Musculoskeletal Examination (Exam Mode) By Rnpedia.Com
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- 1.
A client is 1 day postoperative after a total hip replacement. The client should be placed in which of the following position?
- A.
Supine
- B.
Semi Fowler's
- C.
Orthopneic
- D.
Trendelenburg
Correct Answer
B. Semi Fowler'sExplanation
After a total hip replacement, the client should be placed in a Semi Fowler's position. This position involves elevating the head of the bed to an angle of 30-45 degrees. It helps to reduce pressure on the surgical site, promote lung expansion, and prevent complications such as aspiration and venous stasis. The Supine position (lying flat on the back), Orthopneic position (sitting upright and leaning forward), and Trendelenburg position (head down and feet elevated) are not appropriate for a client post total hip replacement.Rate this question:
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- 2.
A client who has had a plaster of Paris cast applied to his forearm is receiving pain medication. To detect early manifestations of compartment syndrome, which of these assessments should the nurse make?
- A.
Observe the color of the fingers
- B.
Palpate the radial pulse under the cast
- C.
Check the cast for odor and drainage
- D.
Evaluate the response to analgesics
Correct Answer
D. Evaluate the response to analgesicsExplanation
To detect early manifestations of compartment syndrome, the nurse should evaluate the client's response to analgesics. Compartment syndrome occurs when increased pressure within a confined space, such as the forearm, impairs blood flow and damages nerves and muscles. Pain is one of the earliest and most reliable indicators of compartment syndrome. Therefore, by evaluating the client's response to analgesics, the nurse can assess the effectiveness of pain management and determine if there are any signs of worsening compartment syndrome. Observing the color of the fingers, palpating the radial pulse, and checking the cast for odor and drainage are important assessments but may not directly indicate compartment syndrome.Rate this question:
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- 3.
After a computer tomography scan with intravenous contrast medium, a client returns to the unit complaining of shortness of breath and itching. The nurse should be prepared to treat the client for:
- A.
An anaphylactic reaction to the dye
- B.
Inflammation from the extravasation of fluid during injection.
- C.
Fluid overload from the volume of the infusions
- D.
A normal reaction to the stress of the diagnostic procedure
Correct Answer
A. An anapHylactic reaction to the dyeExplanation
After a computer tomography scan with intravenous contrast medium, the client's symptoms of shortness of breath and itching suggest an anaphylactic reaction to the dye. An anaphylactic reaction is a severe allergic reaction that can occur in response to certain substances, such as the contrast dye used in the scan. Symptoms of an anaphylactic reaction can include difficulty breathing, itching, and hives. The nurse should be prepared to treat the client for this potentially life-threatening reaction.Rate this question:
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- 4.
While caring for a client with a newly applied plaster of Paris cast, the nurse makes note of all the following conditions. Which assessment finding requires immediate notification of the physician?
- A.
Moderate pain, as reported by the client
- B.
Report, by client, the heat is being felt under the cast
- C.
Presence of slight edema of the toes of the casted foot
- D.
Onset of paralysis in the toes of the casted foot
Correct Answer
D. Onset of paralysis in the toes of the casted footExplanation
The onset of paralysis in the toes of the casted foot is a concerning finding that requires immediate notification of the physician. It could indicate the development of compartment syndrome, which is a serious condition characterized by increased pressure within a confined space (such as the cast), leading to reduced blood flow and potential nerve damage. Prompt medical intervention is necessary to prevent further complications and ensure the client's well-being.Rate this question:
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- 5.
Which of these nursing actions will best promote independence for the client in skeletal traction?
- A.
Instruct the client to call for an analgesic before pain becomes severe.
- B.
Provide an overhead trapeze for client use
- C.
Encourage leg exercise within the limits of traction
- D.
Provide skin care to prevent skin breakdown.
Correct Answer
B. Provide an overhead trapeze for client useExplanation
Providing an overhead trapeze for client use will best promote independence for the client in skeletal traction. This allows the client to move and reposition themselves without assistance, improving their mobility and sense of control. It also helps to prevent complications such as pressure ulcers and muscle atrophy.Rate this question:
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- 6.
A client presents in the emergency department after falling from a roof. A fracture of the femoral neck is suspected. Which of these assessments best support this diagnosis.
- A.
The client reports pain in the affected leg
- B.
A large hematoma is visible in the affected extremity
- C.
The affected extremity is shortnend, adducted, and extremely rotated
- D.
The affected extremity is edematous
Correct Answer
C. The affected extremity is shortnend, adducted, and extremely rotatedExplanation
The assessment of the affected extremity being shortened, adducted, and extremely rotated is indicative of a fracture of the femoral neck. This is known as the classic presentation of a hip fracture. The shortening occurs due to the displacement of the fractured bone, the adduction occurs due to the pull of the adductor muscles, and the rotation occurs due to the twisting force applied during the fall. These findings are consistent with a fracture of the femoral neck and support the diagnosis.Rate this question:
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- 7.
The nurse is caring for a client with compound fracture of the tibia and fibula. Skeletal traction is applied. Which of these priorities should the nurse include in the care plan?
- A.
Order a trapeze to increase the client's ambulation
- B.
Maintain the client in a flat, supine position at all times.
- C.
Provide pin care at least every hour
- D.
Remove traction weights for 20 minutes every two hours.
Correct Answer
C. Provide pin care at least every hourExplanation
The nurse should prioritize providing pin care at least every hour for a client with a compound fracture of the tibia and fibula who has skeletal traction applied. Pin care is important to prevent infection and ensure proper healing of the fracture. The nurse should clean the pin sites using sterile technique and monitor for any signs of infection or complications. This intervention is crucial in the care plan to promote the client's recovery and prevent further complications.Rate this question:
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- 8.
To prevent foot drop in a client with Buck's traction, the nurse should:
- A.
Place pillows under the client's heels.
- B.
Tuck the sheets into the foot of the bed
- C.
Teach the client isometric exercises
- D.
Ensure proper body positioning.
Correct Answer
D. Ensure proper body positioning.Explanation
To prevent foot drop in a client with Buck's traction, ensuring proper body positioning is essential. Proper body positioning helps maintain the correct alignment of the body, including the feet, which reduces the risk of foot drop. This can be achieved by using pillows or other supportive devices to keep the client's body in the correct position. Placing pillows under the client's heels may provide some comfort, but it does not directly address the prevention of foot drop. Tucking the sheets into the foot of the bed and teaching isometric exercises do not specifically address proper body positioning or the prevention of foot drop.Rate this question:
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- 9.
Which nursing intervention is appropriate for a client with skeletal traction?
- A.
Pin care
- B.
Prone positionin
- C.
Intermittent weight
- D.
5lb weight limit
Correct Answer
A. Pin careExplanation
For a client with skeletal traction, pin care is an appropriate nursing intervention. Skeletal traction involves the use of pins or wires inserted into the bone to immobilize and align fractured bones. Pin care is essential to prevent infection and ensure proper healing. It involves cleaning the pin sites with an antiseptic solution, monitoring for signs of infection, and providing appropriate wound care. The other options, prone positioning, intermittent weight, and a 5lb weight limit, may be interventions used in other situations but are not specific to skeletal traction.Rate this question:
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- 10.
In order for Buck's traction applied to the right leg to be effective, the client should be placed in which position?
- A.
Supine
- B.
Prone
- C.
Sim's
- D.
Lithotomy
Correct Answer
A. SupineExplanation
Buck's traction is a method used to immobilize and align fractures or dislocations in the lower extremities. It involves the application of a pulling force to the affected limb. In order for Buck's traction applied to the right leg to be effective, the client should be placed in a supine position. This position allows for proper alignment and distribution of the pulling force, ensuring that the traction is applied correctly and effectively.Rate this question:
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- 11.
An elderly client has sustained intertrochanteric fracture of the hip and has just returned from surgery where a nail plate was inserted for internal fixation. The client has been instructed that she should not flex her hip. The best explanation of why this movement would be harmful is:
- A.
It will be very painful for the client
- B.
The soft tissue around the site will be damaged
- C.
Displacement can occur with flexion
- D.
It will pull the hip out of alignment
Correct Answer
C. Displacement can occur with flexionExplanation
Flexion of the hip can cause displacement of the nail plate used for internal fixation, leading to improper alignment of the hip. This can hinder the healing process and potentially cause further damage to the hip.Rate this question:
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- 12.
When the client is lying supine, the nurse will prevent external rotation of the lower extremity by using a:
- A.
Trochanter roll by the knee
- B.
Sandbag to the lateral calf
- C.
Trochanter roll to the thigh
- D.
Footboard
Correct Answer
C. Trochanter roll to the thighExplanation
When the client is lying supine, the nurse will prevent external rotation of the lower extremity by using a trochanter roll to the thigh. This is because a trochanter roll is a cushion placed along the lateral aspect of the thigh to prevent the hip from rotating outward. It helps to maintain proper alignment of the hip joint and prevent potential injury or discomfort to the client. Using a trochanter roll to the thigh is a common nursing intervention to promote proper positioning and prevent complications in supine patients.Rate this question:
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- 13.
A client has just returned from surgery after having his left leg amputated below the knee. Physician's orders include elevation of the foot of the bed for 24 hours. The nurse observes that the nursing assistant has placed a pillow under the client's amputated limb. The nursing action is to:
- A.
Leave the pillow as his stump is elevated
- B.
Remove the pillow and elevate the foot of the bed
- C.
Leave the pillow and elevate the foot of the bed
- D.
Check with the physician and clarify the orders
Correct Answer
B. Remove the pillow and elevate the foot of the bedExplanation
The correct answer is to remove the pillow and elevate the foot of the bed. Placing a pillow under the client's amputated limb is not appropriate as it does not provide proper elevation. Elevation of the foot of the bed is important to reduce swelling and promote healing. Therefore, the nurse should remove the pillow and follow the physician's orders to elevate the foot of the bed.Rate this question:
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- 14.
A client has sustained a fracture of the femur and balanced skeletal traction with a Thomas splint has been applied. To prevent pressure points from occurring around the top of the splint, the most important intervention is to:
- A.
Protect the skin with lotion
- B.
Keep the client pulled up in bed
- C.
Pad the top of the splint with washcloths
- D.
Provide a footplate in the bed
Correct Answer
C. Pad the top of the splint with washclothsExplanation
To prevent pressure points from occurring around the top of the splint, it is important to pad the top of the splint with washcloths. This will help distribute the pressure evenly and prevent any localized areas of excessive pressure on the skin. Lotion may provide some protection but will not effectively distribute the pressure. Keeping the client pulled up in bed or providing a footplate in the bed are not directly related to preventing pressure points around the top of the splint.Rate this question:
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- 15.
The major rationale for the use of acetylsalicylic acid (aspirin) in the treatment of rheumatoid arthritis is to:
- A.
Reduce fever
- B.
Reduce the inflammation of the joints
- C.
Assist the client's range of motion activities without pain
- D.
Prevent extension of the disease process
Correct Answer
B. Reduce the inflammation of the jointsExplanation
Acetylsalicylic acid (aspirin) is used in the treatment of rheumatoid arthritis to reduce the inflammation of the joints. Rheumatoid arthritis is an autoimmune disease that causes chronic inflammation and pain in the joints. Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that helps to reduce inflammation by inhibiting the production of certain chemicals in the body that cause inflammation. By reducing inflammation, aspirin can help alleviate the symptoms of rheumatoid arthritis, such as joint pain, swelling, and stiffness. It does not directly reduce fever, assist with range of motion activities, or prevent the extension of the disease process.Rate this question:
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- 16.
Following an amputation, the advantage to the client for an immediate prosthesis fitting is:
- A.
Ability to ambulate sooner
- B.
Less change of phantom limb sensation
- C.
Dressing changes are not necessar
- D.
Better fit of the prosthesis
Correct Answer
A. Ability to ambulate soonerExplanation
The advantage of an immediate prosthesis fitting following an amputation is the ability to ambulate sooner. By providing the client with a prosthesis immediately after the amputation, they can start walking and regaining their mobility faster. This can have a positive impact on their overall rehabilitation process and help them regain their independence more quickly.Rate this question:
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- 17.
One method of assessing for sign of circulatory impairment in a client with a fractured femur is to ask the client to:
- A.
Cough and deep breathe
- B.
Turn himself in bed
- C.
Perform biceps exercise
- D.
Wiggle his toes
Correct Answer
D. Wiggle his toesExplanation
Wiggling the toes is a method of assessing for circulatory impairment in a client with a fractured femur because it tests the blood flow to the lower extremities. If the client is unable to wiggle their toes, it could indicate that there is a decrease in blood flow to the area, which may be a sign of circulatory impairment. This assessment can help healthcare professionals identify any potential complications and take appropriate action to prevent further damage.Rate this question:
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- 18.
The morning of the second postoperative day following hip surgery for a fractured right hip, the nurse will ambulate the client. The first intervention is to:
- A.
Get the client up in a chair after dangling at the bedside.
- B.
Use a walker for balance when getting the client out of bed
- C.
Have the client put minimal weight on the affected side when getting up
- D.
Practice getting the client out of bed by having her slightly flex her hips
Correct Answer
D. Practice getting the client out of bed by having her slightly flex her hipsExplanation
The correct answer is to practice getting the client out of bed by having her slightly flex her hips. This intervention is important because it helps the client gradually adjust to the movement and weight-bearing activities after hip surgery. By slightly flexing her hips, the client can minimize strain on the surgical site and reduce the risk of complications. This intervention also helps in promoting proper alignment and stability during ambulation.Rate this question:
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- 19.
A young client is in the hospital with his left leg in Buck's traction. The team leader asks the nurse to place a footplate on the affected side at the bottom of the bed. The purpose of this action is to:
- A.
Anchor the traction
- B.
Prevent footdrop
- C.
Keep the client from sliding down in bed
- D.
Prevent pressure areas on the foot
Correct Answer
B. Prevent footdropExplanation
Placing a footplate on the affected side at the bottom of the bed helps to prevent footdrop. Footdrop is a condition where the foot is unable to maintain a normal flexed position, causing the toes to drag on the ground. By providing a footplate, the nurse ensures that the client's foot remains in a neutral or slightly dorsiflexed position, preventing the development of footdrop. This action helps maintain proper alignment and function of the foot and ankle, promoting optimal mobility and preventing complications associated with footdrop.Rate this question:
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- 20.
When evaluating all forms of traction, the nurse knows the direction of pull is controlled by the:
- A.
Client's position
- B.
Rope/pulley system
- C.
Amount of weight
- D.
Point of friction
Correct Answer
B. Rope/pulley systemExplanation
The direction of pull is controlled by the rope/pulley system because it determines the path and angle of the traction force. The nurse can adjust the position and movement of the pulley to change the direction of pull on the client's body. This allows for precise and controlled application of traction to achieve the desired therapeutic effect.Rate this question:
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- 21.
When a client has cervical halter traction to immobilize the cervical spine counteraction is provided by:
- A.
Elevating the foot of the bed
- B.
Elevating the head of the bed
- C.
Application of the pelvic girdle
- D.
Lowering the head of the bed
Correct Answer
B. Elevating the head of the bedExplanation
When a client has cervical halter traction to immobilize the cervical spine, elevating the head of the bed provides the counteraction. This is because elevating the head of the bed helps to create an opposing force to the traction force applied to the cervical spine. By elevating the head of the bed, the weight of the client's head and upper body can act as a counterforce to the traction force, helping to stabilize and immobilize the cervical spine effectively.Rate this question:
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- 22.
After falling down the basement steps in his house, a client is brought to the emergency room. His physician confirms that his leg is fractured. Following application of a leg cast, the nurse will first check the client's toes for:
- A.
Increase in the temperature
- B.
Change in co
- C.
Edema
- D.
Movemen
Correct Answer
B. Change in coExplanation
After a leg fracture and the application of a leg cast, the nurse would first check the client's toes for a change in color. This is because a change in color, such as pallor or cyanosis, could indicate compromised blood circulation to the toes. It is important to monitor the color of the toes to ensure that there is adequate blood flow and to detect any potential complications, such as ischemia or tissue necrosis.Rate this question:
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- 23.
A 23 year old female client was in an automobile accident and is now a paraplegic. She is on an intermittent urinary catheterization program and diet as tolerated. The nurse's priority assessment should be to observe for:
- A.
Urinary retention
- B.
Bladder distention
- C.
Weight gain
- D.
Bower evacuation
Correct Answer
B. Bladder distentionExplanation
The nurse's priority assessment should be to observe for bladder distention in the client. Bladder distention can occur in paraplegic clients due to the loss of voluntary control over the bladder muscles. This can lead to urinary retention, which can cause discomfort and potential complications such as urinary tract infections. Therefore, it is important for the nurse to assess for bladder distention and intervene promptly to prevent any complications.Rate this question:
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- 24.
A female client with rheumatoid arthritis has been on aspirin grain TID and prednisone 10mg BID for the last two years. The most important assessment question for the nurse to ask related to the client's drug therapy is whether she has
- A.
Headache
- B.
Tarry stool
- C.
Blurred vision
- D.
Decreased appetite
Correct Answer
B. Tarry stoolExplanation
The most important assessment question for the nurse to ask related to the client's drug therapy is whether she has tarry stool. This is because both aspirin and prednisone can cause gastrointestinal bleeding, which can manifest as tarry stool. It is important to assess for this symptom as it could indicate a serious adverse effect of the medication and prompt further investigation or adjustment of the treatment plan.Rate this question:
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- 25.
A 7 year old boy with a fractured leg tells the nurse that he is bored. An appropriate intervention would be to
- A.
Read a story and act out the part
- B.
Watch a puppet show
- C.
Watch television
- D.
Listen to the radio
Correct Answer
C. Watch televisionExplanation
Watching television can be an appropriate intervention for a 7-year-old boy with a fractured leg who is feeling bored. Television can provide entertainment and distraction, helping to alleviate boredom. It can also offer a variety of shows and programs that can engage the child's interest and keep him occupied while he is unable to engage in physical activities due to his fractured leg.Rate this question:
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- 26.
On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. Which of the following would be the nurse most likely to asses
- A.
Limited motion of joint
- B.
Deformed joints of the han
- C.
Early morning stiffnes
- D.
Rheumatoid nodule
Correct Answer
C. Early morning stiffnesExplanation
Early morning stiffness is a common symptom of rheumatoid arthritis. It is characterized by stiffness and difficulty moving the joints, particularly in the morning after a period of rest. This symptom is often one of the earliest signs of rheumatoid arthritis and can be a key indicator for diagnosis. Assessing for early morning stiffness can help the nurse determine if the client is experiencing symptoms consistent with rheumatoid arthritis and can guide further assessment and treatment.Rate this question:
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- 27.
After teaching the client about risk factors for rheumatoid arthritis, which of the following, if stated by the client as a risk factor, would indicate to the nurse that the client needs additional teaching?
- A.
History of Epstein-Barr virus infection
- B.
Female gender
- C.
Adults between the ages 60 to 75 years
- D.
Positive testing for human leukocyte antigen (HLA) DR4 allele
Correct Answer
C. Adults between the ages 60 to 75 yearsExplanation
Adults between the ages of 60 to 75 years is not a risk factor for rheumatoid arthritis. Rheumatoid arthritis typically affects individuals between the ages of 30 and 60, with the peak onset occurring between 40 and 60 years old. Therefore, if the client states that being between the ages of 60 to 75 is a risk factor, it would indicate a need for additional teaching.Rate this question:
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- 28.
When developing the teaching plan for the client with rheumatoid arthritis to promote rest, which of the following would the nurse expect to instruct the client to avoid during the rest periods?
- A.
Proper body alignment
- B.
Elevating the part
- C.
Prone lying positions
- D.
Positions of flexion
Correct Answer
D. Positions of flexionExplanation
During rest periods, the nurse would expect to instruct the client with rheumatoid arthritis to avoid positions of flexion. This is because flexion positions can lead to increased joint stiffness and discomfort for individuals with rheumatoid arthritis. Proper body alignment is important to maintain overall comfort and prevent strain on the joints. Elevating the affected part can help reduce swelling and promote circulation. Prone lying positions may be recommended for some individuals to relieve pressure on certain joints. However, positions of flexion should be avoided to prevent worsening of symptoms.Rate this question:
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- 29.
After teaching the client with severe rheumatoid arthritis about the newly prescribed medication methothrexate (Rheumatrex 0), which of the following statements indicates the need for further teaching?
- A.
"I will take my vitamins while I am on this drug"
- B.
"I must not drink any alcohol while I'm taking this drug"
- C.
I should brush my teeth after every meal"
- D.
"I will continue taking my birth control pills"
Correct Answer
D. "I will continue taking my birth control pills"Explanation
The need for further teaching is indicated by the statement "I will continue taking my birth control pills." Methotrexate is known to cause birth defects and should not be taken during pregnancy. Therefore, it is important for the client to understand that they should not continue taking birth control pills while on this medication.Rate this question:
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- 30.
When completing the history and physical examination of a client diagnosed with osteoarthritis, which of the following would the nurse assess?
- A.
Anemia
- B.
Osteoporosis
- C.
Weight loss
- D.
Local joint pain
Correct Answer
D. Local joint painExplanation
In a client diagnosed with osteoarthritis, the nurse would assess for local joint pain. Osteoarthritis is a degenerative joint disease that primarily affects the cartilage in the joints, leading to pain, stiffness, and swelling in the affected joints. Assessing for local joint pain is important in determining the severity and progression of the disease, as well as guiding the development of an appropriate treatment plan. Anemia, osteoporosis, and weight loss are not directly associated with osteoarthritis and would not be the primary focus of assessment in this case.Rate this question:
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- 31.
At which of the following times would the nurse instruct the client to take ibuprofen (Motrin), prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation?
- A.
At bedtime
- B.
On arising
- C.
Immediately after meal
- D.
On an empty stomach
Correct Answer
C. Immediately after mealExplanation
Taking ibuprofen immediately after a meal helps to minimize gastric mucosal irritation. When taken on an empty stomach, ibuprofen can irritate the lining of the stomach and increase the risk of gastrointestinal side effects such as stomach ulcers and bleeding. Taking it after a meal provides a protective layer in the stomach, reducing the chances of irritation. Taking it at bedtime or on arising does not provide the same protective effect as taking it after a meal.Rate this question:
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- 32.
When preparing a teaching plan for the client with osteoarthritis who is taking celecoxib (Celebrex), the nurse expects to explain that the major advantage of celecoxib over diclofenac (Voltaren), is that the celecoxib is likely to produce which of the following?
- A.
Hepatotoxicity
- B.
Renal toxicity
- C.
Gastrointestinal bleedin
- D.
Nausea and vomitin
Correct Answer
C. Gastrointestinal bleedinExplanation
Celecoxib is a selective COX-2 inhibitor, while diclofenac is a nonselective COX inhibitor. The major advantage of celecoxib over diclofenac is that it is less likely to cause gastrointestinal bleeding. Nonselective COX inhibitors, such as diclofenac, can inhibit both COX-1 and COX-2 enzymes, leading to a higher risk of gastrointestinal bleeding. Celecoxib, on the other hand, selectively inhibits COX-2 enzymes, which reduces the risk of gastrointestinal bleeding while still providing anti-inflammatory effects.Rate this question:
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- 33.
After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse interprets these findings as indicating which of the following?
- A.
A developing infection
- B.
Bleeding in the operative si
- C.
Joint dislocati
- D.
Glue seepage into soft tissu
Correct Answer
C. Joint dislocatiExplanation
The severe sudden pain and inability to move the extremity after surgery and insertion of a total joint prosthesis indicate joint dislocation. This is because joint dislocation can cause intense pain and restrict movement in the affected joint. It is important for the nurse to recognize this complication promptly and take appropriate actions to prevent further damage and facilitate proper joint alignment.Rate this question:
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- 34.
Which of the following would the nurse assess in a client with an intracapsular hip fracture?
- A.
Internal rotatio
- B.
Muscle flaccidity
- C.
Shortening of the affected le
- D.
Absence of pain the fracture ar
Correct Answer
C. Shortening of the affected leExplanation
In a client with an intracapsular hip fracture, the nurse would assess for shortening of the affected leg. This is because an intracapsular hip fracture occurs within the hip joint capsule, which can cause the affected leg to appear shorter than the unaffected leg. This assessment finding is important to note as it can help confirm the presence of a hip fracture and guide further diagnostic and treatment interventions.Rate this question:
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- 35.
Which of the following would be inappropriate to include when preparing a client for magnetic resonance imaging (MRI) to evaluate a rupture disc?
- A.
Informing the client that the procedure is painless
- B.
Taking a thorough history of past surgeries
- C.
Checking for previous complaints of claustropphobia
- D.
Starting an intravenous line at keep-open rate
Correct Answer
D. Starting an intravenous line at keep-open rateExplanation
Starting an intravenous line at keep-open rate would be inappropriate to include when preparing a client for magnetic resonance imaging (MRI) to evaluate a rupture disc. This is because an intravenous line is not typically necessary for an MRI procedure to evaluate a rupture disc. The other options mentioned, such as informing the client that the procedure is painless, taking a thorough history of past surgeries, and checking for previous complaints of claustrophobia, are all relevant and appropriate steps to include in the preparation process.Rate this question:
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- 36.
Which of the following actions would be a priority for a client who has been in the postanesthesia care unit (PACU) for 45 minutes after an above the knee amputation and develops a dime size bright red spot on the ace bondage above the amputation site?
- A.
Elevate the stump
- B.
Reinforcing the dressing
- C.
Calling the surge
- D.
Drawing a mark around the si
Correct Answer
D. Drawing a mark around the siExplanation
Drawing a mark around the site would be a priority for the client in this situation. This action helps to monitor the size and progression of the red spot, which could indicate bleeding or infection. It allows for accurate documentation and assessment of the wound, which is important for the client's ongoing care and treatment.Rate this question:
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- 37.
A client in the PACU with a left below the knee amputation complains of pain in her left big toe. Which of the following would the nurse do first?
- A.
Tell the client it is impossible to feel the pain
- B.
Show the client that the toes are not there
- C.
Explain to the client that the pain is real
- D.
Give the client the prescribed narcotic analgesic
Correct Answer
D. Give the client the prescribed narcotic analgesicExplanation
The nurse would give the client the prescribed narcotic analgesic as the first action because pain management is a priority in the post-anesthesia care unit (PACU). The client's complaint of pain in her left big toe should be taken seriously and addressed promptly. The nurse should administer the prescribed medication to provide relief and ensure the client's comfort.Rate this question:
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- 38.
The client with an above the knee amputation is to use crutches until the prosthesis is being adjusted. In which of the following exercises would the nurse instruct the client to best prepare him for using crutches?
- A.
Abdominal exercises
- B.
Isometric shoulder exercises
- C.
Quadriceps setting exercise
- D.
Triceps stretching exercises
Correct Answer
D. Triceps stretching exercisesExplanation
Triceps stretching exercises would be the best choice to prepare the client with an above the knee amputation for using crutches. Using crutches requires upper body strength and stability, particularly in the arms and shoulders. Triceps stretching exercises specifically target the muscles in the back of the upper arm, which are important for supporting and controlling the crutches. By stretching and strengthening the triceps, the client can improve their ability to use crutches effectively and safely.Rate this question:
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- 39.
The client with an above the knee amputation is to use crutches until the prosthesis is properly lifted. When teaching the client about using the crutches, the nurse instructs the client to support her weight primarily on which of the following body areas?
- A.
Axillae
- B.
Elbows
- C.
Upper arms
- D.
Hand
Correct Answer
D. HandExplanation
The client with an above the knee amputation should primarily support their weight on their hands when using crutches. This is because the hands are stronger and more capable of bearing weight compared to other body areas such as the axillae (armpits), elbows, or upper arms. Placing too much weight on the axillae can lead to nerve damage and discomfort, while relying on the elbows or upper arms may cause strain and fatigue. By distributing the weight onto the hands, the client can maintain balance and stability while using the crutches.Rate this question:
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- 40.
Three hours ago a client was thrown from a car into a ditch, and he is now admitted to the ED in a stable condition with vital signs within normal limits, alert and oriented with good coloring and an open fracture of the right tibia. When assessing the client, the nurse would be especially alert for signs and symptoms of which of the following?
- A.
Hemorrhage
- B.
Infection
- C.
Deformity
- D.
Shock
Correct Answer
A. HemorrhageExplanation
The nurse would be especially alert for signs and symptoms of hemorrhage because the client was thrown from a car and has an open fracture. Hemorrhage is a potential complication in this situation, as there may be internal bleeding or damage to blood vessels. The nurse would assess for signs such as excessive bleeding, low blood pressure, rapid heart rate, and pale skin. Prompt identification and management of hemorrhage is important to prevent further complications and ensure the client's stability.Rate this question:
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- 41.
The client with a fractured tibia has been taking methocarbamol (Robaxin), when teaching the client about this drug, which of the following would the nurse include as the drug's primary effect?
- A.
Killing of microorganism
- B.
Reduction in itching
- C.
Relief of muscle spasms
- D.
Decrease in nervousness
Correct Answer
C. Relief of muscle spasmsExplanation
The nurse would include relief of muscle spasms as the primary effect of methocarbamol (Robaxin). Methocarbamol is a muscle relaxant that works by blocking nerve impulses or pain sensations that are sent to the brain. It is commonly used to relieve muscle spasms and pain associated with musculoskeletal conditions such as a fractured tibia. The drug does not have any antibacterial or antifungal properties, so it does not kill microorganisms. It also does not directly reduce itching or decrease nervousness.Rate this question:
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- 42.
A client who has been taking carisoprodol (Soma) at home for a fractured arm is admitted with a blood pressure of 80/50 mmHg, a pulse rate of 115bpm, and respirations of 8 breaths/minute and shallow, the nurse interprets these finding as indicating which of the following?
- A.
Expected common side effects
- B.
Hypersensitivity reactions
- C.
Possible habituating effects
- D.
Hemorrhage from GI irritation
Correct Answer
A. Expected common side effectsExplanation
The client's low blood pressure, rapid pulse rate, and shallow respirations are indicative of expected common side effects of carisoprodol (Soma). These side effects may include dizziness, drowsiness, and decreased blood pressure. The combination of these symptoms suggests that the client may be experiencing the sedative effects of the medication, which can cause respiratory depression and decreased blood pressure. It is important for the nurse to monitor the client closely and notify the healthcare provider if the symptoms worsen or if the client becomes unresponsive.Rate this question:
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- 43.
When admitting a client with a fractured extremity, the nurse would focus the assessment on which of the following fi
- A.
The area proximal to the fract
- B.
The actual fracture sit
- C.
The area distal to the fracture
- D.
The opposite extremity for baseline comparison
Correct Answer
C. The area distal to the fractureExplanation
When admitting a client with a fractured extremity, the nurse would focus the assessment on the area distal to the fracture. This is because assessing the area distal to the fracture can help determine the circulation, sensation, and movement of the affected extremity. It can also help identify any potential complications such as compartment syndrome or nerve damage. By assessing the area distal to the fracture, the nurse can gather important information about the client's overall condition and the extent of the injury.Rate this question:
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- 44.
A client with fracture develops compartment syndrome. When caring for the client, the nurse would be alert for which of the following signs of possible organ failure
- A.
Rales
- B.
Jaundic
- C.
Generalized edem
- D.
Dark, scanty urine
Correct Answer
D. Dark, scanty urineExplanation
Dark, scanty urine can indicate possible organ failure in a client with compartment syndrome. Compartment syndrome occurs when increased pressure within a confined space, such as a muscle compartment, impairs blood flow and can lead to tissue damage. This can result in decreased kidney perfusion, leading to a decrease in urine output and the production of dark, scanty urine. Monitoring urine output and characteristics is important in assessing kidney function and identifying potential organ failure in this client.Rate this question:
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- 45.
Which of the following would lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus?
- A.
Acute respiratory distress syndrome
- B.
Migraine like headaches
- C.
Numbness in the right leg
- D.
Muscle spasms in the right thigh
Correct Answer
A. Acute respiratory distress syndromeExplanation
The nurse would suspect that a client with a fracture of the right femur may be developing a fat embolus if they are experiencing acute respiratory distress syndrome. Fat embolus occurs when fat globules from the bone marrow enter the bloodstream and travel to the lungs, causing respiratory symptoms such as difficulty breathing, rapid breathing, and low oxygen levels. Acute respiratory distress syndrome is a severe form of respiratory failure, characterized by these symptoms, and can occur as a complication of fat embolism syndrome. Therefore, the presence of acute respiratory distress syndrome would lead the nurse to suspect a fat embolus.Rate this question:
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- 46.
The client who had an open femoral fracture was discharged to her home, where she developed, fever, night sweats, chills, restlessness and restrictive movement of the fractured leg. The nurse interprets these finding as indicating which of the following?
- A.
Pulmonary emboli
- B.
Osteomyelitis
- C.
Fat emboli
- D.
Urinary tract infection
Correct Answer
B. OsteomyelitisExplanation
The symptoms of fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg are indicative of an infection. Osteomyelitis is a bone infection that can occur as a complication of an open fracture. Therefore, the nurse interprets these findings as indicating osteomyelitis.Rate this question:
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- 47.
When antibiotics are not producing the desired outcome for a client with osteomyelitis, the nurse interprets this as suggesting the occurrence of which of the following as most likely?
- A.
Formation of scar tissue interfering with absorption
- B.
Development of pus leading to ischemia
- C.
Production of bacterial growth by avascular tissue
- D.
Antibiotics not being instilled directly into the bone
Correct Answer
C. Production of bacterial growth by avascular tissueExplanation
The nurse interprets the lack of desired outcome from antibiotics in a client with osteomyelitis as suggesting the production of bacterial growth by avascular tissue as the most likely occurrence. This means that the antibiotics are not effectively reaching the site of infection due to the lack of blood supply to the affected tissue, allowing the bacteria to continue growing and causing the infection to persist.Rate this question:
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- 48.
Which of the following would the nurse use as the best method to assess for the development of deep vein thrombosis in a client with a spinal cord injury?
- A.
Homan's sign
- B.
Pain
- C.
Tenderness
- D.
Leg girth
Correct Answer
A. Homan's signExplanation
Homan's sign is the best method to assess for the development of deep vein thrombosis in a client with a spinal cord injury. This test involves the nurse dorsiflexing the client's foot while the knee is extended, and if the client experiences pain in the calf, it may indicate the presence of a blood clot. Pain, tenderness, and leg girth can also be indicators of deep vein thrombosis, but Homan's sign is a more specific and reliable method for assessment.Rate this question:
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- 49.
The nurse is caring for the client who is going to have an arthogram using a contrast medium. Which of the following assessments by the nurse are of highest priority?
- A.
Allergy to iodine or shellfish
- B.
Ability of the client to remain still during the procedure
- C.
Whether the client has any remaining questions about the procedur
- D.
Whether the client wishes to void before the procedure
Correct Answer
A. Allergy to iodine or shellfishExplanation
The highest priority assessment for the nurse is to determine if the client has any allergies to iodine or shellfish. This is because contrast mediums used in arthrograms often contain iodine, which can cause an allergic reaction in individuals with iodine or shellfish allergies. It is important for the nurse to identify any potential allergies to ensure the safety and well-being of the client during the procedure.Rate this question:
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- 50.
The client immobilized skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse formulates which of the following nursing diagnoses for this client?
- A.
Divertional activity defic
- B.
Powerlessness
- C.
Self care deficit
- D.
Impaired physical mobility
Correct Answer
A. Divertional activity deficExplanation
The client in skeletal leg traction is complaining of being bored and restless. This indicates a lack of diversional activities, which can lead to feelings of boredom and restlessness. Therefore, the nurse formulates the nursing diagnosis of Divertional activity deficit. This diagnosis suggests that the client is experiencing a deficiency in engaging in activities that provide enjoyment, entertainment, and distraction from their current situation.Rate this question:
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Mar 21, 2023Quiz Edited by
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Nov 28, 2010Quiz Created by
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