Nursing Interventions
A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The MOST important reason for the nurse to elevate the casted leg is to?
A. Improve venous return
B. Promote the client’s comfort
C. Reduce the drying time
D. Decrease irritation to the skin
A. improve venous return
Rationale: elevating the leg both improves venous returning reduces swelling
When obtaining information about the patient’s use of medications, the nurse recognizes that both bone and muscle function may be impaired when the patient reports taking what type of drug?
A. Corticosteroids
B. Oral hypoglycemic agents
C. Potassium-depleting diuretics
D. NSAIDS
A. Corticosteroids
Cause protein catabolism with skeletal muscle wasting and increased osteoclast activity with loss of bone mass, which can have a marked detrimental effect on mobility and activity. Potassium spearing diuretics may cause hypokalemia, which is associated with muscle weakness and cramping. Oral hypoglycemic drugs and (NSAIDS) are not known to affect the musculoskeletal system
The nurse assesses which of the following clinical manifestations in a client with osteomyelitis? Select all that apply:
A. Restlessness
B. Petechia
C. Cool extremities
D. Night sweats
E. Fever
F. Nausea
A, D, E, F
Rationale: Osteomyelitis is an infection of the bone characterized by both local and systemic manifestations. Systemic manifestations include fever, chills, night sweats, nausea, malaise, and restlessness.
Patients with phantom limp pain should be taught...
A. It will go away in a few weeks.
B. It is a common occurrence after amputation.
C. It is often caused by swelling.
D. It will go away when prosthesis is applied.
B. it is a common occurrence after amputations
You’re explaining to a group of outpatients about the signs and symptoms that may present with osteoarthritis. Select all of the s/s that may present with this condition.
A. Herberden’s node
B. Morning stiffness for less than 30 minutes
C. Soft, tender, warm joints
D. Fever
E. Anemia
F. Hard and bony joints
G. Crepitus
H. Bouchard’s node
A, B, F, G, H
Rationale: . These are common findings found in osteoarthritis. Options C, D, and E are found in rheumatoid arthritis.
During the first 24 hours after an above-the-knee amputation for vascular disease, nursing priority for stump care would be:
A. Elevating to reduce edema
B. Cleansing with soap and water
C. Initiating fitting for prosthesis
D. Inspecting for redness and pressure points
A. elevating to reduce edema
Rationale: Elevating to reduce edema is correct because reducing edema will promote healing and prevent complications. During the early postoperative period, pressure would not be the first concern. If edema develops, breakdown will be more likely. Wound will not be cleansed within the first 24 hours. The stump is wrapped securely after surgery, and the dressing would be reinforced if needed. Prosthesis will not be indicated until there has been sufficient healing.
A patient who is on long term prednisone for Rheumatoid Arthritis (RA) should be instructed to take which of the following supplements?
A. calcium and Vitamin D
B. Folic Acid
C. Biotin and glucosamine
D. B12 and B6
A. Calcium and Vitamin D
Rationale: long term steroid use puts the patient at risk of osteoporosis. Therefore supplements of calcium and vitamin D are important for bone health.
The client is diagnosed with osteoarthritis. Which sign/symptom should the nurse expect the client to exhibit?
A. Waddling gait
B. Swan-neck fingers
C. Severe bone deformity
D. Joint stiffness
D. joint stiffness
Rationale: Pain, stiffness, and functional impairment are the primary clinical manifestations of OA. Stiffness of the joints is commonly experienced after resting but usually lasts less than 30 minutes and decreases with movement. Severe bone deformity is seen in clients diagnosed with rheumatoid arthritis. A waddling gait is usually seen in women in their third trimester of pregnancy or in older children with congenital hip dysplasia. Swan-neck fingers are seen in clients with rheumatoid arthritis.
A client has bilateral knee pain from osteoarthritis. In addition to taking the prescribed NSAID, the nurse should instruct the client to:
A. Avoid foods high in citric acid
B. Rest the knees as much as possible to decrease inflammation
C. Keep legs elevated while sitting
D. Start a regular exercise program
D. start a regular exercise program
Rationale: A regular exercise program is beneficial in treating osteoarthritis. It can restore self-esteem and improve physical functioning.
What bowel program is appropriate for an SCI patient who has sacral sparing (reflexive bowel)?
A. enema
B. suppository and digital stimulation
C. bowel program with timed toileting
D. high fiber, low water
B. suppository and digital stimulaiton
Rational: these patients have some sense of reflex and sensation so stool softness and digital stimulation will be effective
A 78-year-old women has a physiologic change related to aging in her joints. What is an appropriate nursing intervention related to common changes of aging in the musculoskeletal system?
A. Encourage rest to eliminate fatigue
B. Provide all care for the patent to ensure that all care is complete.
C. Encourage eating enough calories to avoid the risk of impaired muscle regeneration
D. Have the patient exercise to maintain strength and avoid the risk of falls
D. Have the patient exercise to maintain strength and avoid the risk of falls
The nurse provides care for a client who is diagnosed with gout and is proscribed allopurinol. The client reports drowsiness. Which is the priority action by the nurse?
A. monitor the client's vital signs
B. Notify the client's health care provider (HCP) immediately
C. Ask the client "Are you experiencing nausea and vomiting?"
D. Tell the client "Use the call bell so that I can assist you with ambulation."
D. Tell the client "Use the call bell so that I can assist you with ambulation."
Rationale: Drowsiness is a common side effect of allopurinol. Drowsiness increases the client's risk for falling with ambulation; therefore instructing the patient to use the call bell to call for help is the priority action.
A complication of Buck’s traction would be noted by a nurse if:
A. Redness and purulent drainage appeared at the pin site
B. Skin over the fracture site was flushed
C. Toes of the affected leg became dusky in color
D. Dorsiflexion developed in the affected foot
C. Toes of the affected leg become dusky in color
Rationale: Buck’s is skin traction to the lower leg. Circulatory disturbances and skin abrasions are the most important nursing concerns. Buck's does not use pins, the fracture site would not be visible due to elastic bandage, and the foam boot puts foot in dorsiflexion position.
A nurse is teaching a client who was recently diagnosed with carpal tunnel syndrome. Which statement should the nurse include?
A. "This condition is associated with various sports"
B. "Surgery is the only sure way to manage this condition"
C. "Ergonomic changes can be incorporated into your workday to reduce stress on your wrist"
D. "Using arm splints will prevent hyperflexion of the wrist"
C. Ergonomic changes can be incorporated into your workday to reduce stress on your wrist
Rationale: Ergonomic changes, such as adjusting keyboard height, can help clients with carpal tunnel syndrome avoid hyperextension of the wrist
Which patient below is presenting with signs and symptoms of rheumatoid arthritis? Select all that apply.
A. A 35 year-old patient who has severe morning stiffness for 45 minutes
B. A 45 year-old male with crepitus in the right knee
C. A 30 year-old female with warm, red, soft joints on the hands and wrists
D. A 40 year-old male whose x-ray imaging results showed osteophytes formation and decreased joint space in the left knee.
A and C
Rationale: These are common findings in RA. However, options B and D are found in OA.
A client has undergone a lumbar laminectomy and has just returned to the nursing unit. It is essential for the nurse to perform which of the following activities during this period?
A. Vital sign checks every half-hour
B. Assessment of bladder function
C. Early ambulation
D. Neurovascular checks
D. Neurovascular checks
Rationale: Bleeding and swelling following a laminectomy may cause compression of nerves in the spinal column that can lead to permanent neurological damage and paralysis. Frequent assessment of the neurovascular status of the client is essential following laminectomy. Neurovascular assessment includes assessing for pain, pulses, pallor, paresthesia, and paralysis.
Your patient, who has osteoporosis, is prescribed to take Calcitonin. Which assessment finding below is a possible adverse reaction of this medication and requires you notify the physician immediately?
A. Constipation
B. Abdominal pain that is found a one-third distance between the belly button and anterior superior iliac spine.
C. Carpopedal spasm while assessing the patient’s blood pressure
D. Absent reflexes
C. Carpopedal spasm while assessing the patient’s blood pressure
Rationale: Calcitonin works to decrease activity of osteoclasts and causes kidneys to excrete more calcium, leading to risk of hypocalcemia. This correct answer (also known as Trousseau's sign) occurs in hypokalemia and is found when there is an occlusion on the upper arm's brachial artery.
A client fractured his femur yesterday. Monitoring for which potential complication must be included by the nurse in the client’s plan of care?
A. Fat emboli syndrome
B. Crush Injury
C. Chronic pain
D. Disturbed body image
A. Fat emboli syndrome
Rationale: Fat emboli syndrome is a potential complication of long bone fractures and occurs when fat globule leave the shaft of the long bone and enter the circulation
The nurse is teaching a client with metastatic bone disease about measures to prevent hypercalcemia. It would be important for the nurse to emphasize?
A. The importance of walking
B. Early recognition of tetany
C. The need to restrict fluid intake to less than 1 liter per day
D. The need to have at least 5 servings of dairy products daily
A. the importance of walking
Rationale: The importance of walking is the correct option. This is because mobility must be emphasized to prevent demineralization and breakdown of bones.
The client is being evaluated for osteoporosis. Which diagnostic test is the most accurate when diagnosing osteoporosis?
A. Dual energy x-ray absorptiometry (DEXA)
B. X-ray of the femur
C. Serum bone Gla-protein test
D. Serum alkaline phosphatase
A. duel energy x-ray absorptiometry (DEXA)
Rationale: This test measures bone density in the lumbar spine or hip and is considered to be highly accurate. Osteoporosis is secondary to poor absorption of calcium, which make this option appropriate for selection
A nurse is caring for a client with a spinal cord injury. The client is experiencing blurred vision and has a blood pressure of 206/110 mm Hg. What should the nurse do first?
A. Position the client on the left side
B. check the client's bladder for distention
C. control the environment by turning off the lights and decreasing stimulation
D. Administer ordered pain medication
B. check the client's bladder for distention
Rational: The client is experiencing autonomic dysreflexia, which is a medical emergency. The nurse should immediately evaluate the client for bladder distention and be prepared to catheterize the client.
A client is scheduled to undergo an open reduction internal fixation of the right femur. The night before surgery, the nurse administers zolpidem as ordered. Which statement about zolpidem is correct?
A. the nurse shouldn't use the liquid if it becomes slightly darkened
B. the nurse should administer the drug immediately before bedtime
C. the nurse should dilute it in fruit juice to improve absorption
D. avoid administration with grapefruit juice; it interferes with absorption
B. the nurse should administer the drug immediately before bedtime
Rationale: Zolpidem (Ambien) is used for short-term treatment of imsomnia and should be administered immediately before bedtime
A client is admitted following a motor vehicle accident where his left thigh was crushed beneath the vehicle. The nurse must assess for which of the following complications?
A. Hypotension
B. Acute renal failure
C. Hypokalemia
D. Fat emboli syndrome
B. acute renal failure
Rationale: A client with a crush injury is at risk for muscle breakdown and release of myoglobin into the circulation. This can result in acute tubular necrosis and renal failure. This client is more likely to develop hyperkalemia from cell destruction than hypokalemia. Hypotension is a risk if the client begins to hemorrhage. Since there is no evidence of a fracture, the risk of fat emboli syndrome is low.
A client who had a total hip replacement 4 days ago is worried about dislocation of the prosthesis. The nurse should respond by saying:
A. "Decreasing the use of the abductor pillow will strengthen the muscles to prevent dislocation"
B. "Do not worry. Your new hip is very strong."
C. "Use of a cushioned toilet seat helps to prevent dislocation."
D. "Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid them."
D. "Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid them."
Rationale: Dislocation precautions include: avoid extremes of internal rotation, adduction, and 90-degree flexion of affected hip for at least 4 to 6 weeks after the procedure
Which nursing diagnosis takes highest priority for a client with a compound fracture?
A. risk for infection related to effects of trauma
B. imbalanced nutrition: less than body requirements related to immobility
C. impaired physical mobility related to trauma
D. activity intolerance related to weight-bearing limitations
A. risk for infection related to effects of trauma
Rationale: A compound fracture involves an opening in the skin at the fracture site. Because the skin is the body's first line of defense against infection, any skin opening places the client at risk for infection.