Silvestri Chapter 58 Ed#576

Silvestri, 3/e, ISBN 1-1460-0052-6 Chapter 058 (edited file)—"Musculoskeletal System" 10/14/08, Page 1 of 34, 9 Figure(s), 1 Table(s), 9 Box(es)

58: Musculoskeletal System PRACTICE QUESTIONS 1. A client is treated in the physician’s physician’s office after a fall, which sprained the ankle. Radiography has ruled out fracture. Before sending the client home, the nurse nurse would plan to teach the client about which item that is to be avoided in the next 24 hours? 1. Application of a heating pad 2. Application of an ace wrap 3. Resting the foot 4. Elevating the ankle on a pillow while sitting or lying lying down Answer: 1 Rationale: Soft tissue injuries injuries such as sprains are treated by RICE by RICE ((r est, est, ice, compression, elevation) for the first 24 hours after the injury. injury. Ice is applied intermittently for 20 to 30 minutes at a time. Heat is not used in the first 24 hours because it could increase venous congestion, which would increase edema and pain. Test-Taking est-Taking Strategy: Note the key word, avoided . This word indicates a false response question and that you need to select select the incorrect intervention. It is likely that sprains should be rested and elevated, so options 3 and 4 are eliminated. Use of an Ace wrap is also helpful in reducing the pain and swelling, so eliminate option 2. By the process of elimination, heat is the item to avoid in the first 24 hours. Review the measures to treat a sprain if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal nursing (4th ed.). St. Louis: References: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Mosby, p. 157. Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd nursing (3rd ed.). Philadelphia: W.B. W.B. Saunders, p. 157. 2. A nurse is collecting physical physical data of the musculoskeletal system on an assigned assigned client. The nurse would document the presence of which of the following as a normal finding? 1. Presence of fasciculations 2. Atrophy on the client’s client’s dominant side 3. Hypertrophy on the client’s client’s dominant side 4. Atrophy on the client’s client’s nondominant side Answer: 3 Rationale: Hypertrophy, Hypertrophy, or increased muscle size on the client’s client’s dominant side of up to 1 cm, is considered normal. Atrophy on either side is considered considered an abnormal finding. finding. Fasciculations are fine muscle twitches that are not normally present. Test-Taking est-Taking Strategy: Use the process of elimination, noting the key word, normal . Options 2 and 4 are eliminated first first because atrophy is not a normal finding. Knowing that fasciculations are not normal helps you you select option 3 over option 1. Review normal musculoskeletal findings findings


if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, pp. 202, 569. Jarvis, C. (2004). Physical (2004). Physical examination and health assessment (4th assessment (4th ed.). Philadelphia: W.B. W.B. Saunders, p. 676. 3. A nurse has given dietary instructions to a client to minimize the risk risk of osteoporosis. The nurse determines that the client understands the recommended changes if the client verbalizes to increase intake of which of these foods? food s? 1. Potatoes 2. Cheese 3. Fish 4. Chicken Answer: 2 Rationale: Calcium intake is important to minimize minimize the risk risk of osteoporosis. osteoporosis. The major dietary source of calcium is from from dairy foods, including milk, milk, yogurt, and a variety of cheeses. Calcium may also be added to certain products, such as orange juice, which are then advertised as being “fortified” with calcium. calcium. Calcium supplements are available and recommended recommended for those with typically low calcium intake. Options 1, 3, and 4 are foods foods that are not high in calcium. calcium. Test-Taking est-Taking Strategy: Use the process of elimination. elimination. Knowing that calcium is required for the client with osteoporosis and recalling the foods high in calcium will direct you to option 2. Review this content if you had difficulty d ifficulty with with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Nix, S. (2005). Williams basic nutrition and diet therapy (11th ed.). St. Louis: Mosby, Mosby, pp. 129-130. 4. A nurse is providing providing care of the the client following a bone biopsy biopsy.. Which action by the nurse is unnecessary in the care of this client? 1. Monitoring the site site for swelling, swelling, bleeding, hematoma 2. Administering intramuscular intramuscular narcotic analgesics 3. Elevating the limb limb for 24 hours 4. Monitoring vitals signs every 4 hours Answer: 2 Rationale: Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, and hematoma formation. The biopsy site is elevated for 24 hours to reduce edema. The vital signs are monitored every 4 hours for 24 hours. The client usually requires mild analgesics; more severe pain usually indicates that complications are arising. Test-Taking est-Taking Strategy: Note the key word, unnecessary. unnecessary. This word indicates a false response response


question and that you need to select select the incorrect action. One way to approach this question question is to look at the method of anesthesia anesthesia used for this procedure. If you know that this this procedure is done under local anesthesia, it makes sense that monitoring vital signs every 4 hours is probably sufficient (option 4). The nurse would routinely monitor for complications (option 1). From the remaining options, site elevation is important to reduce edema, but narcotic administration by the intramuscular route seems excessive for a local procedure. procedure. Review care of the client following a bone biopsy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, pp. 2265-2267. Chernecky, Chernecky, C., & Berger, B. (2004). Laboratory (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. W.B. Saunders, p. 280. 5. A nurse nurse has reinforced instructions to the client returning home after arthroscopy of the the knee. The nurse determines that the client understands the instructions if the client states that he or she will: 1. Stay off the leg entirely for for the rest of the day. day. 2. Resume regular exercise the following day. day. 3. Refrain from eating food for the remainder of the day. day. 4. Report fever or site inflammation to the physician. Answer: 4 Rationale: After arthroscopy, arthroscopy, the client can usually walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for for at least a few days. days. The client may resume the usual diet. diet. Signs and symptoms of infection should be reported to the physician. Test-Taking Test-Taking Strategy: Note the key words, understands the instructions. instructions. Remember, the client is always taught the signs and symptoms of infection infection to report to the physician. physician. Review home care instructions following arthroscopy if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal References: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, p. 112. nursing (3rd ed.). Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd Philadelphia: W.B. W.B. Saunders, p. 799. 6. A nurse nurse is caring for the client who is going to have an arthrogram using a contrast medium. Which of the following data collected b y the nurse would be of highest priority? 1. Allergy to iodine or shellfish 2. Ability of the client to remain still still during the procedure 3. Whether the client has any remaining questions about the procedure 4. Whether the client needs to void before before the procedure


Answer: 1 Rationale: Because of the risk of allergy to contrast dye, dye, the nurse places highest priority on identifying whether the client has an allergy to iodine or shellfish. shellfish. The nurse also reinforces information about the test, tells the client about the need to remain still during the procedure, and encourages the client to void before the procedure for comfort. Test-Taking Test-Taking Strategy: Note the key words, highest priority. priority. This tells you that more than one or all of the options are correct (in fact, they all are). Although options 2, 3, and 4 all compete for priority, priority, only option 1 (allergy to iodine or shellfish) takes takes first preference. The consequence of possible anaphylactic shock (physiological (physiological risk) makes this the correct option. Review care of the client scheduled for an arthrogram if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Effective Care Environment Integrated Process: Process: Nursing Process/Data Process/Data Collection Content Area: Delegating/Prioritizing Reference: Pagana, K., & Pagana, Pagana, T. T. (2003). Mosby’s Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, Mosby, p. 134. 1 34. 7. A client with possible rib rib fracture has never had a chest x-ray. x-ray. The nurse would plan to tell the client which of the following items about the procedure? 1. The x-ray stimulates stimulates a small small amount of pain. 2. It is necessary to to remove jewelry and any other metal objects. 3. The client will be asked to to breathe in and out during the x-ray x-ray.. 4. The x-ray technologist will stand next to the client during the x-ray. x-ray. Answer: 2 Rationale: An x-ray is a photographic image of a part of the body on a special film, which is used to diagnose a wide variety of conditions. The x-ray itself is painless; any discomfort discomfort would arise from repositioning a painful part for filming. filming. The nurse may want to premedicate a client who is at risk for pain. Any radiopaque objects such as jewelry or other metal must be removed. The client is asked to breathe in deeply and then hold the breath while the chest x-ray is taken. To minimize risk of radiation exposure, the x-ray technologist stands in a separate area protected by a lead wall. The client also wears a lead shield over the genital area. Test-Taking est-Taking Strategy: Use the process of elimination. elimination. Visualize Visualize this procedure to eliminate eliminate options 1 and 4. From the remaining options, eliminate option 3 because the client needs to be still during the x-ray. x-ray. Review this diagnostic procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Effective Care Environment Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Pagana, K., & Pagana, Pagana, T. T. (2003). Mosby’s Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, Mosby, p. 239. 2 39. 8. A nurse is teaching the client who is to have a gallium scan about the procedure. The nurse would include which of the following items as part of the instructions? 1. The gallium will be injected injected intravenously 2 to 3 hours before the procedure. 2. The procedure takes about 15 minutes to perform.


3. The client must stand erect during the filming. 4. The client should remain on bed rest rest for the remainder of the day after the scan. scan. Answer: 1 Rationale: A gallium gallium scan is similar to a bone scan, but with an injection of gallium isotope instead of technetium Tc 99m. Gallium is injected 2 to 3 hours before the procedure. The procedure takes 30 to 60 minutes to to perform. The client must lie still still during the procedure. There is no special aftercare. Test-Taking est-Taking Strategy: Use the process of elimination. elimination. If you know that a gallium scan is similar similar to a bone scan, then you begin by eliminating options 3 and 4. The time frame in option 2 is rather short, so eliminate this option. Review this test if you you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal References: Chernecky, Chernecky, C., & Berger, Berger, B. (2004). Laboratory (2004). Laboratory tests and diagnostic d iagnostic procedures (4th ed.). Philadelphia: W.B. W.B. Saunders, p. 572. Mosby’s diagnostic and laboratory test reference (6th ed.). St. Pagana, K., & Pagana, T. T. (2003). Mosby’s Louis: Mosby, Mosby, p. 437. 9. A client has had a bone scan procedure. The nurse determines that the client understands the elements of follow-up care if the client states that he or she will: 1. Report any feelings of nausea or flushing. 2. Ambulate at least three times before the end of the day. day. 3. Eat only small meals for the remainder of the day. day. 4. Drink plenty of water for for a day or two following the procedure. Answer: 4 Rationale: There are no special special restrictions following a bone scan. The client is encouraged to drink large amounts of water for 24 to 48 hours to flush the radioisotope radioisotope from the system. There are no hazards to the client or staff from the minimal amount of radioactivity of the isotope. Test-Taking est-Taking Strategy: Use the process of elimination. elimination. There is no purpose for options options 2 or 3, which allows you to eliminate eliminate them first. Nausea and flushing could accompany dye injection injection during a procedure, but this procedure proced ure uses radioisotopes and the question relates to care after the procedure. Thus, option 1 is is eliminated also. also. This leads you you to option 4, which which will hasten elimination of the isotope from the client’s client’s system. Review this diagnostic procedure if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Chernecky, Chernecky, C., & Berger, Berger, B. (2004). Laboratory (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 382. 10. A client seeks treatment in the emergency room for a lower leg injury. injury. There is visible deformity to the lower aspect of the leg, and the injured leg appears shorter than the other. other. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this


client has experienced a: 1. Contusion 2. Fracture 3. Sprain 4. Strain Answer: 2 Rationale: Typical Typical signs and symptoms of fracture include pain, loss of function in the area, deformity, deformity, shortening of the extremity, extremity, crepitus, swelling, and ecchymosis. Not all fractures lead to the development of every sign. A contusion contusion results from a blow to soft tissue and causes pain, swelling, and ecchymosis. A sprain sprain is an injury to a ligament caused by a wrenching or twisting motion. Symptoms include pain, swelling, and inability to use the joint or bear weight normally. normally. A strain strain results from a pulling force on the muscle. Symptoms include soreness and pain with muscle use. Test-Taking est-Taking Strategy: Use the process of elimination. elimination. Within the the list of signs and symptoms in the question, note the one stating that one leg is shorter shorter than another. another. Only a fractured bone (which shortens with displacement) displacement) could cause this sign. This makes it easy to eliminate each of the incorrect options. Review the signs of a fracture if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Linton, A., & Maebius, N. N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd nursing (3rd ed.). Philadelphia: W.B. W.B. Saunders, pp. 821, 824-825. 11. A nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. fractured. The nurse would plan to: 1. Stay with the person person and encourage the person to remain still. still. 2. Assist the person to get up and walk to the sidewalk. 3. Leave the person for a few moments to call an ambulance. ambulance. 4. Try to manually reduce reduce the fracture. Answer: 1 Rationale: With a suspected fracture, fracture, the client is not moved unless it is dangerous to remain in that spot. The nurse should remain with the client, and have someone else call for emergency help. A fracture is not reduced at the scene. Before moving the client, the site site of the fracture is immobilized to preven preventt further injury. Test-Taking est-Taking Strategy: Use the process of elimination. elimination. Eliminate options 2 and 4 first because these actions could result in in further injury to the client. From the remaining options, the most prudent action would be for the nurse to remain with the client and have someone else call for emergency assistance. assistance. Review immediate care of the client client with a fracture if you had difficulty difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal


Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, pp. 623, 2501. 12. A nurse nurse witnesses a client sustain a fall and suspects that the client’s client’s leg may be fractured. Which action is the priority? 1. Take a set of vital signs. signs. 2. Call the radiology department. 3. Reassure the client that everything will be fine. 4. Immobilize the leg before moving the client. Answer: 4 Rationale: When a fracture is suspected, it is imperative that the area is splinted splinted before the client is moved. Emergency help should be called for if the client is not hospitalized, and a physician physician is called for the hospitalized hospitalized client. The nurse should remain with the client and provide realistic realistic reassurance. The nurse does not prescribe radiology tests. Test-Taking est-Taking Strategy: Note the key word, priority word, priority.. Eliminate option 2 because the the nurse does not order x-rays. Option 3 is eliminated next, because the nurse never tells a client that “everything will be fine.” fine.” From the remaining options, focus on the data in the question. question. Immobilizing the limb is imperative for the client’s safety, safety, which makes it a better choice cho ice than taking vital signs. signs. Review care of the the client when a fracture is suspected if if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, pp. 623, 2501. 13. A nurse in the emergency room is caring for a client with a fractured arm. The nurse understands that which item is not necessary before reduction of the fracture in the casting room? 1. Explanation of the the procedure to the client 2. Administration of an analgesic analgesic 3. Anesthesia consent 4. Consent for the procedure Answer: 3 Rationale: Before a fracture is reduced, the client is informed about the procedure and consent is obtained. An analgesic is given as prescribed, because the procedure is painful. Administration of anesthesia may or may not be done, depending on severity. severity. Closed reductions may be done in the emergency room without anesthesia. If anesthesia is used, used, the procedure is done in the operating room. room. Options 1 and 4 are Test-Taking Test-Taking Strategy: Note the key words, not necessary and casting room. obviously needed, so these options are are eliminated first. The question specifically states states that the procedure is going to be done in the casting room, which helps you select option 3 (anesthesia consent) as the unnecessary item. item. Review the procedure for reduction of a fracture if you you had difficulty with this question. Level of Cognitive Ability: Comprehension


Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, pp. 623-626. deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. W.B. Saunders, p. 33. Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd nursing (3rd ed.). Philadelphia: W.B. W.B. Saunders, pp. 189, 825. 14. A nurse nurse provides cast application instructions to a client who is going to have a plaster cast applied. The nurse determines that the client needs further instructions if the the client states that: 1. A stockinette will be placed over the the leg area to be casted. 2. The cast edges may be trimmed trimmed with a cast knife. 3. The cast will give off off heat as it dries. dries. 4. The client may bear weight on the cast in 30 minutes. Answer: 4 Rationale: The procedure for casting involves washing washing and drying the skin and placing placing a stockinette material over the area to be casted. A roll of padding is then applied smoothly and evenly. evenly. The plaster is rolled onto the padding, and the edges are trimmed or smoothed as needed. A plaster cast gives off heat as it dries. A plaster cast can tolerate weight-bearing once it is dry, dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast. instructions. These words Test-Taking Test-Taking Strategy: Note the key words, needs further instructions. words indicate a false response question and that you need to select the incorrect incorrect client statement. Familiarity with the different types of casting materials and their differences helps you answer this question. Options 1, 2, and 3 are all true for plaster plaster casts. Option 4 is true for nonplaster casts. Review the procedure for applying a cast if you had h ad difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, p. 148. 15. A nurse nurse is planning to teach the client with a left arm cast about measures to keep the left shoulder from becoming stiff. stiff. Which suggestion would the nurse nurse include in the teaching plan? 1. Lift the left arm up over the head. 2. Lift the right right arm up over the head. 3. Make a fist with the hand of the casted arm. 4. Use a sling on the left arm. Answer: 1 Rationale: Immobility and the weight weight of a casted arm may may cause the shoulder above an arm fracture to become stiff. stiff. The shoulder of a casted arm should be lifted over the head periodically as a preventive measure. The use of slings further further immobilizes the shoulder and may be contraindicated. Making fists with the left hand provides isometric isometric exercise to maintain muscle muscle


strength. Range of motion of the affected fingers fingers is also a useful general measure. Lifting the right arm is of no particular value. Test-Taking est-Taking Strategy: Use the process of elimination. elimination. Visualize Visualize each of the movements and think about the muscle groups that that are moved with each. Options 2 and 4 provide for no movement of the left arm and are eliminated first. first. Making a fist with with hand on the casted arm provides good isometric exercise to the muscles surrounding the fracture but, again, does nothing for the shoulder. shoulder. The only helpful suggestion is raising the arm over the head, which provides some range of motion for the shoulder joint. Review these measures if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal nursing (4th ed.). St. Louis: Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Mosby, p. 150. 16. A client has a fiberglass fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when he will be able to walk walk on the cast. The nurse replies that the client will be able to to bear weight on the cast: 1. Within 20 to 30 minutes minutes of application 2. In approximately 8 hours 3. In 24 hours 4. In 48 hours Answer: 1 Rationale: A fiberglass fiberglass cast is made of water-activated water-activated polyurethane materials, which are dry to the touch within minutes and reach reach full rigid strength in about 20 minutes. Because of this, the client can bear weight on the cast within 20 to 30 minutes. Test-Taking est-Taking Strategy: Use the process of elimination. Options 3 and 4 should be eliminated first, because these time frames are similar similar to the drying times for plaster casts. casts. Knowing that the nonplaster type of cast is lighter and dries e xtremely quickly may help you choose the 20- to 30-minute time frame as correct. Review client teaching points related related to casts if you you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal nursing (4th ed.). St. Louis: Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Mosby, p. 150. 17. A nurse nurse has reinforced instructions with the client with a nonplaster (fiberglass) (fiberglass) leg cast about cast care at home. The nurse determines that the client client needs further instructions instructions if the client makes which statement? 1. “I should avoid walking on wet, slippery floors.” 2. “It’s “It’s all right to wipe dirt off the top of the cast with with a damp cloth.” 3. “I’m not supposed supposed to scratch the skin underneath the the cast.”


4. “If the cast gets wet, I can dry it with a hair dryer dryer turned to the warmest setting.” Answer: 4 Rationale: Client instructions should should include avoidance of walking on wet, slippery slippery floors to prevent falls. Surface soil on a cast may be removed with with a damp cloth. If the cast gets wet, it can be dried with a hair dryer dryer set to a cool setting setting to prevent skin breakdown. If the skin under the cast itches, cool air from a hair dryer may be used to relieve it. The client should never scratch under a cast because of risk of skin breakdown and ulcer u lcer formation. Test-Taking Test-Taking Strategy: Note the key words, needs further instructions. instructions. These words words indicate a false response question and that you need to select the incorrect incorrect client statement. Options 1 and 3 are certainly true and are therefore eliminated. Knowledge of nonplaster cast material material is needed to select between the remaining options. A fiberglass fiberglass cast may be wiped with a damp cloth, because it is water resistant. It may be helpful to remember never to use a hair dryer on a cast or on the skin under any cast with the dryer set at the warmest setting; only cool settings are used to prevent burns. Review client teaching points related to casts if you you had difficulty with with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal nursing (4th ed.). St. Louis: Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Mosby, p. 150. 18. A client client with a hip fracture asks the nurse why Buck’s Buck’s extension traction is being applied before surgery. surgery. The nurse’s nurse’s response is based on the understanding that Buck’s Buck’s extension traction primarily: 1. Provides rigid immobilization of the the fracture site site 2. Provides comfort by reducing reducing muscle spasms and provides fracture fracture immobilization 3. Lengthens the fractured leg leg to prevent severing severing of blood vessels vessels 4. Allows bony healing to begin before surgery Answer: 2 Rationale: Buck’s Buck’s extension traction is a type of skin traction often applied after hip fracture, before the fracture is reduced in surgery. surgery. It reduces muscle spasms and helps immobilize the fracture. It does not lengthen the leg for for the purpose of preventing blood vessel vessel severance. It also does not allow for bony bon y healing to begin. Test-Taking est-Taking Strategy: Use the process of elimination. Recalling the purpose of traction will will assist in eliminating eliminating options 3 and 4. From the remaining options, options, eliminate option 1 because of the words “rigid immobilization.” Review this type of traction if you you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal nursing (4th ed.). St. Louis: Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Mosby, p. 150.

Silvestri, 3/e, ISBN 1-1460-0052-6 Chapter 058 (edited file)—"Musculoskeletal System" 10/14/08, Page 11 of 34, 9 Figure(s), 1 Table(s), Table(s), 9 Box(es)

19. A client client in skeletal leg traction with an overbed frame is not allowed to turn from side to side. Which action by the nurse would be most useful in trying to provide good skin care of the client ? 1. Asking the client to lift up by digging into the mattress with with the unaffected leg 2. Pushing down on the mattress of the bed while administering care 3. Having another nurse tilt tilt the client to the side 4. Asking the client pull up on a trapeze to lift the hips off the bed Answer: 4 Rationale: If the client in skeletal traction may not turn from side to side, the nurse should have the client pull up on a trapeze and try to lift the hips off the be d for skin care, bed pan use, and linen changes. If the client is unable to pull up on a trapeze, the nurse can push down on the mattress with one hand while administering care with the other. Test-Taking est-Taking Strategy: Use the process of elimination. Option 3 is contraindicated because it ignores a medical order. order. Option 1 is not feasible feasible as stated. The client cannot lift up from from the bed using one foot only. only. Options 2 and 4 are both acceptable alternatives. Because the question asks which would be “most useful,” useful,” the answer is option 4. Providing care for the client client who can lift the hips off the bed using a trapeze is easier and more efficient than providing care to one who cannot. Review care of the client in in traction if you you had difficulty with with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal nursing (4th ed.). St. Louis: Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Mosby, p. 153. 20. A nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding? 1. Purulent drainage 2. Serous drainage 3. Pain at a pin site 4. Inflammation Answer: 2 Rationale: A small amount of serous oozing is expected at pin insertion sites. sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported. Test-Taking Test-Taking Strategy: Note the key words, least concerned with. with. Options 1 and 4 seem seem to indicate an infectious problem, and are eliminated. To select between options 2 and 3, look look at them carefully. carefully. The complaint of pain is at “a pin site” only. only. It gives no indication that the pain is related to the fracture fracture or muscle spasm. Because serous drainage is an expected finding, you would select this over the the complaint of pain as the answer to the question. Review care of the client in skeletal traction if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal


References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 635. Christensen, B., & Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, Mosby, p. 153. 21. A client has Buck’s Buck’s extension traction applied to the the right leg. The nurse would plan which intervention to prevent complications of the device? 1. Massaging the skin of the right leg with lotion every 8 hours 2. Giving pin care care once a shift 3. Inspecting the skin on the right right leg at least once every 8 hours 4. Releasing the weights on the right right leg for range-of-motion exercises exercises daily Answer: 3 Rationale: Buck’s Buck’s extension traction is a type type of skin traction. traction. The nurse inspects the skin of the limb in traction at least once every 8 hours for irritation irritation or inflammation. Massaging the skin with lotion is not indicated. The nurse never releases the weights weights of traction unless specifically ordered by the physician. There are no pins to care for with skin traction. Test-Taking est-Taking Strategy: Use the process of elimination. A basic knowledge of Buck’s Buck’s extension traction allows you to eliminate options 2 and 4 easily. easily. There are no pins, and the nurse never removes weights without a specific specific order to do so. Because the apparatus would have to be removed to apply lotion, which is unnecessary, unnecessary, then the answer is to inspect the skin. Review care of the client with Buck’s extension traction if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Effective Care Environment Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, p. 153. 22. A nurse is caring for the client who has had skeletal traction applied to the left leg. The client is complaining of severe severe left leg pain. Which action should the nurse take first? 1. Medicate the client client with an analgesic. 2. Provide pin care. 3. Call the physician immediately. immediately. 4. Check the client’s client’s alignment in bed. Answer: 4 Rationale: A client client who complains of severe pain may need realignment or may have had traction weights ordered that are too heavy. heavy. The nurse realigns the client and, if ineffective, then calls the physician. Severe leg pain, once traction has been established, indicates a problem. Medicating the client should be done after after trying to determine determine and treat the cause. Providing pin care is unrelated to the problem as described. Test-Taking est-Taking Strategy: Note the key word, first word, first . Use the steps of the nursing process. Option 4 is the only option that addresses addresses data collection. Review care of the client in in skeletal traction if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation


Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, p. 153. 23. A nurse nurse has reinforced instructions regarding specific leg exercises for the client immobilized in right skeletal skeletal lower leg traction. The nurse determines that the client client needs further instruction if the nurse observes the client: 1. Pulling up on the trapeze 2. Flexing and extending the feet 3. Performing active range range of motion to to the right ankle and knee 4. Doing quadriceps-setting and gluteal-setting exercises Answer: 3 Rationale: Exercise is indicated within within therapeutic limits for for the client in skeletal traction to maintain muscle strength and range of motion. The client may pull up on the the trapeze, perform active ROM with uninvolved joints, and do isometric muscle-setting exercises (e.g., quadricepsand gluteal-setting exercises). The client may also flex flex and extend his or her feet. feet. instruction. These words Test-Taking Test-Taking Strategy: Note the key words, needs further instruction. words indicate indicate a false response question and that you need to select the incorrect incorrect client action. Options 1 and 4 are most easily identified as correct actions, and are therefore e liminated as possible answers to this question. To select between options 2 and 3, imagine the lines of pull on the fracture site with the movements described. Although flexing and extending the feet does not disrupt the line of pull from the traction, traction, performing active ROM to the affected knee and ankle does. Review care of the client in traction if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 637. 24. A nurse is checking the casted extremity extremity of a client. The nurse would check for which of the following signs and symptoms indicative of infection? 1. Coolness and pallor of the extremity 2. Presence of a “hot spot” on the cast 3. Diminished distal pulse 4. Dependent edema Answer: 2 Rationale: Signs and symptoms of infection under a casted area area include odor or purulent drainage from the cast, or the presence p resence of “hot spots,” which are areas of the cast that are warmer than others. The physician should be notified if any of these these occur. occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished arterial pulse, and edema. Test-Taking est-Taking Strategy: Begin to answer this question by thinking of what you would expect to find with infection: redness, swelling, heat, and purulent drainage. With these in mind, mind, options 1 and 3 can be eliminated. To select between options 2 and 4, “dependent “dependent edema” is not necessarily indicative of infection; swelling would be continuous. The “hot spot” on the cast


could signify infection underneath that that area. Review the complications of a cast cast if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 633. Christensen, B., & Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, Mosby, p. 148. nursing (3rd ed.). Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd Philadelphia: W.B. W.B. Saunders, p. 824. 25. A client client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving relieving the pain. The nurse interprets that this pain may be caused by: 1. Impaired tissue perfusion 2. The newness of the fracture 3. The anxiety of the client 4. Infection under the cast cast Answer: 1 Rationale: Most pain associated with with fractures can be minimized with with rest, elevation, application of cold, and administration of analgesics. Pain that is not relieved relieved from these measures should should be reported to the physician, because it may ma y be the result of impaired tissue perfusion, tissue breakdown, or necrosis. Because this is a new closed fracture and cast, infection would not have had time to set in. Test-Taking est-Taking Strategy: Use the process of elimination. elimination. Options 2 and 3 can be eliminated eliminated first, based on the description in the question. Because the fracture and cast are so new, it it is extremely unlikely that infection could have possibly set in. The most likely option is impaired tissue perfusion, because pain from ischemia is not relieved by comfort measures and analgesics. Review the complications of a cast if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, pp. 633, 644. Christensen, B., & Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, Mosby, p. 151. 26. A nurse nurse is assigned to care for a client with multiple trauma who is admitted to the hospital. hospital. The client has a leg fracture fracture and a plaster cast has been applied. In positioning the casted leg, leg, the nurse should: 1. Keep the leg in a level position. 2. Keep the leg level for 3 hours, hours, and elevate it for 1 hour. hour. 3. Elevate the leg on pillows continuously for 24 to 48 hours.


4. Elevate the leg for 3 hours, and put it flat for 1 hour. hour. Answer: 3 Rationale: A casted casted extremity is elevated continuously for the first 24 to 48 hours to minimize minimize swelling and to promote venous drainage. Test-Taking est-Taking Strategy: Use the process of elimination. elimination. Recall that edema sets in after fracture, and can be aggravated by casting. For this reason, options 1 and 2 are the least helpful, and can be eliminated first. first. There is no useful purpose for the timing in option 4. Review care of the client with a cast if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed). St. Louis: Mosby, p. 151. 27. A client client is complaining of skin irritation from the edges of a cast applied the previous day. day. The nurse should plan for which of the following actions? 1. Massaging the skin at the rim of the cast 2. Applying lotion to the skin at the rim of the cast 3. Using a rough file to smooth the cast edges 4. Petaling the cast edges with adhesive tape Answer: 4 Rationale: The edges of the the cast can be petaled with tape to minimize skin skin irritation. If a client has a cast applied and returns home, the client can be taught to do the same. Test-Taking est-Taking Strategy: Use the process of elimination. elimination. Options 1 and 2 are similar similar,, and neither helps to get rid of the cause of the irritation, so they are eliminated first. first. Imagine the use of a “rough file”; it would would create plaster chips and dust, which could go underneath the cast. Review cast petaling if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal nursing (3rd Reference: Linton, A., & Maebius, N. N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 827. 28. A client is being discharged discharged to home after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client states that he or she will: 1. Avoid getting the cast wet. 2. Use the fingertips to lift and move the leg. 3. Cover the casted casted leg with with warm blankets. 4. Use a padded coat hanger end to scratch under the cast. Answer: 1 Rationale: A plaster cast must remain remain dry to keep its strength. The cast should be handled using the palms of the hands, not the fingertips, until fully dry. dry. Air should circulate freely around the


cast to help it dry; the cast also gives off heat as it dries. The client should never scratch under the cast; a cool hair dryer may be used to eliminate itching. Test-Taking est-Taking Strategy: Knowledge of cast care care is needed to answer this question. question. Knowing that a wet cast can be dented den ted with the fingertips, causing pressure underneath, helps you eliminate option 2 first. first. Knowing that the cast needs to dry helps you you eliminate option 3 next. Option 4 is dangerous to skin integrity and is also eliminated. Plaster casts, once they have dried after application, should not become wet. Review home care instructions for for a client with a cast if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, p. 150. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Lou is: Mosby, Mosby, p. 1669. 29. A client client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. support. The nurse’s nurse’s response is based on the the understanding that this could result in: 1. Impaired range of motion while the client ambulates 2. Skin breakdown in the area of the axilla 3. Injury to the brachial plexus nerves 4. A fall and further further injury Answer: 3 Rationale: Crutches are measured so that that the tops are three or four fingerbreadths or 1 to 2 inches from the axilla. This ensures that the client’s client’s axilla are not resting on the crutch or bearing the weight of the crutch. This could result in injury to the nerves of the brachial plexus. Test-Taking est-Taking Strategy: Use the process of elimination, recalling the anatomy of the arm and axillary area. This will direct you to to option 3. Review measures for for crutch walking if if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal References: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, p. 153. Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd nursing (3rd ed.). Philadelphia: W.B. W.B. Saunders, p. 830. 30. A nurse is planning to reinforce reinforce instructions to the the client about how to stand on crutches. crutches. In the written instructions, the nurse plans to tell the client to place the crutches: 1. 3 inches to the front and side side of the client’s client’s toes 2. 8 inches to the front and side side of the client’s client’s toes 3. 20 inches to the front and side side of the client’s client’s toes


4. 15 inches to the front and side side of the client’s client’s toes Answer: 2 Rationale: The classic tripod position position is taught to the client client before giving instructions on gait. The crutches are placed an ywhere from 6 to 10 inches in front and to the side of the client, depending on the client’s client’s body size. This provides a wide enough base of support to the client and improves balance. Test-Taking est-Taking Strategy: Use the process of elimination and visualize each position. Three inches and 20 inches seem excessively short short and long, respectively. respectively. These options can be eliminated first. Of the remaining options, 8 inches seems more in keeping with with the normal length of a stride than 15 inches for someone wearing a cast; this is the correct option. Review crutch walking if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal References: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, Mosby, pp. 153-155. Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd nursing (3rd ed.). Philadelphia: W.B. W.B. Saunders, p. 830. 31. A nurse nurse is giving the client with a left leg cast crutch-walking instructions using using the three point gait. The client is allowed touch-down of the the affected leg. The nurse tells the client to advance the: 1. Left leg and right crutch, then right right leg and left crutch 2. Crutches and then then both legs simultaneously 3. Crutches and the right right leg, then advance the left leg 4. Crutches and the left left leg, then advance the right leg Answer: 4 Rationale: A three-point gait requires requires good balance and arm strength. The crutches are advanced with the affected leg, leg, and then the unaffected leg is moved forward. Option 1 describes a two point gait. Option 2 describes a swing-to gait. Option 3 describes the three-point gait used for a right leg problem. Test-Taking est-Taking Strategy: Option 1 does not provide the support needed for the casted extremity described in the question and should be eliminated. Option 2 is not necessary if the client is allowed to let the extremity touch the floor. floor. Of the remaining options, option 4 is the option that provides support to the left leg. Review crutch walking if you had difficulty with this this question. Level of Cognitive Ability: Application Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Linton, A., & Maebius, N. N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 830. 32. A nurse has given the client instructions instructions regarding crutch safety. safety. The nurse determines that the client needs reinforcement of the instructions if the client states:


1. The need to have spare crutches and tips tips available 2. That crutch tips will not slip, slip, even when wet 3. Not to use someone someone else’s else’s crutches 4. That crutch tips should be inspected periodically for wear Answer: 2 Rationale: Crutch tips should remain remain dry. dry. Water could cause slipping by decreasing decreasing the surface friction of the rubber tip on the floor. floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The client should use only crutches measured for the client. The tips should be inspected for wear, and spare crutches and tips should be available if needed. instructions. These words Test-Taking Test-Taking Strategy: Note the key words, needs reinforcement of the instructions. indicate a false response question and that you need to select the incorrect client statement. Option 3 is a correct statement, and is therefore eliminated. Options 1 and 4 are also also correct. Remember, crutch tips can slip when they get wet, posing a possible threat to the unsuspecting client. Review crutch safety if you had difficulty difficulty with this question. question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, p. 153. 33. A client has slight weakness in the right leg. Based on this data, the nurse nurse determines that the client would benefit most from the use of a: 1. Walker 2. Wooden crutch 3. Lofstrand crutch 4. Straight-leg cane Answer: 4 Rationale: A straight-leg cane is useful useful for the client with with slight weakness in one leg. leg. A walker is beneficial to the client with greater or bilateral weakness or who is at risk for falls. Wooden crutches are often used by clients with a leg cast. cast. Lofstrand crutches aid clients who need crutches, but have limited arm strength. Test-Taking est-Taking Strategy: Use the process of elimination. elimination. Giving a walker to a client with a slight leg weakness is excessive, and is eliminated first. Because there is no evidence in the situation situation of the question that the client has weight-bearing difficulty, difficulty, crutches are not indicated either. This leaves the straight-leg straight-leg cane as the correct option. Review the purpose of these various various assistive devices if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Linton, A., & Maebius, N. N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 831. 34. A client client who has experienced a cerebrovascular accident (CVA) (CVA) has partial hemiplegia of the


left leg. The straight-leg cane formerly used by the client is not quite sufficient any longer. longer. The nurse determines that the client could benefit bene fit from the somewhat greater support and stability provided by a: 1. Quad cane 2. Wooden crutch 3. Lofstrand crutch 4. Wheelchair Answer: 1 Rationale: A quad cane may be used by the client requiring greater support support and stability than is provided by a straight-leg cane. The quad cane provides a four-point base of support and is indicated for use by clients clients with partial or complete hemiplegia. Neither crutches nor a wheelchair are indicated for a client such as described in the question. Test-Taking est-Taking Strategy: Use the process of elimination. elimination. Giving a wheelchair to a client client with partial hemiplegia is excessive, and is eliminated first. first. Wooden crutches are not indicated, because there is no restriction in weight-bearing. A Lofstrand Lofstrand crutch is useful for clients with bilateral weakness. This leaves the quad cane as the correct option. Review these various assistive devices if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal References: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, Mosby, pp. 154-155. deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. W.B. Saunders, p. 807. 35. A client with right-sided right-sided weakness needs to learn how to use use a cane. The nurse plans to teach the client to position the cane c ane by holding it with the: 1. Left hand, and placing the cane in front of the left foot 2. Right hand, and placing the the cane in front front of the right right foot 3. Left hand, and 6 inches lateral to the left foot 4. Right hand, and 6 inches lateral to the right foot Answer: 3 Rationale: The client is taught to hold the the cane on the opposite opposite side of the weakness. This is done because, with normal walking, the opposite arm and leg move together (called reciprocal motion). The cane is placed 6 inches lateral to the fifth toe. Test-Taking est-Taking Strategy: Use the process of elimination. elimination. Knowing that the cane is held at the client’s client’s side, not in front, helps you eliminate options 1 and 2 first. Knowing that the preferred method is to have the cane positioned on the stronger side helps you select option 3 over option 4. Review client instructions for the use of a cane if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: deWit, S. (2005). Fundamental (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B.


Saunders, p. 807. 36. A client client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. The nurse provides the client with the greatest reassurance by telling the client that: 1. Canes prevent falls, falls, not cause them. 2. The cane has a flared tip with concentric rings to provide stability. stability. 3. The physical therapist will will determine if the cane is inadequate. 4. The cane would help to break a fall, even if the client does slip. slip. Answer: 2 Rationale: A cane should have a slightly flared tip, with flexible concentric rings. This tip acts as a shock absorber and provides optimal stability. stability. Options 1, 3, and 4 are not incorrect. Test-Taking Test-Taking Strategy: Note the key words, greatest words, greatest reassurance. reassurance. Eliminate options 1 and 4 because neither of these statements provide reassurance for the client. Option 3 also provides no information to relieve the client’s client’s anxiety. anxiety. Option 2 is a true statement and addresses, in a factual way, way, the client’s concerns about safety. safety. Review client instructions for the use of a can e if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Psychosocial Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal nursing (4th ed.). St. Louis: Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Mosby, p. 154. 37. A nurse is evaluating the client’s client’s use of a cane for left-sided weakness. The nurse would intervene and correct the client if the nurse observed that the client: 1. Holds the cane on the right side 2. Keeps the cane 6 inches out to the side of the right foot foot 3. Moves the cane when the right leg is moved 4. Leans on the cane when when the right leg leg swings through through Answer: 3 Rationale: The cane is held on the stronger side to minimize stress on the affected extremity extremity and provide a wide base base of support. The cane is held 6 inches lateral to the fifth fifth great toe. The cane is moved forward with the affected leg. The client leans on the cane for added support while the stronger side swings through. Test-Taking est-Taking Strategy: Note the key word, intervenes. intervenes. This word indicates indicates a false response question and that you need to select select the incorrect client action. Knowing that the cane is held on the stronger side helps you eliminate options 1 and 2 first. To select from the remaining options, recall that the client moves the cane with the weaker leg, and leans on it for support when the stronger leg swings through. Review client instructions for for cane walking if you you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal References: deWit, S. (2005). (2005). Fundamental Fundamental concepts and skills for nursing. Philadelphia: W.B.


Saunders, p. 807. Potter, P., & Perry, A. (2005). Fundamentals (2005). Fundamentals of nursing (6th nursing (6th ed.). St. Louis: Lou is: Mosby, Mosby, pp. 948-949. 38. A nurse nurse is caring for the client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this this can happen. The nurse’s nurse’s response is is based on the understanding that: 1. An injured artery causes impaired arterial perfusion through through the compartment. 2. The fascia expands with injury, injury, causing pressure on underlying underlying nerves and muscles. 3. A bone fragment has injured the nerve supply in the area. 4. Bleeding and swelling cause increased pressure in an area that cannot expand. Answer: 4 Rationale: Compartment syndrome is caused by bleeding and swelling within within a compartment lined by fascia, which does not expand. The bleeding and swelling places pressure pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms. Test-Taking est-Taking Strategy: A basic understanding of the concept of a compartment is n eeded to answer this question. Option 1 can be eliminated first because it is not the result of an arterial injury. injury. Knowing that the fascia itself itself cannot expand eliminates option 2. To select from the remaining options, it is necessary to know that bleeding and swelling cause the symptoms, not a nerve injury. injury. Review the cause of compartment syndrome if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Linton, A., & Maebius, N. N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd nursing (3rd ed.). Philadelphia: W.B. W.B. Saunders, pp. 823-824. 39. A nurse is caring for a client with fresh application of a plaster leg cast. The nurse plans to prevent the development of compartment syndrome by: 1. Elevating the limb and applying ice to to the affected affected leg 2. Elevating the limb and covering the limb limb with bath blankets 3. Placing the leg in a slightly slightly dependent position and applying ice ice 4. Keeping the leg horizontal and applying ice to to the affected affected leg Answer: 1 Rationale: Compartment syndrome syndrome is prevented by controlling controlling edema. This is achieved most optimally with elevation and application of ice. Test-Taking est-Taking Strategy: Use the process of elimination. Recalling that edema is controlled or prevented with limb elevation helps you eliminate options 3 and 4 first. From the remaining options, think about the effects effects of ice versus bath blankets. Ice will further control edema, but bath blankets will produce heat and prevent air circulation needed for the cast to dry. dry. Review measures to prevent compartment syndrome if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal


nursing (4th ed.). St. Louis: Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Mosby, Mosby, pp. 143-144. 40. A nurse nurse is monitoring a confused older client admitted to the hospital with a hip fracture. Which of the following data obtained by the nurse would not place the client at increased risk for disturbed thought processes? 1. Stress induced induced by the fracture 2. Hearing aid available available and in working order 3. Unfamiliar hospital setting 4. Eyeglasses left at home Answer: 2 Rationale: Confusion in the older client with hip fracture could result result from the unfamiliar unfamiliar hospital setting, stress from the fracture, concurrent systemic diseases, cerebral ischemia, or side effects of medications. Use of eyeglasses and hearing aids enhances the client’s client’s interaction with the environment, and can reduce disorientation. Test-Taking est-Taking Strategy: Note the key words, would not place the client at increased risk . These word indicates a false response question and that you need to select the item that would be helpful to the client. Stress from the fracture (option (option 1) and unfamiliar setting (option 3) are not likely to help the client’s client’s functional level, and are eliminated first. Eyeglasses and hearing aids are both useful adjuncts in communicating communicating with a client. Because the eyeglasses were left left at home, they are of no help at the current time. Review the psychosocial aspects of care for the client with a hip fracture if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Needs: Psychosocial Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal nursing (3rd Reference: Linton, A., & Maebius, N. N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 835. 41. A nurse is caring for an older client who had a hip pinned pinned after being fractured. In planning nursing care, which of the following would the nurse avoid to minimize the chance chan ce for further injury? 1. Side rails in the “up” position 2. Use of night-light in hospital room room and bathroom 3. Call bell placed within reach 4. Delays in responding to call light Answer: 4 Rationale: Safe nursing actions intended intended to prevent injury to the client include keeping side rails up, having the bed in a low position, and providing a call bell that is within the client’s reach. Responding promptly to the client’s use of the call light minimizes the chance that the client will try to get up alone, which could result in a fall. Test-Taking est-Taking Strategy: Note the key word, avoid . Because options 1 and 3 (side rails rails up and call bell in reach) are standard nursing actions, they are eliminated eliminated first. Use of a night-light would help prevent falls, which is also helpful. This leaves the delay in answering the call light as the correct option. Delays will give the the client reason to try to get up unattended and risk another fall fall


and possible injury. injury. Review safety measures for a client following hip surgery surgery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Effective Care Environment Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal nursing (3rd Reference: Linton, A., & Maebius, N. N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 804. 42. A nurse nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right right hip. The nurse plans to use use a: 1. Pillow to keep the right leg leg abducted during turning 2. Pillow to keep the right leg leg adducted during turning 3. Trochanter roll to prevent external rotation while while turning 4. Trochanter roll roll to prevent abduction while turning Answer: 1 Rationale: Following internal fixation of a hip fracture, the client is turned turned to the affected side or the unaffected side, as prescribed by the surgeon. surgeon. Before moving the client, the nurse nurse places a pillow between the client’s client’s legs to keep the affected leg in abduction. The client is then repositioned while proper alignment and abduction are maintained. A trochanter trochanter roll is useful in preventing external rotation, but it is used once the client has been repositioned. It is not used while turning the client. Test-Taking est-Taking Strategy: Use the process of elimination. elimination. A trochanter roll is useful useful in preventing external rotation, but it is used once the client has been repositioned, not while turning the client. Therefore, eliminate options 3 and 4. To select between options 1 and 2, recall that use of a pillow would keep the legs abducted, not adducted. Thus, option 1 is the the answer to the question. Review care of the client following hip surgery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal References: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, Mosby, pp. 126-127. nursing (3rd ed.). Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd Philadelphia: W.B. W.B. Saunders, p. 804. 43. A client client who has had a right total knee replacement asks the nurse how long the right leg must be kept in the continuous passive motion (CPM) machine. The nurse’s response is based on the understanding that the device should be used: 1. For 30 minutes out of every hour 2. Every other hour for 60 minutes 3. For 3 hours at a time, time, followed by 1 hour of rest 4. As much as the client can tolerate Answer: 4 Rationale: The client who has received a total knee replacement often has the leg put into a


CPM machine while in the postanesthesia care unit. The device increases circulation and movement of the knee joint. It should be used as much as the client can tolerate. Test-Taking est-Taking Strategy: Use the process of elimination. elimination. Recalling the purpose and effects effects of a CPM machine will direct direct you to option 4. Review the purpose and use of this this machine if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: deWit, S. (2005). Fundamental (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 791-792. 44. A nurse nurse has an order to get the client out of bed to a chair on the first postoperative day after total knee replacement. The nurse plans to do which of the following to protect the knee joint? 1. Apply a knee immobilizer before getting the client up, and elevate the client’s client’s surgical leg while sitting. 2. Apply an ace wrap around the dressing, dressing, and put ice on the knee while sitting. 3. Lift the client to the bedside chair, leaving leaving the continuous passive motion (CPM) (CPM) machine in place. 4. Obtain a walker to minimize minimize weight-bearing by the client on the the affected leg. Answer: 1 Rationale: The nurse assists the client to get out of bed on the first postoperative day after after putting a knee immobilizer on the affected joint for stability. stability. The surgeon orders the weight bearing limits on the affected leg. The leg is elevated while the client is sitting in the chair to minimize edema. Test-Taking est-Taking Strategy: Use the process of elimination. elimination. A compression dressing should already be in place on the wound, so option 2 can be eliminated first. Because the CPM machine is used only while the client is is in bed, option 3 is incorrect and is eliminated. eliminated. From the remaining options, recalling that ambulation is not started until the second postoperative day will direct you to option 1. Also, the knee immobilizer will protect the knee joint. joint. Review care of the the client following total knee replacement if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, p. 126. 45. A client with diabetes mellitus has had a right below-knee amputation. The nurse would be especially vigilant in monitoring for which of the following becau se of the client’s history of diabetes mellitus? 1. Edema of the stump stump 2. Hemorrhage 3. Separation of wound edges 4. Slight redness of incision incision


Answer: 3 Rationale: Clients with diabetes mellitus are more prone to to wound infection and delayed wound healing due to the disease. Postoperative stump edema and hemorrhage hemorrhage are complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long it is dry and intact. Test-Taking est-Taking Strategy: The question guides you to look for complications that are primarily the result of the coexisting coexisting condition of diabetes mellitus. Recalling that diabetes mellitus increases the client’s risk risk of developing infection and delayed wound healing helps eliminate e liminate options 1 and 2 first. From the remaining options, select option 3 because separation of wound edges is a more serious problem than a slight slight redness to the incision incision line, which is considered considered normal. Review the complications of an amputation if you ha d difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal References: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, p. 486. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, Mosby, p. 1684. 46. A client client is admitted to the nursing unit after a left below-knee amputation following a crush injury to the foot and lower leg. The client tells the nurse nurse “I think I’m going crazy. crazy. I can feel my left foot itching.” The nurse interprets the client’ client’ss statement to be: 1. A normal response, and indicates the presence of phantom limb sensation sensation 2. A normal response, and indicates the presence of phantom limb pain 3. An abnormal response, and indicates that that the client needs more psychological psychological support 4. An abnormal response, and indicates that that the client is in denial about the limb loss Answer: 1 Rationale: Phantom limb sensations are felt felt in the area of the amputated limb. These can include itching, warmth, and cold. The sensations are caused by intact intact peripheral nerves in the area amputated. Whenever possible, clients should be prepared for these sensations. The client may also feel painful sensations in the amputated limb, limb, called phantom limb pain. The origin of the pain is less well understood, but the client should also be prepared for this, whenever possible. Test-Taking est-Taking Strategy: Use the process of elimination. By knowing that sensation and pain may be felt in the residual limb helps you eliminate e liminate options 3 and 4 first, because the sensations are not abnormal responses. From the remaining options, select select option 1 because the client has described an itching sensation, but has not complained of pain in the residual limb. Review the expected findings following amputation if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Needs: Psychosocial Integrity Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes (6th ed.). Philadelphia: W.B. W.B. Saunders, p. 1410.


47. A client is complaining of low low back pain, with radiation down the left posterior thigh. The nurse continues to collect data from the client to see if the pain is worsened or aggravated by: 1. Bed rest 2. Application of heat 3. Bending or lifting 4. Ibuprofen (Motrin) Answer: 3 Rationale: Low back pain with radiation into into one leg (sciatica) is consistent with herniated lumbar disk. The nurse continues to collect data from the client to see see if the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, coughing or lifting the leg straight up while supine (straight leg raising test). test). Options 1, 2, and 4 assist in alleviating pain. Test-Taking est-Taking Strategy: Focus on the issue, the causes of back pain and the factors that alleviate or aggravate it. Recall that bed rest, heat (or (or sometimes ice), and nonsteroidal nonsteroidal anti-inflammatory agents usually relieve back pain, whereas whereas bending, lifting and straining aggravate it. If this question was difficult, review the causes of back pain and the factors that alleviate or aggravate it. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal nursing (4th ed.). St. Louis: Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Mosby, p. 160. 48. A client has just undergone undergone spinal fusion after suffering suffering a herniated lumbar disk. The nurse would avoid which of the following to maintain client safety after this procedure? 1. Logrolling technique for repositioning 2. Pillows under the length of the legs 3. Head of bed flat 4. Overhead trapeze Answer: 4 Rationale: Following spinal fusion, the head of bed is generally kept in a flat position. position. The client is logrolled from from side to side as ordered. Pillows may be placed under the entire length of the legs by surgeon surgeon preference to relieve tension on the lower back. The use of an overhead trapeze is contraindicated because its use could cou ld promote twisting of the spine after surgery. surgery. Test-Taking est-Taking Strategy: Note the key word, avoid . After spinal surgery, surgery, the nurse uses positioning techniques and aids that will keep the spine in good alignment. Thus, options 1 and 3 are indicated and are therefore eliminated as items to avoid, according to the question. To select from the remaining options, recall that using pillows under the length of the legs promotes slight flexion of the spine while avoiding pressure on the popliteal space, which predisposes to thrombophlebitis. Using an overbed trapeze could allow the client to twist the the spine, which is directly contraindicated. Review postoperative care following spinal spinal fusion if you you had difficulty with this question. Level of Cognitive Ability: Application


Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal nursing (4th ed.). St. Louis: Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Mosby, p. 161. 49. A nurse nurse has reinforced instructions with a client with a herniated lumbar disk about proper body mechanics and other items pertinent pertinent to low back care. The nurse determines that the client client needs further instructions if the client verbalizes that he or she will: 1. Get out of bed by sitting sitting straight up and swinging swinging legs over the side of the bed. 2. Increase fiber and fluids in the the diet. 3. Strengthen the back muscles muscles by swimming swimming or walking. 4. Bend at the knees to pick up objects. objects. Answer: 1 Rationale: Clients are taught to get out of bed by sliding near to to the edge of the mattress. The client then rolls onto one side and pushes up from the bed using one or both arms. The back is kept straight and the legs are swung over the side. Increasing fluids and dietary fiber helps prevent straining at stool, thereby preventing increases in intraspinal intraspinal pressure. Walking and swimming are excellent exercises for strengthening lower back muscles. muscles. Proper body mechanics includes bending at the knees, not the waist, to lift objects. instructions. These words Test-Taking Test-Taking Strategy: Note the key words, needs further instructions. words indicate a false response question and that you need to select the incorrect incorrect client statement. Options 3 and 4 are examples of interventions that are indicated and are eliminated eliminated first. Clients with low back pain should avoid situations that increase intraspinal pressure; option 2 prevents increases in intraspinal pressure. Option 1 causes an increase in intraspinal pressure if you think of the body mechanics involved in getting out of bed this way. way. Review the principles of proper proper body mechanics if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, p. 161. 50. A client client who has had spinal fusion and insertion of hardware is extremely concerned about the perceived lengthy rehabilitation period. period. The client expresses concerns about finances finances and ability to return to prior employment. The nurse understands that the client’s client’s needs could best be addressed by referral to the: 1. Surgeon 2. Clinical nurse specialist 3. Social worker 4. Physical therapist Answer: 3 Rationale: Following spinal surgery surgery,, concerns about finances and employment are best best handled by referral to a social worker. worker. This individual will provide information about resources available


to the client. The physical therapist has the best knowledge of techniques for for increasing mobility and endurance. The clinical nurse specialist and surgeon do not have information information related to financial resources. Test-Taking est-Taking Strategy: An understanding of the roles of the various members of the health care team helps you answer this question. Focusing on the data in the question and the issue, concerns about finances and ability a bility to return to prior employment, will direct you to option 3. Review health care professional roles if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Effective Care Environment Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Linton, A., & Maebius, N. N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 449. 51. A nurse nurse is planning to reinforce instructions to the client about proper use of a thoracolumbosacral orthosis (TLSO) (TLSO) after spinal fusion fusion with instrumentation. The nurse plans to include which of the following teaching points in discussion with the client? 1. Areas of skin redness at the edges of the brace indicates a good, snug fit. 2. The device is applied before getting out of bed in the morning. 3. The brace should be applied directly next to the skin. skin. 4. The Velcro Velcro closures should be fairly loose to avoid constriction. Answer: 2 Rationale: A back brace or thoracolumbosacral orthosis is individually fitted fitted to the client. client. The brace should not irritate the skin with proper fitting. fitting. The brace is applied in the the morning before getting out of bed. The closures should be secure, but not overly loose or tight. tight. A layer of clothing is worn between the orthosis and the skin. Test-Taking est-Taking Strategy: Use the process of elimination. elimination. Skin irritation irritation is not likely to to be a good sign, so eliminate option 1 first. Loose connections are also not likely likely to indicate proper fit, fit, so option 4 should be eliminated next. From the remaining options, eliminate option 3 because the orthosis is likely to become soiled with perspiration perspiration or cause skin irritation. Review care of the client with a brace if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, p. 2147. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Lou is: Mosby, Mosby, p. 1622. 52. A client client is being transferred to the nursing unit from the postanesthesia care unit following following spinal fusion with rod insertion. The nurse would prepare to transfer the client from the stretcher to the bed by using: 1. A bath blanket and the assistance of three people 2. A bath blanket and the assistance of four people


3. A slider board and the assistance assistance of two people 4. A slider board and the assistance assistance of four people Answer: 4 Rationale: Following spinal fusion, fusion, with or without instrumentation, instrumentation, the client is transferred transferred from stretcher to bed using a slider board and the assistance of four people. This permits optimal stabilization and support of the spine while allowing the client to be moved smoothly and gently. gently. Test-Taking est-Taking Strategy: Use the process of elimination. This question can be answered by analyzing the level of comfort and stability provided to the client’s spine with the amounts of assistance given in each option. Using this approach, you you can eliminate each of the incorrect options. Review care of the client following rod insertion if you you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Effective Care Environment Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Lewis, S., Heitkemper, Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, Mosby, p. 1619. 161 9. 53. A client is being discharged discharged to home following spinal fusion fusion with insertion of rods. The nurse would suggest a consultation with the continuing care nurse regarding the need for follow-up modification of the home environment if the client states that: 1. The bedroom and bath are on the second second floor of the the home. 2. The bathroom has hand railings in the shower. shower. 3. The family has rented a commode for use by the client. client. 4. There are three steps to to get up to the front door. door. Answer: 1 Rationale: Stair climbing may be restricted or limited limited for several weeks following spinal fusion with instrumentation. The nurse ensures that resources are in place prior to discharge so that the client may sleep and perform all ADLs on a single living level. Test-Taking est-Taking Strategy: Use the process of elimination. elimination. Options 2 and 3 are obviously useful to the client, and can therefore be eliminated. To select between options 1 and 4 (both of which involve stairs), option 4 is the least problematic, whereas option 1 poses a significant problem to the client who is restricted restricted from stair climbing. Review the home care needs of the client client following rod insertion if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Effective Care Environment Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, p. 161. 54. A client client with a left arm fracture exhibits loss of sensation sensation in the left fingers, pallor, pallor, poor capillary refill, and diminished diminished left radial pulse. pulse. The nurse should take which of the following actions? 1. Administer an analgesic.


2. Check the circulation circulation again in 30 minutes. 3. Provide range-of-motion exercises to to the fingers of the left left hand. 4. Contact the physician. Answer: 4 Rationale: The client with pallor, slow slow capillary refill, weakened or lost pulse, and absence of sensation or motion to the distal limb may have arterial damage from a lacerated, contused, thrombosed, or severed artery. artery. These signs can occur with constriction from a tight cast as well. Regardless of the cause, the nurse notifies the physician immediately. immediately. Emergency intervention is needed, which could include removal of the constricting bandage, fracture reduction, or surgery to repair the area. Test-Taking est-Taking Strategy: Use the process of elimination. Recall that these these signs indicate insufficient arterial arterial circulation and can lead to irreversible irreversible ischemia and damage. Because of this, eliminate options 1 and 3 first as not being helpful. Rechecking the circulation in 30 minutes loses valuable time for action to restore the impaired circulation, so eliminate option 2. The physician should be notified immediately. immediately. Review the complications of a fracture if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal nursing (3rd Reference: Linton, A., & Maebius, N. N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. W.B. Saunders, pp. 832-833. 55. A client is complaining complaining of pain underneath a cast in the area of a bony prominence. The nurse interprets that this client may need to have: 1. The cast replaced with with an air splint 2. Extra padding put over this area of the cast 3. The cast bivalved 4. A window cut in the cast Answer: 4 Rationale: A window window may be cut in a dried cast to relieve pressure, monitor pulses, relieve discomfort, or remove drains. Bivalving the cast involves splitting splitting the cast along both sides sides to allow space for swelling, facilitate taking x-rays, or make a half-cast for use as an intermittent splint. Padding is not placed on top of a cast. The use of an air splint is not indicated. indicated. Test-Taking Test-Taking Strategy: Note the key words, bony prominence. prominence. Wherever there is a bony prominence, there is a risk risk of pressure and skin breakdown. breakdown. If the pressure area is under a cast, the cast must be removed in in that area to relieve the pressure. pressure. Therefore, options 1 and 3 can be eliminated. Because extra padding over the area of the the cast does no good either, either, option 2 can be eliminated next. This leaves putting a window in in the cast as the correct correct answer. answer. This will relieve the pressure in that one area without disrupting the cast. cast. Review the complications of a cast and the treatments for complications if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Evaluation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal


nursing (4th ed.). St. Louis: Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th Mosby, p. 151. 56. A client is fearful about having an arm cast removed. Which of the following actions by the nurse would be the most helpful? 1. Telling the client that the the saw makes a frightening noise noise 2. Reassuring the client that no one has had an arm lacerated yet yet 3. Stating that the hot cutting cutting blades cause burns only very rarely 4. Showing the client the cast cutter and explaining how it works Answer: 4 Rationale: Clients may be fearful fearful of having a cast removed because of misconceptions about the cast cutting blade. The nurse should show the the cast cutter to the client before it is used, and explain that the client may feel heat, vibration, and pressure. The cast cutter resembles a small electric saw with a circular blade. The nurse should reassure the the client that the blade does not cut like a saw, but instead cuts the cast by vibrating side to side. Test-Taking Test-Taking Strategy: Note the key words, most helpful . Option 2 gives no information, although it may be well-intentioned, well-intentioned, and is eliminated first. first. Options 1 and 3 give accurate information, but are not reassuring. reassuring. Option 4 gives the client the most reassurance because it best prepares the client for for what will happen when the cast is removed. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Psychosocial Integrity Integrated Process: Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, p. 149. 57. A nursing nursing instructor asks a nursing student about the risk factors associated associated with osteoporosis. The instructor tells the student that she needs to to read and learn about this disorder disorder if the student states that which of the following is an associated risk factor? 1. High-calcium diet consumption 2. Postmenopausal age 3. Long-term use use of corticosteroids 4. Family history of osteoporosis osteoporosis Answer: 1 Rationale: Risk factors associated associated with osteoporosis include a diet diet that is deficient in calcium. Options 2, 3, and 4 include risk factors associated with osteoporosis. Additional risk factors include being sedentary, cigarette smoking, excessive alcohol consumption, chronic illness, and long-term use of anticonvulsants and furosemide. Test-Taking Test-Taking Strategy: Note the key words, needs to read and learn about this disorder . These words indicate a false response question and that you need to select the incorrect student statement. Remember, risk factors associated with osteoporosis include a diet that is deficient in calcium. Review these risk factors if you are not familiar familiar with them. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion Promotion and Maintenance


Integrated Process: Teaching/Learning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal References: Christensen, B., & Kockrow, Kockrow, E. (2003). Adult (2003). Adult health nursing (4th nursing (4th ed.). St. Louis: Mosby, Mosby, pp. 121-122. Linton, A., & Maebius, N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd nursing (3rd ed.). Philadelphia: W.B. W.B. Saunders, pp. 812-813. 58. A nurse nurse is providing instructions to a client with osteoporosis regarding regarding appropriate food items to include in the the diet. The nurse tells the client client that which food item would provide the least amount of calcium? 1. Plain yogurt 2. Seafood 3. Sardines 4. Pork Answer: 4 Rationale: Foods high in calcium include include plain yogurt, dairy products, seafood, sardines, green vegetables, calcium-fortified orange juice, and cereal. Of the items listed in the options, option option 4 would contain the least amount of calcium. Test-Taking Test-Taking Strategy: Note the key words, least amount of calcium. calcium. Recalling the foods that are high and low in calcium will direct you to option 4. Review foods high in calcium if if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Linton, A., & Maebius, N. N. (2003). Introduction (2003). Introduction to medical-surgical nursing (3rd nursing (3rd ed.). Philadelphia: W.B. W.B. Saunders, pp. 613-614. 59. A client has several fractures of the lower leg and has been placed in an external fixation device. The client is upset about the appearance of the leg, which is very edematous. The nurse suggests which of the following nursing diagnoses for the client? 1. Disturbed Body Image 2. Activity Intolerance 3. Risk for Impaired Physical Physical Mobility 4. Social Isolation Answer: 1 Rationale: In regard to nursing diagnoses, diagnoses, the client experiences a Disturbed Disturbed Body Image related to a change in the structure and function of the affected affected leg. There are no data in the question question to support a diagnosis of (actual) Activity Intolerance or Social Isolation. The client does have an actual Impaired Physical Mobility because of the fixation device. Test-Taking Test-Taking Strategy: Note the key words, upset about the appearance. appearance. Next, note the relation relation between these words and option 1. Review the defining characteristics for Disturbed Body Image if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Needs: Psychosocial Integrity


Integrated Process: Process: Nursing Process/Planning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Gulanick, M., Myers, J., Klopp, A., Gradishar, D., Galanes, S., S., & Puzas, M. (2003). Nursing care plans: Nursing diagnosis and intervention (5th ed.). St. Louis: Lo uis: Mosby, Mosby, p. 19. 60. A nurse nurse is caring for a client with a diagnosis of gout. Which of the following laboratory values would the nurse expect to note in the client? 1. Uric acid level of 8.0 mg/dL 2. Calcium level of 9.0 mg/dL 3. Phosphorus level level of 3.0 mg/dL 4. Potassium level level of 4.0 mEq/L Answer: 1 Rationale: In addition to the presence presence of clinical manifestations, gout is diagnosed by the presence of persistent hyperuricemia, hyperuricemia, with the uric acid level level higher than 7 mg/dL. Options 2, 3, and 4 all indicate normal laboratory values. Additionally, Additionally, the presence of uric acid in an aspirated sample of synovial fluid confirms the diagnosis. Test-Taking est-Taking Strategy: Use the process of elimination and knowledge of normal laboratory values. Recalling that increased uric acid levels levels occur in gout and noting that option option 1 is the only abnormal value will assist assist in answering the question. Review the manifestations of gout and the normal uric acid level if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Chernecky, Chernecky, C., & Berger, Berger, B. (2001). Laboratory (2001). Laboratory tests and diagnostic procedures (3rd ed.). Philadelphia: W.B. W.B. Saunders, p. 1042. 61. A nurse is caring for a client with osteoarthritis. osteoarthritis. The nurse collects data, knowing that which of the following is a clinical manifestation associated with the disorder? 1. Pain that is most severe later later in the day 2. An elevated platelet count 3. Dull aching pain in the affected joints 4. Elevated antinuclear antibody levels Answer: 3 Rationale: The stiffness and joint pain that occur in osteoarthritis osteoarthritis increase with lack of activity, activity, are usually more severe in the morning, and may be aggravated by cold, damp weather. weather. No specific laboratory findings are useful in diagnosing osteoarthritis. osteoarthritis. The client may have a normal or slightly elevated sedimentation sedimentation rate. Dull, aching pain occurs in the affected affected joints and, unlike rheumatoid arthritis, systemic manifestations are absent and joint involvement is not symmetrical. Elevated white blood cell counts, platelet counts, and antinuclear antibodies occur in rheumatoid arthritis. Test-Taking est-Taking Strategy: Use the process of elimination and knowledge about the differences between osteoarthritis and rheumatoid arthritis to answer answer this question. Remember, dull, dull, aching pain occurs in the affected joints in osteoarthritis. osteoarthritis. Review the characteristics of osteoarthritis if if you had difficulty with the question.


Level of Cognitive Ability: Analysis Client Needs: Needs: Physiological Integrity Integrated Process: Process: Nursing Process/Data Process/Data Collection Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Phipps, W., W., Monahan, F., F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, Mosby, p. 1523. 62. A nurse nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Select all instructions that the nurse includes on the list. list. ____Keep the cast and extremity elevated. ____Allow the wet cast 24 to 48 hours to dry. ____Use a hair dryer set on a warm to hot setting to dry the cast. ____Tingling and numbness in the extremity are expected. ____Use a soft padded object o bject that will fit under the cast to scratch the skin under the cast. ____The cast needs to be b e kept clean and dry. dry. Answers: Keep the cast and extremity elevated. Allow the wet cast 24 to 48 hours to dry. The cast needs to be kept clean and dry. Rationale: A plaster cast takes 24 to to 48 hours to dry (synthetic casts dry in 20 minutes). The cast and extremity are elevated to prevent swelling and circulatory compromise. A wet cast cast is handled with the palms of the hand until it is dry and the extremity ex tremity is turned (unless contraindicated) so that all sides of the wet cast will dry. dry. A cool setting setting on the hair dryer can be used to dry a plaster cast (heat cannot canno t be used on plaster cast because bec ause the cast heats up and an d burns the skin). The cast needs to be kept clean and dry, and the client is instructed instructed not to stick anything under the cast because of the risk of breaking skin integrity. integrity. The client is instructed to monitor the extremity for circulatory impairment such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. pulse. The physician is notified notified immediately if circulatory circulatory compromise occurs. Test-Taking est-Taking Strategy: Focus on the issue, a plaster cast. Recalling that edema occurs following a fracture and recalling the complications co mplications associated with a cast will assist in answering the question. Review cast care instructions if you had difficulty difficulty with this question. Level of Cognitive Ability: Application Client Needs: Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Musculoskeletal Health/Musculoskeletal Reference: Black, J., & Hawks, J., (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. W.B. Saunders, pp. 631-633.

Silvestri Chapter 58 Ed#576

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