neck control but may tire easily using sore muscles around the incision area to hold up the head. Therefore, the head and neck of the wheelchair should be high. The seat of the wheelchair should be lower than normal to facilitate transfer from the bed to the wheelchair. When a client can use the hands and arms to move the wheelchair, the placement of the back to the client's scapula is necessary. This client cannot use the arms and will need an electric chair with breath, chin, or voice control to manipulate movement of the chair. A firm or hard cushion adds pressure to bony prominences; the cushion should instead be padded to reduce the risk of pressure ulcers.

A client is being admitted with a spinal cord transection at C7. Which assessments take priority upon the client's arrival? Select all that apply.

• temperature • respirations • blood pressure Explanation: The nurse should assess the client for spinal shock, which is the immediate response to spinal cord transection. Hypotension occurs, and the body loses core temperature to environmental temperature. The nurse must treat the client immediately to manage hypotension and hypothermia. The nurse should also ensure that there is an adequate airway and respirations; there may be respiratory compromise due to intercostal muscle involvement. Once the client is stable, the nurse should conduct a complete neurologic check. The nurse should take all precautions to keep the client's head, neck, and spine position in straight alignment. If the client is conscious, the nurse should briefly assess major reflexes, such as the Achilles, patellar, biceps, and triceps tendons, and sensation of the perineum for bladder function.

A nurse is preparing to help a client with weakness in his or her right leg move from the bed to a chair. Where should the nurse place the chair?

45 degrees to the bed on the left side Explanation: The nurse should place the wheelchair at a 45 degree angle or parallel to the bed on the client's strong side to help prevent a fall. The nurse should not place the chair perpendicular to the bed because the client won't be able to support his weight on his right leg.

The nurse is caring for a client admitted for pneumonia with a history of hypertension and heart failure. The client has reported at least one fall in the last 3 months. The client may ambulate with assistance, has a saline lock in place, and has demonstrated appropriate use of the call light to request assistance. Using the Morse Fall Scale (see chart), what is this client's total score and risk level?

60, high risk Explanation: Several factors designate this client as a high fall risk based on the Morse Fall Scale: history of falling (25), secondary diagnosis (15), plus IV access (20). The client's total score is 60. There is also concern that the client's gait is at least weak if not impaired due to hospitalization for pneumonia, which may add to the client's fall risk. After evaluating the client's risk, the nurse must develop a plan and take action to maximize the client's safety.

A client is admitted with a possible diagnosis of osteomyelitis. Based on the documentation below, which laboratory result is the priority for the nurse to report to the physician?

Blood culture Explanation: Osteomyelitis is a bacterial infection of the bone and soft tissue that occurs by extension of soft tissue infection, direct bone contamination following surgery, or spreading from other infection sites in the body. A positive blood culture would be reported immediately to the physician so that specific antibiotic therapy can begin or be adjusted based on the positive culture. A negative rheumatoid factor would be expected in a possible diagnosis of osteomyelitis. An alkaline phosphatase level of 60 IU/L (1.0 nkat/L) is within the normal range, and an ESR of 10 mm/hour is also within the normal range.

When assisting a client to ambulate after repair of a fractured right hip, what is the best way for the nurse to be positioned to protect the nurse and the client from potential injury in the event of the client becoming weak?

On the client's left side Explanation: When ambulating a client, the nurse walks on the client's stronger or unaffected side. This provides a wide base of support and therefore increases stability during the phase of ambulation that calls for weight bearing on the affected side as the unaffected limb moves forward.

A nurse is caring for a client who is recovering from an illness requiring prolonged bed rest. Based on the nursing documentation above, which procedures would the nurse implement next?

Performing active range-of-motion exercises of the legs Explanation: Active range-of-motion exercises involve moving the client's joints through their full range of motion; they require some muscle strength and endurance. The client should have received passive range-of-motion exercises since admission to maintain joint flexibility and should have been taught isometric exercises to build strength and endurance for transfers and ambulation. Walking to the bathroom would be unsafe without the ability to first dangle the legs over the bedside and transfer from bed to chair.

A client has a leg immobilized in traction. Which observation by the nurse indicates that the client understands actions to take to prevent muscle atrophy?

The client performs isometric exercises to the affected extremity three times per day. Explanation: Isometric contractions increase the tension within a muscle but do not produce movement. Repeated isometric contractions make muscles grow larger and stronger. Adduction of the leg puts work onto the hip joint as well as altering the pull of traction. Rolling the leg, or external rotation, alters the pull of traction. Additional weight should not be added to traction unless prescribed by the health care provider (HCP); it will not prevent muscle atrophy.

What factor has the potential to lead to chronic respiratory acidosis in older adults?

Thoracic skeletal changes Explanation: Poor respiratory exchange as the result of chronic lung disease, inactivity, or thoracic skeletal changes may lead to chronic respiratory acidosis. Decreased renal function in older adults can cause an inability to concentrate urine and is usually associated with fluid and electrolyte imbalance. A poor appetite, erratic meal patterns, inability to prepare nutritious meals, or financial circumstances may influence nutritional status, resulting in imbalances of electrolytes. Overuse of sodium bicarbonate may lead to metabolic alkalosis.

A nurse is completing a physical assessment of a neonate following birth. When completing the musculoskeletal assessment, which findings would indicate developmental dysplasia of the hip (DDH)?

• Positive Barlow test. • Asymmetrical leg skin folds. Explanation: Developmental dysplasia (dislocation) of the hip is an abnormal formation of the hip joint in which the ball on the top of the femur is not held firmly in the socket. A neonate with DDH will have a positive Ortolani test, a positive Barlow test, and asymmetrical skin folds in the thigh. The affected leg has limited abduction and appears shorter than the unaffected leg in a neonate with DDH.

A nurse is evaluating the proper use of crutches by a client who has fractured the right leg. Which statement indicates the client is using the correct technique?

"I feel pressure on the palms of my hands when I am walking with my crutches." Explanation: It is normal for the client to feel pressure on the palms of the hands when walking with crutches. The client should move her affected (right) leg forward first as she swings forward with the crutches. Leaning on the crutches can apply pressure to the axillae, leading to neurovascular impairment. If the client's arms are tingling after she uses her crutches, she is probably applying pressure on her axillae when walking.

Which statement would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment?

Activity is resumed gradually; the client can resume usual activities in 5 to 6 weeks. Explanation: The scarring of the retinal tear needs time to heal completely. Therefore, resumption of activity should be gradual; the client may resume usual activities in 5 to 6 weeks. Successful healing should allow the client to return to a previous level of functioning.

The nurse is explaining the nature of the fracture to the parents of a 10-year-old who has a greenstick fracture. Which drawing should the nurse choose to explain the fracture to the parents?

Explanation: The nurse should show the parents the figure of the greenstick fracture as noted in answer C in which the fracture does not completely cross through the bone. Answer A is a plastic deformation, or a bend in the bone. Answer B is a buckle. Answer D is a complete fracture.

Which action should the nurse take for a client with a fiberglass cast on the left leg?

Assess movement and sensation of the toes Explanation: Neurological checks to the left leg are essential to assess for complications such as ischemia. Radial and brachial pulses are found in the upper extremities. A four-point gait resembles normal walking and would involve weight bearing, which is contraindicated. The fiberglass cast would be dry almost immediately after application, so elevating it to dry is not necessary.

Which nursing action best addresses the outcome: The client will be free from falls?

Encourage use of grab bars and railings in the bathroom and halls Explanation: To address the client outcome of being free from falls, it is best to place assistive devices of grab bars especially in the bathroom and railing in the halls to promote balance. It is a nursing focused action to use large muscle groups when transferring a client. It is important to place an emergency contact number close by and have an emergency monitoring system; however, they will not prevent falls.

The nurse is performing an assessment in the nursery on an infant with a developmental hip dysplasia. Which of the following findings should the nurse anticipate?

Ortolani's sign Explanation: Assessment in a child with a congenital hip dislocation typically reveals Ortolani's sign, asymmetrical thigh and gluteal folds, limited hip abduction, femoral shortening, and Trendelenburg's sign.

Which cells are involved in bone resorption?

Osteoclasts Explanation: Osteoclasts carry out bone resorption by removing unwanted bone while new bone is forming in other areas. Chondrocytes are responsible for forming new cartilage. Osteoblasts are bone-forming cells that secrete collagen and other substances. Osteocytes, derived from osteoblasts, are the chief cells in bone tissue.

An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. What should the nurse advise the mother to do?

Remove any unsafe items from the area in which the infant is mobile. Explanation: Safety is the priority in caring for this infant. Infants adapt easily, increasing mobility even with a splint in place. Therefore, the mother needs to ensure that the area in which the infant is mobile is safe. There is no need to contact the HCP to alter the treatment plan. Confining the infant to one room may not allow the child to achieve normal development. The child needs different environments for maximum development. The infant needs to wear the splint as prescribed by the HCP to ensure optimal healing.

Which nursing diagnosis is most appropriate for an elderly client with osteoarthritis?

Risk for injury related to altered mobility Explanation: Typically, a client with osteoarthritis has stiffness in large, weight-bearing joints, such as the hips. This joint stiffness alters functional ability and range of movement, placing the client at risk for falling and injury. Therefore, Risk for injury is the most appropriate nursing diagnosis. Impaired urinary elimination, Ineffective breathing patterns, and Imbalanced nutrition: Less than body requirements are incorrect because osteoarthritis doesn't affect urinary elimination, breathing, or nutrition.

The nurse is caring for an elderly client with a fractured hip who is on bed rest. Which nursing interventions would be included on the plan of care?

Turn the client every 2 hours, and encourage coughing and deep breathing. Explanation: Appropriate interventions for a bedridden client include turning every 2 hours, providing adequate nutrition, and encouraging coughing and deep breathing. Hydration, active and passive ROM, and adequate pain medication are also appropriate nursing measures. To prevent contractures, the client would not limit fluid intake or lie as still as possible

When planning care for a client with myasthenia gravis, the nurse understands that the client is at highest risk for:

aspiration. Explanation: Loss of motor function to the face and throat can cause dysphagia and places the client at risk for aspiration. Bladder dysfunction and hypertension are not associated with myasthenia gravis. Myasthenia affects nerve impulses at the neuromuscular junction, causing loss of motor function; there is no sensory deficit.

The nurse advises the client who has had a femoral head prosthesis placement on the type of chair to sit in during the first 6 to 8 weeks after surgery. Which chair would be the correct type to recommend?

a high-backed chair with armrests Explanation: A high-backed straight chair with armrests is recommended to help keep the client in the best possible alignment after surgery for a femoral head prosthesis placement. Use of this type of chair helps to prevent dislocation of the prosthesis from the socket. A desk-type swivel chair, padded upholstered chair, or recliner should be avoided because it does not provide for good body alignment and can cause the overly flexed femoral head to dislocate.

To assess the joints, a nurse asks a client to perform various movements. As the client moves his arm away from the midline, the nurse evaluates his ability to perform:

abduction. Explanation: A client performs abduction when moving a body part away from the midline. Protraction refers to drawing out or lengthening of a body part. Retraction, the opposite of protraction, refers to drawing back or shortening of a body part. Adduction, the opposite of abduction, is movement of a body part toward the midline

A nurse caring for a child with a right leg fracture should include which of the following statements when teaching the child how to bear weight on the affected leg using crutches?

"Move both crutches then your broken leg forward." Explanation: When walking with crutches, a child should be instructed to advance both crutches, then advance the affected leg. The unaffected leg then supports much of the weight associated with ambulation. It would not be effective to move the unaffected leg forward first. It would not be safe for the child to advance using only one crutch.

Which is not a typical clinical manifestation of multiple sclerosis (MS)?

sudden bursts of energy Explanation: With MS, hyperexcitability and euphoria may occur, but because of muscle weakness, sudden bursts of energy are unlikely. Visual disturbances, weakness in the extremities, and loss of muscle tone and tremors are common symptoms of MS.

A teenage boy suffers a broken leg as a result of a car accident and is taken to the emergency department. A plaster cast is applied. Before discharge, the nurse provides the client with instructions regarding cast care. Which instructions are appropriate? Select all that apply.

• Support the wet cast with pillows until it dries. • Avoid putting straws or hangers inside the cast. Explanation: Supporting the wet cast with pillows prevents the cast from changing shape and interfering with alignment of the fractured bone. The nurse should instruct the client not to place sharp objects, such as straws or hangers, down the inside of the cast to avoid the risk of impairing the skin and causing infection. Using a hair dryer is not advised, because it dries the cast unevenly, can cause burns to the tissue, and can crack the cast, causing poor alignment to the injured bone. The palms, not the fingertips, should be used when handling the wet cast because fingertips can dent the cast, thus causing pressure points that can affect the skin's integrity. Powder should not be used, because it can cake under the cast. Itching is a common occurrence with casts, because the skin cells cannot slough as they normally would and the dry skin causes itching. Normally, the physician is not called for this problem.

A 74-year-old client receiving fluphenazine decanoate therapy develops pseudoparkinsonism, and is ordered amantadine hydrochloride. With the addition of this medication, the client reports feeling dizzy when standing. Which response by the nurse is best?

"When you change positions, do so slowly." Explanation: Both the fluphenazine decanoate and amantadine hydrochloride can have orthostatic hypotensive effects. Clients should be educated about this side effect especially in the elderly. Telling the client to change positions slowly will help ease the dizziness. If the dizziness is prolonged, the client should report those results to their practitioner. The client does not need a dose change or taken off the medication. The symptoms reported are orthostatic hypotensive effects not signs and symptoms of a stroke. The client could consider taking the medications at bedtime, but symptoms will likely persist. It would be safer to teach the client how to deal with symptoms as they occur.

Using the Morse Fall Scale (see chart), place the clients in order from lowest to highest fall risk. All options must be used.

50-year-old client admitted for chest pain while running. The client has been healthy and has no history of falling; she is alert and oriented, has IV access, and has been cleared to ambulate independently. 38-year-old client who has been blind since birth, admitted for abdominal pain and nausea with IV in place. The client has steady gait and no history of falling and requires cuing and assistance due to unfamiliar surroundings. 56-year-old client with diabetes admitted with osteomyelitis of right ankle, receiving IV antibiotics per peripherally inserted central catheter. The client is alert and cooperative, is non-weight bearing on the right lower extremity but may stand pivot into a wheelchair. The client has no history of falling. Elderly client admitted from assisted living facility with new-onset confusion secondary to urinary tract infection. The client has a history of hypertension and diabetes; gait is weak due to illness, but the client has no known history of falling. The client may be up with assistance using a walker and is receiving intravenous (IV) antibiotics. Explanation: The 50-year-old client has the lowest risk for falling with points assigned for IV access only (20); this client should be monitored regularly for changes that would increase the client's risk, and interventions should be instituted if they become necessary to ensure safety. The 38-year-old blind client is medium risk for falling with 35 points (secondary diagnosis and IV access); due to unfamiliar surroundings, the nurse may need to provide extra attention to cuing and providing assistance to keep this client safe. The client admitted with osteomyelitis is a high fall risk with points assigned for secondary diagnosis of diabetes (15), impaired gait (20), and IV access (20) to a total of 55; the nurse should institute high fall precautions and reassess need regularly. The elderly client with new-onset confusion is at highest risk for falling, acquiring points for a history of falling (25), secondary diagnosis (15), IV access (20), weak gait (10), and confusion (15) to a total of 85 points; the nurse should institute fall precautions, taking care to identify this client to all health care team members as high fall risk.

What activity orders would be appropriate for a client with an internal radium implant for cervical cancer?

bed rest with the head of the bed flat Explanation: The client with a cervical implant is kept on strict bed rest, flat in bed. Limitation of movement is designed to prevent accidental displacement or dislodgment of the implant. Client knowledge and understanding are critical to compliance with these restrictions. The client will not be allowed out of bed while the implant is in.

The nurse is preparing a 45-year-old female for a vaginal examination. The nurse should place the client in which postion?

lithotomy position Explanation: Although other positions may be used, the preferred position for a vaginal examination is the lithotomy position. This position offers the best visualization. If the client is elderly and frail, staff members may need to support the client's flexed legs while the examiner conducts the examination and obtains the Papanicolaou smear. Positioning the client in the other positions will make visualization more difficult and may not be as comfortable for the client.

The nurse is caring for a child in Bryant's traction (see figure). The nurse should:

provide frequent skin care. Explanation: The traction is positioned correctly; the nurse should provide frequent skin care to the back and shoulder areas. The hips and buttocks should be lifted off the bed to provide counter traction; the nurse should not adjust the weights. The nurse should not place a pillow under the buttocks as this would prevent counter traction. The elastic wraps should remain on the legs unless removal is prescribed by the health care provider (HCP).

A nurse is admitting a client scheduled for a laminectomy of the L1 and L2 vertebrae. Indicate where the nurse assesses the surgical incision following completion of the procedure.

Explanation: In a laminectomy, one or more of the bony laminae that cover the vertebrae are removed. The incision for the surgery is at the site of the vertebrae. There are five lumbar vertebrae that are numbered from top to bottom. L5 is the closest to the sacrum. Count up from the sacrum to locate L1 and L2.

The nurse is aware that frequent repositioning in bed will assist in the prevention of which of the following for a client?

Pneumonia Explanation: By frequently changing positions in bed, the client can prevent the development of pneumonia, urinary stasis, and deep vein thrombosis. These movements promote blood, oxygen, and fluid circulation throughout the body systems and prevent stasis. Postural hypotension can often be associated with medications and no information is given about this in the question. Arterial thrombosis is incorrect because decreased movement would more likely result in a venous thrombosis.

Over the past few weeks, a client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which of the following measures does not comply with a least restraint policy?

Raising all side rails while the client is in bed Explanation: Raising all side rails on the bed would be a restraint and may increase the client's risk of a falling if he or she climbs out of bed. All the other options would comply with a least restraint policy.

The nurse enters the room to do an initial assessment on a client with a fracture of the femoral head. What would be the expected findings on the affected limb?

Shortening of the affected extremity with external rotation Explanation: As a result of the muscles contracting and pulling on the two portions of bone, there is a characteristic shortening of the femur with external rotation of the extremity. The other answers are incorrect based on pathology of a hip fracture.

A client with respiratory complications of multiple sclerosis (MS) is admitted to the intensive care unit. Which equipment is most important for the nurse to keep at the client's bedside?

Suction machine with catheters Explanation: MS weakens the respiratory muscles and impairs swallowing, putting the client at risk for aspiration. To ensure a patent oral airway, the nurse should keep a suction machine and suction catheters at the bedside. A sphygmomanometer is no more important for this client than for any other. A padded tongue blade is an appropriate seizure precaution, but should not be used in this client because its large size could cause oral airway obstruction. A nasal cannula and oxygen would be ineffective to ensure adequate oxygen delivery; this client requires a mechanical ventilator.

A nurse must restrain a client to ensure the safety of other clients. When using restraints, which principle is a priority?

Use an organized, efficient team approach to apply and secure the restraints. Explanation: Emergency department personnel should use an organized, team approach when restraining violent clients so that no one is injured in the process. The leader, located at the client's head, should take charge; four staff members are required to hold and restrain the limbs. For safety reasons, restraints should be fastened to the bed frame instead of the side rails. For quick release, loops should be used instead of knots.

The nurse is planning care for a client on complete bed rest. The plan of care should include all except:

maintaining the client in the supine position. Explanation: Three factors contribute to the formation of venous thrombus and thrombophlebitis: damage to the inner lining of the vein (prolonged pressure), hypercoagulability of the blood, and venous stasis. Bed rest and immobilization are associated with decreased blood flow and venous pooling in the lower extremities. Keeping the client in the supine position would not be appropriate. Turning the client every 1 to 2 hours, passive and active range-of-motion exercises, and use of TED hose help prevent venous stasis in the lower extremities.

A client has a cast applied to the left leg after sustaining a femur fracture during a skiing accident. Which interventions would the nurse provide to avoid complications from the cast application? Select all that apply.

• Monitor distal pulses of the affected extremity • Maintain the leg elevated above the level of the heart. • Administer anticoagulation per healthcare provider's order. Explanation: The nurse would monitor the tightness of the cast by assessing the distal pulses and tightness of the cast. Edema can cause the cast to become tight and lead to compartment syndrome. Unless contraindicated, the leg would be elevated above the heart in order to increase venous return and decrease edema. Prophylactic anticoagulation will decrease the risk of clot formation. The nurse would apply cool compresses not warm. It is not within the nurse's scope of practice to cut the cast or bivalve the cast.

The nurse should assess which clients for risk for falling? Select all that apply.

• client who is 45 years of age, in hospice with terminal cancer, and receiving morphine every 2 hours • client who is 62 years of age, recovering from breast biopsy in outpatient surgery, and has a fear of falling • client who is 80 years of age and in a locked facility for clients with cognitive impairment • client who is 75 years of age and recovering at home from hip replacement surgery on the left hip Explanation: Clients who are at risk for falling include the client taking narcotics, the client with a known fear of falling, the client with cognitive impairment, and the client with gait problems. Age and setting are not necessarily risks for fallings.

A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan? 1. Elevating the stump for the first 24 hours 2. Maintaining the client on complete bed rest 3. Applying heat to the stump as the client desires 4. Removing the pressure dressing after the first 8 hours

1. Elevating the stump for the first 24 hours Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility. Heat application would be inappropriate because it promotes vasodilation, which may cause hemorrhage and increase pain. The initial pressure dressing usually remains in place for 48 to 72 hours after surgery.

A nurse is caring for a client who had hip pinning surgery 6 hours ago to treat inter-trochanteric fracture of the right hip. What assessment finding requires further investigation by the nurse?

Client is anxious and confused Explanation: The client is anxious and confused is the appropriate answer. Postoperative complications of hip fractures include hemorrhage, pulmonary emboli, and fat emboli. Anxiety and confusion may be indicative of hypoxia as a result of any of above these complications and needs further investigation. Capillary refill of 2-3 seconds is an expected finding, edema is present from both the injury and the surgical intervention. 100 milliliters of bright red drainage 6 hours after surgery should be watched, but is not of immediate concern.

A public health nurse is providing an information session focusing on injury prevention for young children diagnosed with juvenile arthritis. Of the information offered below, what should be included in this session?

Daily range of motion exercises are required to support joint mobility. Explanation: Daily range of motion exercises are required to help children with juvenile arthritis strengthen their muscles and use their joints to their full range of motion. Children should be encouraged to participate in as much of their own care as possible to keep their joints fluid. Excessive exercise, as evidenced by running, jumping, and so on, should be discouraged because it puts an excessive amount of pressure on the joints. The children should also remain active and independent, but should not overexert themselves. Home schooling is not required in this situation.

Which home care activity should the nurse tell a client who underwent a laryngectomy to do?

Participate in activities such as walking and golfing. Explanation: The client should be encouraged to participate in activities such as walking, golfing, and other moderate recreational sports. It is not necessary to keep the stoma covered at all times, although a gauze bib can be used to protect the clothes from mucus and to keep irritants from entering the stoma. Clients with a new laryngectomy may find air-conditioning too cool and dry at first, so they should avoid such environments. It is not necessary to remain in air-conditioning in the summer.

Bone resorption is a possible complication of Cushing's disease. To help the client prevent this complication, the nurse should recommend that the client:

maintain a regular program of weight-bearing exercise. Explanation: Osteoporosis is a serious outcome of prolonged cortisol excess because calcium is resorbed out of the bone. Regular daily weight-bearing exercise (e.g., brisk walking) is an effective way to drive calcium back into the bones. The client should also be instructed to have a dietary or supplemental intake of calcium of 1,500 mg daily. Potassium levels are not relevant to prevention of bone resorption. Vitamin D is needed to aid in the absorption of calcium. Isometric exercises condition muscle tone but do not build bones.

A client with a ruptured intervertebral disc at L4-5 stands with a flattened spine slightly tilted forward and slightly flexed to the affected side. The nurse interprets this finding as indicating:

postural deformity. Explanation: Standing with a flattened spine slightly tilted forward and slightly flexed to the affected side indicates a postural deformity. Motor changes would include findings such as hypotonia or muscle weakness. Absent or diminished reflexes related to the level of herniation would indicate alteration in reflexes. Sensory changes would include findings such as paresthesia and numbness related to the specific tract of the herniation.

Which information should the nurse include when performing discharge teaching with a client who had an anterolateral approach for a total hip replacement? Select all that apply. • Avoid turning the toes or knee outward. • Use an elevated toilet seat and shower chair. • Do not extend the operative leg backwards.

• Avoid turning the toes or knee outward. • Use an elevated toilet seat and shower chair. • Do not extend the operative leg backwards. Explanation: A client who has had a total hip replacement via an anterolateral approach has almost the opposite precautions as those for a client who has had a total hip replacement through the posterolateral approach. The hip joint should not be actively abducted. The client should avoid turning the toes or knee outward. The client should keep the legs side by side without a pillow or wedge. The client should use an elevated toilet seat and shower chair and should not extend the operative leg backwards. The client should perform range-of-motion exercises as directed by the physical therapist.

When performing an assessment, the nurse identifies the following signs and symptoms in the client: decreased muscle strength, limited range of motion, and reluctance to move. Based on these symptoms, the nurse should perform which of the following interventions? Select all that apply.

• Encouraging client turning and repositioning every 2 hours • Having call bell within easy reach • Initiating hospital fall risk protocols Explanation: The client with discoordination, decreased muscle strength, limited range of motion, and reluctance to move is at risk for falls and also for pressure ulcers. The nurse should encourage/assist the client in turning and repositioning every 2 hours and ensure that the call bell is within easy reach. The hospital's fall risk protocols should be initiated at this time. Having four-sided rails up is considered a restraint and is not indicated at this time. Gowning and gloving when in the room is appropriate for clients needing isolation precautions—these are not indicated at this time.

A client had a posterolateral total hip replacement 2 days ago. What information should the nurse include in the client's plan of care? Select all that apply.

• Position a pillow between the legs to maintain abduction. • Allow the client to be in the supine position or lateral position on the unoperated side. • Do not allow the client to bend down or to tie or slip on shoes. • Place ice on the incision after physical therapy. Explanation: A client who has had a posterolateral total hip replacement should not adduct the hip joint, which would lead to dislocation of the ball out of the socket; therefore, the client should be encouraged to keep the toes pointed slightly outward when using a walker. An abduction pillow should be kept between the legs to keep the hip joint in an abducted position. The client should rotate between lying supine and lateral on the unoperated side, but not on the operated side. Ice is used to reduce swelling on the operative side. The client should not flex the operated hip beyond a 90-degree angle, such as when bending down to tie or slip on shoes. Doing so could lead to joint dislocation.

An older adult is admitted with a fracture of the femur. The nurse should first assess:

mechanism of injury. Explanation: The nurse first assesses the mechanism of injury to help determine related injuries, tests needed, and potential treatment options. The next step is to assess the location, type, quality, and intensity of the pain. Neurovascular stasis of the injured site is assessed after pain; therefore, the nurse checks for functional ability or changing positions. Although the nurse can also determine the extent of anxiety while assessing the injury and can use communication strategies to minimize anxiety, it is not the first priority for assessing this client.

When developing the teaching plan for a client who uses a walker, which principle should a nurse consider?

When maximum support is required, the walker should be moved ahead approximately 6″ (15 cm) while both legs support the client's weight. Explanation: To prevent falls, a client who needs maximum support should move the walker ahead approximately 6″. The client's legs should bear the weight of his body. The hand bar of the walker should be level with the client's waist, not below it. If one leg is weaker than the other, the walker and the weak leg move together while the stronger leg bears the client's weight. To use a standard walker correctly, a client should pick it up to move it. However, some walkers have wheels and can glide across the floor.

Following a total hip replacement, the nurse should position the client by:

keeping the extremity in slight abduction using an abduction splint or pillows placed between the thighs. Explanation: After total hip replacement, proper positioning by the nurse prevents dislocation of the prosthesis. The nurse should place the client in a supine position and keep the affected extremity in slight abduction using an abduction splint or pillows or Buck's extension traction. The client must not abduct or flex the operated hip because this may produce dislocation.

After undergoing surgery the previous day for a total knee replacement, a client states that he doesn't feel ready to ambulate yet. What should the nurse do? You selected: Discuss the complications that the client's may experience if he doesn't cooperate with the care plan.

Discuss the complications that the client's may experience if he doesn't cooperate with the care plan. Explanation: The nurse should discuss the care plan and its rationale with the client. Calling the physician to report the client's noncompliance won't alter the client's degree of participation and shouldn't be used to force the client to comply. Doing nothing isn't acceptable. Although the client does have the right to make choices, it's the nurse's responsibility to provide education to help the client make informed decisions. Although the nurse should ultimately document the client's refusal, she should first discuss the care plan with the client.

A nurse prepares to transfer a client from a bed to a chair. Which principle demonstrates safe body mechanics?

The nurse uses a rocking motion while helping the client to stand. Explanation: Rocking provides extra force when pushing or pulling. The nurse should keep any weight as close to her body as possible when lifting — not at arm's length. The nurse should keep her knees slightly bent and her feet spread apart to provide a wide base of support. Keeping the knees straight and stiff and bending at the waist and keeping the feet close together aren't examples of safe body mechanics. These positions could result in injury to the nurse or to the client.

When assessing the client with Parkinson's disease, the nurse should observe the client for:

a stiff, masklike facial expression. Explanation: Typical signs of Parkinson's disease include drooling; a low-pitched, monotonous voice; and a stiff, masklike facial expression. Dry mouth is not associated with Parkinson's disease. Aphasia is not a symptom of Parkinson's disease. An exaggerated sense of euphoria would not be typical; more likely, the client would exhibit depression, probably related to the progressive nature of the disease and the client's difficulties dealing with it.

Which positioning technique is not appropriate when the nurse changes a client's position in bed if the client has hemiparalysis?

sliding the client to move up in bed Explanation: Sliding a client on a sheet causes friction and is to be avoided. Friction injures skin and predisposes to pressure ulcer formation. Rolling the client is an acceptable method to use when changing positions as long as the client is maintained in anatomically neutral positions and the limbs are properly supported. The client may be lifted as long as the nurse has assistance and uses proper body mechanics to avoid injury to himself or herself or the client. Having the client help lift off the bed with a trapeze is an acceptable means to move a client without causing friction burns or skin breakdown.

Following a tonsillectomy, a client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. In which position should the nurse place the client?

Side-lying Explanation: Lethargy puts the post-tonsillectomy client at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he's fully awake is best. The semi-Fowler's, supine, and high-Fowler's positions don't allow for adequate oral drainage of a lethargic post-tonsillectomy client and increase the risk of blood aspiration.

The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which position is appropriate?

• placing a pillow in the axilla so the arm is away from the body • inserting a pillow under the slightly flexed arm so the hand is higher than the elbow • positioning a hand cone in the hand so the fingers are barely flexed Explanation: Placing a pillow in the axilla so the arm is away from the body keeps the arm abducted and prevents skin from touching skin to avoid skin breakdown. Placing a pillow under the slightly flexed arm so the hand is higher than the elbow prevents dependent edema. Positioning a hand cone (not a rolled washcloth) in the hand prevents hand contractures. Immobilization of the extremity may cause a painful shoulder-hand syndrome. Flexion contractures of the hand, wrist, and elbow can result from immobility of the weak or paralyzed extremity. It is better to extend the arms to prevent contractures.

The emergency room nurse is caring for a client who fell breaking the tibia. The nurse determines that a client understands the risk of compartment syndrome when knowing to report which early symptom following treatment? Paresthesia

Paresthesia Explanation: Compartment syndrome is the compression of the nerves, blood vessels, and muscle inside a closed space. Paresthesia is the earliest sign of compartment syndrome. Pain, heat, and swelling are also signs but occur after paresthesia. Skin pallor is not a sign of compartment syndrome.

A nurse is caring for a 14-year-old client in skeletal traction to the left leg. The client is reporting pain on the 0 to 10 pain scale of 8. Which action would the nurse take first?

Realign the client in bed. Explanation: The client who reports moderate-to-severe pain may need realignment in bed. This also requires assessment of the client, which is completed prior to all other options. Assessment of the pin site is completed if the client has drainage or discomfort in that area.

A child with spastic cerebral palsy is to begin botulinum toxin type A injections. Which treatment goals should the health care team set for the child related to botulinum toxin? Select all that apply.

• decreased pain from spasticity • improved motor function • enhanced self-esteem • reduced caregiver strain and improved self-care Explanation: Botulinum toxin injections can be used to improve many aspects of quality of life for the child with cerebral palsy. The injections can help decrease pain from spasticity. Injections improve motor status by reducing rigidity and allowing for more effective physical therapy to improve range of motion. Decreased spasms enhance self-esteem. Improved motor status facilitates the ability to provide some aspects of care, especially transfers. Botulinum does not significantly affect nutritional status or speech.

Which nursing diagnosis is most appropriate for an elderly client with osteoarthritis? 1. Risk for injury related to altered mobility 2. Impaired urinary elimination related to effects of aging 3. Ineffective breathing pattern related to immobility 4. Imbalanced nutrition: Less than body requirements related to effects of aging

1. Risk for injury related to altered mobility Typically, a client with osteoarthritis has stiffness in large, weight-bearing joints, such as the hips. This joint stiffness alters functional ability and range of movement, placing the client at risk for falling and injury. Therefore, Risk for injury is the most appropriate nursing diagnosis. The other options are incorrect because osteoporosis doesn't affect urinary elimination, breathing, or nutrition.

An obese client has returned to the unit after receiving electroconvulsive therapy (ECT). A nurse requests assistance in moving the client from the stretcher to the bed. Which direction should the nurse give to a nurse who volunteers to help?

"Obtain the sliding board or two other people to assist us." Explanation: To successfully move an obese client from the stretcher to the bed without incurring injury, at least four staff members must perform the transfer. If only two people are available, the nurse should use the sliding board. The hydraulic lift isn't the appropriate equipment to use with a sedated patient. The nurse shouldn't place the client in a semi-Fowler's position unless he has a head injury or other complicated medical condition. To perform a safe transfer using a drawsheet, the nurse must place the sheet directly under the client's body.

The nurse is caring for a 17-year-old male client with Duchenne muscular dystrophy. When assisting the client during a hospitalization for pneumonia, which anticipated nursing interventions would reflect client specific care? Select all that apply.

• Assisting the client to a Fowler's position for a breathing treatment • Clearing a path to the bathroom for safe and easy access • Providing directions to the client's educational level Explanation: Duchenne muscular dystrophy typically occurs in males with symptoms appearing in the preschool years. The course of the disease is fairly predictable with weakness occurring in the voluntary muscles of the legs and trunk. By the teens, the heart and respiratory muscles can also be affected. Nursing interventions anticipated include assisting the client to an upright position for breathing treatments as the client has difficulty sitting up. Clearing a path to the bathroom is important as the client has an unsteady gait with possible braces and is unable to safely step over and around medical equipment. If wheelchair bound, a clear path is important for navigating to the bathroom.

A nurse is caring for a client, diagnosed with Alzheimer's disease, who scored a 7 (High risk) on the Hendrich II Fall Risk Model. Which nursing interventions would the nurse implement? Select all that apply.

• Implement a bed alarm. • Maintain the bed in the lowest position. • Offer toileting every 2 to 3 hours. • Advise family to notify staff when leaving. Explanation: Preventing a client from falling and causing further illness or injury is a role of the nurse. The Hendrich II Fall Risk Model is used in some acute care facilities to determine the potential for a fall. Assessment of a client's fall risk is a National Patient Safety Goal set by the Joint Commission and would be completed on admission. Nursing interventions such as implementing a bed alarm, maintaining the bed in the lowest position, offering toileting, and having the family notify staff when leaving are all appropriate nursing interventions to prevent falls. Sedating a client using chemical restraints is a last resort. Instructing a client to ask for help before ambulating is not effective in a client with Alzheimer's disease who will have difficulty remembering the instructions.

The client has been diagnosed with septic arthritis in a hip joint. Which outcomes are desired from a client-focused teaching plan? Select all that apply.

• Report pain that is severe enough to limit activities. • Discuss how to take prescribed medications. • Describe the septic arthritis physiologic process. • Explain the importance of supporting the affected joint. • Describe how to use ambulatory aids and assistive devices. Explanation: The nurse should determine that a client with rheumatoid arthritis can describe the septic arthritis physiologic process and knows how to relieve pain using pharmacologic and nonpharmacologic interventions. Prolonged immobility and limited activity may promote formation of a deep vein thrombosis and possibly subsequent pulmonary emboli. The client should also understand the importance of supporting the affected joint, weight-bearing and activity restrictions, and how to use ambulatory aids and assistive devices safely to promote recovery of normal function. The local application of heat and cold to an injured body part can provide therapeutic benefits; however, "high" heat may cause a thermal injury and further promote edema formation. The client should inform the health care provider (HCP) about pain that is not relieved by the current management plan.

The nurse is preparing a teaching plan for a client about crutch walking using a two-point gait pattern. What information should the nurse include?

Advance a crutch on one side, and simultaneously advance and bear weight on the opposite foot; repeat on the opposite side. Explanation: A two-point gait involves partial weight bearing on each foot, with each crutch advancing simultaneously with the opposing leg. Advancing a crutch on one side and then advancing the opposite foot, and repeating on the opposite side, illustrates the four-point gait. When the client advances both crutches together and follows by lifting both lower extremities to the same level as the crutches, the gait is called a "swing to" gait. When the client advances both crutches together and follows by lifting both lower extremities past the level of the crutches, the gait is called a "swing through" gait. The "swing through" gait is often used by paraplegic clients because it allows them to place weight on their legs while the crutches are moved one stride ahead

The nurse is assisting a client who has had a spinal fusion apply a back brace. In which order of priority should the nurse assist the client applying the brace?

Verify the prescriptions for the settings for the brace. Have the client in a side-lying position. Assist the client to log roll and rise to a sitting position. Ask the client to stand with arms held away from the body. Explanation: The nurse should first verify the settings for the brace and activity prescriptions. Next, the client should be in a side-lying position; explain that the spine should be kept aligned and in a neutral position, and the client should not pull on objects with arms. For getting out of bed, log roll client to side, splint back, and rise to a sitting position by pushing against the mattress while swinging legs over the side of the bed. Finally, the client should stand with the arms outstretched so the nurse can apply the brace.

When the client who has had a hip replacement is lying on the side, the nurse should place pillows or an abductor splint between the legs to prevent:

adduction of the hip joint. Explanation: After hip replacement surgery, the client should be positioned on the nonoperative side with pillows or an abductor splint between the legs to help prevent adduction of the operative leg. This positioning places the hip in proper alignment. Dislocation of the hip can occur if the leg on the affected side is allowed to adduct. Flexion of the knees is not contraindicated. Abduction of the legs is the correct position. Placing a pillow between the legs will not result in hyperextension of the knee. Hyperextension of the knee is to be avoided in any case because it can result in injury.

After undergoing surgery the previous day for a total knee replacement, a client states that he doesn't feel ready to ambulate yet. What should the nurse do?

The nurse is teaching an older adult how to prevent falls. The nurse should tell the client to:

instruct the client to rise slowly from a supine position. Explanation: Normal age-related changes can predispose older adults to falling and include vision, hearing, cardiovascular, musculoskeletal, and neurological changes. One of the most common problems facing older adults is the loss of tissue elasticity that affects the arteries. This loss of elasticity results in a decrease in tissue recoil and leads to changes in blood pressure with position changes. When they rise too quickly from a supine position, they feel light-headed and dizzy and can fall. The nurse should instruct clients to change positions slowly and to dangle the legs a few minutes when arising from a supine position. When aging, the lens of the eye becomes sensitive to very bright light which can causes a glare and visual disturbances that can lead to falls. Rooms should be well lit, but not with bright lights that cause a glare. Neurological changes are seen in impaired reflexes and thus postural instability. This loss of postural stability leads to falls. The need of assistive devices (hand rails, cane, walkers) helps reduce falls and promote independence. If joint pain develops and remains untreated, it can cause older adults to become sedentary or immobile. This disuse of muscles contributes to muscle weakness and falls. Nursing interventions should be directed at encouraging regular ambulation and joint movement (range of motion).

The client with an above-the-knee amputation is to use crutches while the prosthesis is being adjusted. Which exercises will best prepare the client for using crutches?

triceps strengthening exercises Explanation: Use of crutches requires significant strength from the triceps muscles. Therefore, efforts are focused on strengthening these muscles in anticipation of crutch walking. Bed and wheelchair push-ups are excellent exercises targeted at the triceps muscles. Abdominal exercises, range-of-motion and isometric exercises of the shoulders, and quadriceps and gluteal setting exercises are not helpful in preparing for crutch walking.

The nurse has been assigned to care for the following six clients. Which clients would the nurse expect to be at risk for the development of pulmonary embolism? Select all that apply.

• A client who is on complete bed rest following extensive spinal surgery. • A client who has a large venous stasis ulcer on the right ankle area. • A client who has recently been admitted with a broken femur and is awaiting surgery. • A client who has undergone a total vaginal hysterectomy and is now on estrogen replacement therapy. Explanation: Bed rest, poor venous circulation, fractures, and hormone replacement therapy can cause formation of a thromboembolus, placing these clients at risk for developing a PE. A deep vein thrombosis could break loose in the leg and travel to the lungs as a pulmonary embolus. The clot would then lodge in the pulmonary arteries or arterioles and impede blood flow. The client who is on complete bed rest is at risk for venous stasis, and the client who has a venous stasis ulcer is already demonstrating this condition. The client with a broken femur is at risk for a fat embolus, another form of PE. The client on estrogen replacement therapy is at increased risk for thromboembolic disorders. Pleural effusion and infection usually have no effect on thrombus formation, and oxygen therapy does not cause venous stasis or increase the risk of a pulmonary embolism.

When planning home care for the child with Legg-Calvé-Perthes disease, what should be the primary focus for family teaching?

management of the corrective appliance Explanation: Because most of the child's care takes place at home, the primary focus of family teaching would be on the care and management of the corrective device. Devices such as an abduction brace, a leg cast, or a harness sling are used to protect the affected joint while revascularization and bone healing occur. As long as the child is eating a well-balanced diet, there is no need for an intake of protein-rich foods. The parents can encourage range of motion in the unaffected leg, but motion in the affected leg is limited until it heals. Once therapy has been initiated, pain is usually not a problem. The key is management of the corrective device.

The nurse teaches the client to perform isometric exercises to strengthen the leg muscles after arthroplasty. Isometric exercises are particularly effective for clients with rheumatoid arthritis because they:

strengthen the muscles while keeping the joints stationary. Explanation: An exercise program is recommended to strengthen muscles after arthroplasty. Isometric (or muscle-setting) exercises strengthen muscles but keep the joint stationary during the healing process. Isometric exercise do not require specialized equipment, but this does not explain the benefits of the exercises. Isometric exercises may help improve a client's morale by promoting self-care, but this is not the reason for doing them. Because the joint is kept stationary, isometric exercise will not help prevent joint stiffness.

The nurse develops a plan of care for a client in the initial postoperative period following a lumbar laminectomy. Which activity is contraindicated?

sitting all afternoon in the room Explanation: After a lumbar laminectomy, a client should not sit for prolonged periods in a chair because of the increased pressure against the nerve root and incision site. Assisting with daily hygiene is an appropriate activity during the initial postoperative period because, as with any surgical procedure, the client needs to return to an optimal level of functioning as soon as possible. There is no limitation on the client's participation in daily hygiene activities except for individual responses of pain, nausea, vomiting, or weakness. Lying flat in bed is appropriate because it does not cause stress on the spinal column where the laminectomy was performed and the disc tissue was removed. Positions that should be avoided are those that would cause twisting and flexion of the spine. Walking in the hall is an acceptable activity. It promotes good postoperative ventilation, circulation, and return of peristalsis, which are needed for all surgical clients. In addition, walking provides the postoperative lumbar laminectomy client an opportunity to build up endurance and muscle strength and to promote circulation to the operative and incision sites for healing without twisting or stressing them.

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