Nursing 2, Unit 3

A nurse in a provider’s office is preparing to assess a young adult male client’s musculoskeletal system as
part of a comprehensive physical examination. Which of the following findings should the nurse expect?
(Select all that apply.)
A. A concave thoracic spine posteriorly
B. An exaggerated lumbar curvature
C. A concave lumbar spine posteriorly
D. An exaggerated thoracic curvature
E. Muscles slightly larger on his dominant side
A. A concave thoracic spine posteriorly
C. A concave lumbar spine posteriorly
E. Muscles slightly larger on his dominant side
A nurse is evaluating a client’s neurosensory system. To evaluate stereognosis, she should ask the client to close his eyes and identify which of the following items?
A. A word she whispers 30 cm from his ear
B. A number she traces on the palm of his hand
C. The vibration of a tuning fork she places on his foot
D. A familiar object she places in his hand
D. A familiar object she places in his hand
A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of her right
shoulder. Which of the following activities is this problem likely to affect?
A. Mopping her floors
B. Brushing the back of her hair
C. Fastening her bra behind her back
D. Reaching into a cabinet above her sink
C. Fastening her bra behind her back
A nurse is performing a neurosensory examination for a client. Which of the following tests should the
nurse perform to test the client’s balance? (Select all that apply.)
A. Romberg test
B. Heel-to-toe walk
C. Snellen test
D. Spinal accessory function
E. Rosenbaum test
A. Romberg test
B. Heel-to-toe walk
A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the
following findings should the nurse expect as changes associated with aging? (Select all that apply.)
A. Slower light touch sensation
B. Some vision and hearing decline
C. Slower fine finger movement
D. Some short-term memory decline
E. Slower superficial pain sensation
B. Some vision and hearing decline
C. Slower fine finger movement
D. Some short-term memory decline
A nurse is caring for a client who has been sitting in a chair for 3 hr. Which of the following problems is
the client at risk for developing?
A. Stasis of secretions
B. Muscle atrophy
C. Pressure ulcer
D. Fecal impaction
C. Pressure ulcer
A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse
implement to maintain the patency of the client’s airway?
A. Encourage isometric exercises.
B. Suction every 8 hr.
C. Give low-dose heparin.
D. Promote incentive spirometer use.
D. Promote incentive spirometer use.
A nurse is caring for a client who is postoperative. Which of the following nursing interventions reduce
the risk of thrombus development? (Select all that apply.)
A. Instruct the client not to use the Valsalva maneuver.
B. Apply elastic stockings.
C. Review laboratory values for total protein level.
D. Place pillows under the client’s knees and lower extremities.
E. Assist the client to change position often.
B. Apply elastic stockings.
E. Assist the client to change position often.
A nurse is instructing a client who is postoperative about the sequential compression device the provider
has prescribed. Which of the following client statements should indicate to the nurse that the client
understands the teaching?
A. “This device will keep me from getting sores on my skin.”
B. “This thing will keep the blood pumping through my leg.”
C. “With this thing on, my leg muscles won’t get weak.”
D. “This device is going to keep my joints in good shape.”
B. “This thing will keep the blood pumping through my leg.”
To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the
left lower extremity, which of the following instructions should the nurse provide? (Select all that apply.)
A. Hold the cane on the right side.
B. Keep two points of support on the floor.
C. Place the cane 15 inches in front of the feet before advancing.
D. After advancing the cane, move the weaker leg forward.
E. Advance the stronger leg so that it aligns evenly with the cane.
A. Hold the cane on the right side.
B. Keep two points of support on the floor.
D. After advancing the cane, move the weaker leg forward.
A nurse is reviewing preoperative teaching with a client who is to undergo an arthroscopy to repair injury
to a shoulder. Which of the following statements by the nurse are appropriate? (Select all that apply.)
A. “Avoid damage or moisture to the cast on your arm.”
B. “Inspect your incision daily for signs of infection.”
C. “Resume normal activity within 12 hours.”
D. “Position your affected extremity in a dependent position.”
E. “Perform isometric exercises as directed.”
B. “Inspect your incision daily for signs of infection.”
E. “Perform isometric exercises as directed.”
A nurse is contributing to the plan of care for a client who is postoperative following an arthroscopy of
the knee. Which of the following should the nurse include in the plan of care? (Select all that apply.)
A. Inspect color and temperature of the extremity.
B. Apply warm compresses to incision sites.
C. Elevate the extremity.
D. Administer opioid medication.
E. Check pulses and sensation in the foot.
A. Inspect color and temperature of the extremity.
C. Elevate the extremity.
D. Administer opioid medication.
E. Check pulses and sensation in the foot.
A nurse is reinforcing teaching with a client who is scheduled for a bone scan. Which of the following
statements by the nurse is appropriate?
A. “The procedure will take about 1 hour.”
B. “You will be placed in a tubelike structure during the procedure.”
C. “You will need to take precautions with your urine for 24 hours after the procedure.”
D. “A radioactive substance will be injected before the procedure.”
D. “A radioactive substance will be injected before the procedure.”
A nurse is reviewing information with a client scheduled for a dual x-ray absorptiometry (DXA) scan.
Which of the following should the nurse include? (Select all that apply.)
A. The test requires the use of contrast material.
B. The hip and spine are the usual areas to be scanned.
C. The scan is used to detect osteoarthritis.
D. Bone pain can indicate a need for a scan.
E. At age 40 years, a baseline scan is recommended.
B. The hip and spine are the usual areas to be scanned.
D. Bone pain can indicate a need for a scan.
E. At age 40 years, a baseline scan is recommended.
A nurse is assisting with care of a client who is to have an electromyography (EMG). Which of the
following should the nurse expect to be included in the plan of care? (Select all that apply.)
A. Inspect the client’s skin for bruising.
B. Apply ice to insertion sites.
C. Determine whether the client takes a muscle relaxant.
D. Instruct the client to flex muscles while the needle is inserted.
E. Expect swelling, redness, and tenderness at the insertion sites.
A. Inspect the client’s skin for bruising.
B. Apply ice to insertion sites.
C. Determine whether the client takes a muscle relaxant.
D. Instruct the client to flex muscles while the needle is inserted.
A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse
should recognize which of the following findings as a contraindication to this procedure?
A. Age of 78
B. History of cancer
C. Previous joint replacement
D. Bronchitis 2 weeks ago
D. Bronchitis 2 weeks ago
A nurse is assisting with the care of a client on the orthopedic unit following a total knee arthroplasty.
Which of the following actions by the nurse are appropriate? (Select all that apply.)
A. Maintain continuous passive motion device.
B. Palpate dorsalis pedis pulses.
C. Place pillow behind the knee.
D. Elevate heels off bed.
E. Apply heat therapy to incision.
A. Maintain continuous passive motion device.
B. Palpate dorsalis pedis pulses.
D. Elevate heels off bed.
A nurse is reviewing discharge teaching with a client who had a total hip arthroplasty. Which of the
following should the nurse include in the teaching? (Select all that apply.)
A. Clean the incision daily with soap and water.
B. Turn the toes inward when sitting or lying.
C. Sit in a straight-backed armchair.
D. Bend at the waist when putting on socks.
E. Use a raised toilet seat.
A. Clean the incision daily with soap and water.
C. Sit in a straight-backed armchair.
E. Use a raised toilet seat.
A nurse is collecting data from a client who is to undergo a right knee arthroplasty. Which of the
following are expected findings? (Select all that apply.)
A. Skin reddened over the joint
B. Pain when bearing weight
C. Joint crepitus
D. Swelling of the affected joint
E. Limited joint motion
B. Pain when bearing weight
C. Joint crepitus
D. Swelling of the affected joint
E. Limited joint motion
A nurse is contributing to the preoperative teaching plan for a client who is to have a total hip
arthroplasty. Which of the following should the nurse include in the teaching plan? (Select all that apply.)
A. Encouraging complete autologous blood donation
B. Sitting in a low reclining chair
C. Having the client roll onto the operative hip
D. Using an abductor pillow when turning
E. Performing isometric exercises
A. Encouraging complete autologous blood donation
D. Using an abductor pillow when turning
E. Performing isometric exercises
A nurse is reinforcing information with a client who is scheduled for lower extremity angiography. The
nurse should instruct the client that which of the following is the purpose of angiography?
A. Measure the speed of blood flow in an extremity.
B. Measure the adequacy of oxygen pressures in an extremity.
C. Examine the blood vessels for areas of impaired circulation.
D. Compare systolic blood pressures between the extremities.
C. Examine the blood vessels for areas of impaired circulation.
A nurse is collecting data from an older adult client who has arteriosclerosis and is scheduled for a
possible right lower extremity amputation. Which of the following are expected findings in the affected
extremity? (Select all that apply.)
A. Skin cool to touch from mid-calf to the toes
B. Lower leg appears dusky when client is sitting
C. Palpable pounding pedal pulse
D. Lack of hair on lower leg
E. Blackened areas on several toes
A. Skin cool to touch from mid-calf to the toes
B. Lower leg appears dusky when client is sitting
D. Lack of hair on lower leg
E. Blackened areas on several toes
A nurse is caring for a client following a below-the-elbow amputation. Which of the following are
appropriate actions by the nurse? (Select all that apply.)
A. Encourage dependent positioning of the residual limb.
B. Inspect for presence and amount of drainage.
C. Implement shrinkage intervention of the residual limb.
D. Wrap the residual limb in a circular manner using gauze.
E. Monitor for feelings of body image changes.
A. Encourage dependent positioning of the residual limb.
B. Inspect for presence and amount of drainage.
C. Implement shrinkage intervention of the residual limb.
E. Monitor for feelings of body image changes.
A nurse is caring for a client who had an above-the-knee amputation and who reports having sharp,
stabbing type of phantom pain. Which of the following is an appropriate action by the nurse?
A. Facilitate counseling services.
B. Encourage use of cold therapy.
C. Question whether the pain is real.
D. Administer an antiepileptic medication
D. Administer an antiepileptic medication
A nurse is contributing to the a plan of care for a client following a below-the-knee amputation 24 hr ago.
Which of the following should the nurse include in the plan of care to prevent the client from developing
flexion contractions?
A. Elevate the residual limb on a pillow.
B. Position the client prone several times each day.
C. Wrap the stump in a figure-eight pattern.
D. Encourage sitting in a chair during the day.
B. Position the client prone several times each day.
A nurse is admitting an older adult client who has suspected osteoporosis. Which of following is an
expected clinical finding? (Select all that apply.)
A. History of consuming one glass of wine daily
B. Loss in height of 2 in (5.1 cm)
C. Body mass index (BMI) of 21
D. Kyphotic curve at upper thoracic spine
E. History of lactose intolerance
B. Loss in height of 2 in (5.1 cm)
C. Body mass index (BMI) of 21
D. Kyphotic curve at upper thoracic spine
E. History of lactose intolerance
A nurse is performing health screenings of clients at a health fair. Which of the following clients are at
risk for osteoporosis? (Select all that apply.)
A. A 40-year-old client who takes prednisone for asthma
B. A 30-year-old client who jogs 3 miles daily
C. A 45-year-old client who takes phenytoin (Dilantin) for seizures
D. A 65-year-old client who has a sedentary lifestyle
E. A 70-year-old client who has smoked for 50 years
A. A 40-year-old client who takes prednisone for asthma
C. A 45-year-old client who takes phenytoin (Dilantin) for seizures
D. A 65-year-old client who has a sedentary lifestyle
E. A 70-year-old client who has smoked for 50 years
A nurse is providing instructions on home safety for an older adult client who has osteoporosis. Which
of the following information should the nurse include in the teaching? (Select all that apply.)
A. Remove throw rugs in walkways.
B. Use prescribed assistive devices.
C. Remove clutter from the environment.
D. Walk with caution on icy surfaces.
E. Maintain lighting of doorway areas.
A. Remove throw rugs in walkways.
B. Use prescribed assistive devices.
C. Remove clutter from the environment.
E. Maintain lighting of doorway areas.
A nurse is providing dietary teaching about calcium-rich foods to a client who has osteoporosis. Which
of the following foods should the nurse include in the instructions?
A. White bread
B. White beans
C. White meat of chicken
D. White rice
B. White beans
A nurse is providing care for a client who had a vertebroplasty of the thoracic spine. Which of the
following is an appropriate action by the nurse?
A. Apply heat to the client’s puncture site.
B. Place the client in a supine position.
C. Turn the client every 4 hr.
D. Ambulate the client within the first hour post-procedure.
B. Place the client in a supine position.
A nurse is reinforcing to teaching a client on how to manage an external fixation device upon discharge.
Which of the following statements by the client indicates an understanding of safe management?
(Select all that apply.)
A. “I will clean the pins twice a day.”
B. “I will use a separate cotton swab for each pin.”
C. “I will report loosening of the pins to my doctor.”
D. “I will move my leg by lifting the device in the middle.”
E. “I will remove any crusting that forms at the pin site.”
A. “I will clean the pins twice a day.”
B. “I will use a separate cotton swab for each pin.”
C. “I will report loosening of the pins to my doctor.”
A nurse is collecting data on a client who has a casted compound fracture of the right forearm. Which of
the following findings is an early indication of neurovascular compromise?
A. Paresthesia
B. Pulselessness
C. Paralysis
D. Pallor
A. Paresthesia
A nurse is collecting data on a client who had an external fixation device applied 2 hr ago for a fracture
of the left tibia and fibula. Which of the following findings indicate compartment syndrome? (Select all
that apply.)
A. Intense pain when the left foot is passively moved
B. Edematous left toes compared to the right
C. Hard, swollen muscle in the left leg
D. Burning and tingling of the distal left foot
E. Minimal pain relief following a second dose of opioid medication
A. Intense pain when the left foot is passively moved
C. Hard, swollen muscle in the left leg
D. Burning and tingling of the distal left foot
E. Minimal pain relief following a second dose of opioid medication
A nurse is reinforcing teaching to a client who had a wound debridement for osteomyelitis. Which of
the following information should the nurse include in the teaching?
A. Antibiotic therapy should continue for 3 months.
B. Relief of pain indicates the infection is eradicated.
C. Contact precautions are used during wound care.
D. Dressing changes are performed using aseptic technique.
A. Antibiotic therapy should continue for 3 months.
A nurse is planning care for a client who has a right hip fracture. Which of the following immobilization
devices should the nurse anticipate in the plan of care?
A. Skeletal traction
B. Buck’s traction
C. Halo traction
D. Gardner-Wells traction
B. Buck’s traction
A nurse is collecting data on a client who has osteoarthritis of the knees and fingers. Which of the
following clinical manifestations should the nurse expect to find? (Select all that apply.)
A. Heberden’s nodes
B. Swelling of all joints
C. Small body frame
D. Enlarged joint size
E. Limp when walking
A. Heberden’s nodes
D. Enlarged joint size
E. Limp when walking
A nurse is providing information to a client who has osteoarthritis of the hip and knee. Which of the
following information should the nurse include in the information? (Select all that apply.)
A. Apply heat to joints to alleviate pain.
B. Ice inflamed joints following activity.
C. Install an elevated toilet seat.
D. Take tub baths.
E. Complete high-energy activities in the morning.
A. Apply heat to joints to alleviate pain.
B. Ice inflamed joints following activity.
C. Install an elevated toilet seat.
E. Complete high-energy activities in the morning.
A nurse is providing information about capsaicin (Capsin) cream to a client who reports continuous knee
pain from osteoarthritis. Which of the following information should the nurse include in the discussion?
A. Continuous pain relief is provided.
B. Inspect for skin irritation and cuts prior to application.
C. Cover the area with tight bandages after application.
D. Apply the medication every 2 hr during the day.
B. Inspect for skin irritation and cuts prior to application.
A nurse is providing educational information on glucosamine to a group of clients at a health fair.
Which of the following should the nurse include in the teaching?
A. It decreases the amount of synovial fluid produced in the joints.
B. The medication aids in the rebuilding of cartilage.
C. A prescription is required for this medication.
D. This medication is injected into the joint to decrease joint pain.
B. The medication aids in the rebuilding of cartilage.
A nurse is preparing a client who is to receive hyaluronic acid (Synvisc) injection for osteoarthritis.
Which of the following statements by the nurse is appropriate?
A. “Hyaluronic acid is currently approved for shoulder joint inflammation.”
B. “Report an allergy to shellfish before receiving hyaluronic acid.”
C. “Hyaluronic acid is a natural joint replacement fluid.”
D. “Hyaluronic acid is made from the combs of chickens.”
D. “Hyaluronic acid is made from the combs of chickens.”
A nurse is reinforcing teaching for a client about proper crutch walking using the swing-through gait. Which of the following statements is appropriate to include?
“Move both crutches forward, then lift and swing your body past the crutches.”
A nurse is reinforcing teaching for a client who has rheumatoid arthritis (RA) about self-care techniques. Which of the following strategies should she include to illustrate the concept of joint protection?
Press water from a sponge rather than wringing it.
A nurse is assisting a client who is postoperative with ambulation. While ambulating with the nurse, the client feels faint and starts to fall. Which of the following is an appropriate action by the nurse?
Ease the client gently to the floor.
A nurse is assisting a client who has generalized weakness out of bed to a wheelchair. Which of the following is an appropriate action for the nurse to take?
Lock the wheels of the bed and the wheelchair.
A nurse is contributing to the plan of care for a client to achieve the outcome of functional healing of a fracture. Which of the following nursing interventions is the highest priority to assist in meeting this outcome?
Maintain immobilization and alignment.
A nurse is reinforcing teaching to a parent and a school-age child following application of a fiberglass cast for a radius fracture. Which of the following statements by the parent or child indicates the need for further teaching?
“I will try not to move my fingers very much while I have the cast on.”
A nurse is caring for a client who is postoperative following a below-the knee-amputation and will soon undergo fitting for a leg prosthesis. Which of the following is an appropriate nursing intervention for this client at this time?
Wrap the stump with an elastic bandage in a figure-eight configuration.
A nurse is reinforcing discharge instructions to client who had an internal repair of a right hip fracture. The nurse knows the client understands the instructions when he tells her that he will rest during the day sitting on which of the following pieces of furniture?
A straight-backed chair with an elevated seat
A nurse is caring for a client who has an exacerbation of gout. When collecting data from the client, which of the following joint alterations should the nurse expect to observe? (Select all that apply.)
Hyperemia
Erythema
Tophi
Decreased mobility
A nurse is planning care for a child who has juvenile rheumatoid arthritis. Which of the following is an appropriate action for the nurse to take?
Maintain night splints to the affected joint.
A nurse is reviewing the causes of osteoporosis with a group of nursing students. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis?
Thyroid hormones
A client returns to the surgical unit from the postanesthesia care unit in skeletal traction. The nurse should take action to correct which of the following problems with the traction setup?
The weights rest against the foot of the bed.
A client comes to the clinic reporting shoulder pain. When obtaining the client’s history, the nurse suspects a rotator cuff injury. When collecting data from the client, the nurse expects to find which of the following?
Inability to abduct the arm at the shoulder
A nurse is caring for an older adult client who had a femoral head fracture 24 hr ago and has skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?
Fat embolism
A nurse is caring for four clients on a surgical unit. Which of the following tasks should the nurse delegate to the assistive personnel (AP)?
Assist a client to a chair who is 2 days postoperative following a cervical laminectomy.
A nurse is preparing to assist a client who can partially bear weight and is cooperative from the bed to a chair. Which of the following actions by the nurse will be most safe for the client and the nurse?
Use a powered standing-assist lift.
While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following complications does this finding indicate?
Infection
A nurse is caring for an older adult client who has had a right hip arthroplasty. A newly licensed nurse has completed the plan of care for this client. Which of the following interventions should the nurse recognize as inappropriate for the client’s plan of care?
Perform the client’s personal care activities for her.
A nurse is caring for a client who has a femur fracture and is in skeletal traction. The nurse understands that it is permissible to remove the weights from the traction device if the client is in which of the following situations?
A life-threatening situation.
A nurse is caring for a client who has a fractured femur. Which of the following techniques should the nurse use when collecting data about the client’s circulatory status?
Instruct the client to wiggle his toes.
A nurse is reinforcing teaching for a middle-age client who is at high risk for osteoporosis and is taking a calcium supplement. Which of the following instructions should the nurse include?
Take vitamin D supplements.
A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching?
Report decreased sensation of the affected extremity to the provider.
A nurse in a provider’s office is talking with a client about risk factors for osteoporosis. Which of the following factors should the nurse include? (Select all that apply.)
Sedentary lifestyle
Aging
Caffeine intake
Secondhand smoke
A charge nurse is making client care assignments. Which of the following tasks should the nurse plan to delegate to assistive personnel (AP)? (Select all that apply.)
Bathing a client who had an amputation 2 days ago.
Assisting a client to ambulate using a gait belt.
Feeding a client who had a stroke 3 months ago.
A client is about to undergo electromyography. The nurse should explain to the client that this diagnostic test involves which of the following?
Placement of thin needles into the muscles with recording of responses to stimuli
A nurse is reinforcing teaching to a client with a history of falls about home safety. Which of the following statements by the client indicates an understanding of the teaching?
“I will place a bath seat in my shower to use when I bathe.”
A client who has a lower-leg cast reports skin irritation around the upper edge of the cast. Which of the following actions should the nurse take?
Petal the edges of the cast.
A nurse is caring for a client who has osteoporosis and is taking a calcium supplement. When the client tells the nurse she has been having some flank pain, which of the following adverse effects should the nurse suspect?
Renal stones
A nurse is caring for a client who is scheduled for outpatient surgery. The client indicates taking celecoxib (Celebrex) daily. A history of which of the following would indicate a need for this type of medication?
Osteoarthritis
A nurse is discussing skeletal and skin traction with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding?
“Skeletal traction is more appropriate than skin traction for reducing a fracture. “
A nurse is reinforcing teaching for a client who has fibromyalgia about strategies that might help reduce her symptoms. Which of the following interventions should the nurse include?
Establish a regular sleep pattern.
A nurse is collecting data from a client who has diabetes and is overweight. The client tells the nurse that she wants to start an exercise program. Which of the following actions should the nurse take first?
Determine the client’s usual pattern of activity.
A nurse is caring for a client diagnosed with rheumatoid arthritis. When performing assisted range of motion on the client’s joints, the nurse is likely to note the presence of which of the following?
Boutonniere deformity
A client comes to the clinic reporting chronic low back pain. He asks the nurse to recommend specific exercises for him. Which of the following activities should the nurse suggest?
Swimming
A nurse is collecting data from a client who has a herniated intervertebral disc. Which of the following findings should the nurse expect? (Select all that apply.)
Tingling in the arms
Shoulder pain
Stiff neck
A nurse is discharging a client who came to the outpatient clinic with an ankle sprain. Which of the following client statements demonstrates that he understands the discharge instructions?
“I’ll apply ice to my ankle for 20 minutes every hour.”
A nurse is talking with a client who has a new diagnosis of acute bursitis in her right shoulder. Which of the following self-care strategies should the nurse recommend?
Intermittent ice and heat
A nurse is talking with a client who has a new diagnosis of gout. When the client asks the nurse how she got this disorder, the nurse should explain, in terminology the client can understand, that gout develops when
the intra-articular deposition of urate crystals causes inflammation.
A provider prescribes cyclobenzaprine (Flexeril) for a client who has a fractured ulna. When the client asks the nurse what this medication is supposed to do for him, the nurse should explain that cyclobenzaprine will
Relieve muscle spasms.
A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)
Teach the clients to use the call light.
Place a fall risk sign above the clients’ beds.
A client comes to the clinic reporting wrist pain. When obtaining the client’s history, the nurse suspects carpal tunnel syndrome. When collecting data from the client, the nurse expects to find which of the following?
Positive Phalen’s sign
A nurse in an urgent care center is caring for a child who has a forearm fracture. The parent tells the nurse that the provider said it was a greenstick fracture and asks what that means. The nurse should explain that
the bone cracked lengthwise but didn’t break all the way through.
A goal for a client who has difficulty with the physical aspects of feeding herself due to rheumatoid arthritis is to use adaptive devices to enhance her capabilities. The nurse caring for the client should initiate a referral with which of the following members of the collaborative health care team?
Occupational therapist
A nurse is caring for an adolescent client who has a fractured tibia. Following the application of a fiberglass cast, which of the following is the nurse’s priority action?
Perform a neurovascular check.
A client has returned to the surgical unit after a mastectomy. The nurse caring for the client should assist her in performing which of the following exercises on her affected side on the first postoperative day? (Select all that apply.)
Squeezing a rolled washcloth
Flexing and extending her hands
Flexing and extending her elbow
A nurse is reinforcing teaching to a client diagnosed with osteoarthritis. The nurse explains that strategies to slow the degenerative process in the joints include which of the following?
Maintaining an appropriate body mass index (BMI)
A nurse is reinforcing teaching for a client at high risk for osteoporosis about dietary measures she can take to increase her calcium level. The nurse should advises the client t to increase her intake of
spinach.
A nurse is reinforcing teaching for a client who is about to start therapy with alendronate (Fosamax) to treat osteoporosis. Which of the following adverse effects should the nurse remind the client to report? (Select all that apply.)
Jaw pain
Blurred vision
Dysphagia
A older adult client on an orthopedic unit has an intracapsular fracture of the right hip following a fall. The client is in Buck’s traction and will have hip prosthesis surgery in the morning. The nurse reinforces with the client that this type of traction helps
relieve muscle spasms.
A school nurse is screening an 11-year-old client for idiopathic scoliosis. Which of the following instructions should the nurse give the client for this examination?
“Bend forward from the waist with your head and arms downward.”
A nurse is talking with a client who is about to start taking allopurinol (Zyloprim) to treat gout. Which of the following statements indicates that the client understands how to take this medication?
“I need to drink at least 3 quarts of water a day.”
A client has a fractured tibia as a result of a fall. The x-ray shows that the bone is splintered into several pieces around the shaft. The nurse knows that this client’s fracture is
comminuted.
A client is about to start taking celecoxib (Celebrex) to treat osteoarthritis symptoms. The nurse should remind the client to watch for and report which of the following possible indications of a serious reaction to this drug?
Black, tarry stools
A nurse is instructing coworkers about how to minimize low back pain and avoid repeated episodes of back pain. Which of the following strategies should the nurse include?
Avoid prolonged sitting.
Sleep in a side-lying position with flexed knees.
Try shoe insoles.
A client tells the nurse at the clinic that she thinks she might be developing rheumatoid arthritis (RA) because she has some stiffness in her joints. Which other early manifestation of RA should the nurse expect to find when she collects data from the client?
Fatigue
A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse include in the plan? (Select all that apply)
Reinforcing teaching about balance and strengthening exercises.
Providing information about home safety checks.
Locking beds and wheelchairs during transfers.
Placing a bedside table within the client’s reach.
A nurse is caring for a client who is postoperative from a total hip arthroplasty. The nurse assists the client into a supine position. Which of the following actions is appropriate to prevent external rotation of the lower extremity?
Place a trochanter roll against the thigh.
A client who has had rheumatoid arthritis (RA) for 3 years reports increasing pain and stiffness in her hands, especially in the morning. On physical examination, the nurse in the clinic should expect which of the following findings?
Knuckle deformity
A client is taking ibuprofen (Advil, Motrin) to treat hip pain. The nurse should teach the client that, to minimize gastric mucosal irritation, she should take this medication at which of the following times?
Immediately after a meal
A nurse is reinforcing teaching for a client who is preparing for an amputation below the knee. Which of the following statements is appropriate regarding the postoperative placement of a prosthesis? “The prosthesis will be in place immediately following surgery to
improve your ability to ambulate sooner.”
In addition to pain management, the nurse’s priority of care for clients diagnosed with bone disorders is:
a. Resolving knowledge deficits
b. Assessing circulation
c. Promoting self-esteem
d. Maintaining correct body alignment
d. Maintaining correct body alignment
The client enters the outpatient clinic and says “I think I have the flu. I’m so tired, I have no appetite, and everything hurts.” The nurse assesses the client and finds a rash over the nose and on the client’s cheeks, and suspects a diagnosis of:
a. Fibromyalgia
b. Systemic lupus erythematosus
c. Lyme disease
d. Gout
b. Systemic lupus erythematosus
The nurse admits a 14-year-old with an edematous painful left forearm after having an accident while driving an all-terrain vehicle. The x-ray shows a comminuted fracture of the radius and displaced fracture of the ulna. The nurse anticipates the client’s treatment will be:
a. External fixation
b. Internal fixation
c. Casting
d. Traction
b. Internal fixation
The nurse admits a 75-year-old client with a diagnosis of septicemia who had a cast placed two weeks ago for a fractured radius. While measuring vital signs, the nurse smells a foul odor emanating from the cast, and suspects:
a. The client might have spilled something into the cast.
b. An infection inside the cast might be the case of the septicemia.
c. The client might not be bathing because of the cast.
d. The odor is the result of the diagnosis of septicemia.
b. An infection inside the cast might be the case of the septicemia.
The nurse admits an elderly woman with a diagnosis of osteoporosis. The nurse plans which intervention to prevent complications related to this diagnosis?
a. Pad the side rails of the bed to prevent fractures.
b. Encourage a moderate exercise program to reduce bone loss.
c. Administer analgesics for pain.
d. Obtain an order from the physician for vitamin K supplements.
b. Encourage a moderate exercise program to reduce bone loss.
The nurse examines a client who had a total knee replacement and has been place in a continuous passive motion machine. The client asks, “What is the purpose of that machine?” The nurse explains the purpose by saying:
a. “The machine is used to prevent scarring of the incision site and keep the knee elevated.”
b. “The machine prevents rusting of the artificial joint, which could occur because of the fluids in your body coming in contact with it.”
c. “The machine helps to decrease swelling and maintain normal function until you can begin exercising your knee independently.”
d. “The machine helps to provide exercise so you don’t gain weight while you activity level is diminished.”
c. “The machine helps to decrease swelling and maintain normal function until you can begin exercising your knee independently.”
The nurse is caring for a client suspected of having a muscle injury in the left upper arm, and anticipates the provider will order what diagnostic test?
a. X-ray
b. MRI
c. Myelogram
d. Arthroscopy
b. MRI
The nurse is caring for a client with a diagnosis of a torn ligament in the knee. The client asks the nurse, “What does the ligament do?” The nurse’s best response would include the fact that ligaments:
a. Connect bone to bone
b. Connect muscle to bone
c. Encapsulate joints
d. Connect muscle to muscle
a. Connect bone to bone
The nurse is caring for a client with osteoarthritis, and plans nonpharmacological pain management to include: (Select all that apply)
a. X-rays
b. Moderate activity plan
c. Ice pack to the moist painful area
d. Application of warm moist heat
e. NSAIDS
b. Moderate activity plan
d. Application of warm moist heat
The nurse is caring for an adolescent admitted with a fractured femur who was placed in traction several days ago. The nurse prepares to perform an initial assessment, and walks into the client’s room to find him dyspneic and reporting severe chest pain. The nurse suspects the client has developed:
a. Pneumonia
b. Pneumothorax
c. Myocardial infarction
d. Fat embolism
d. Fat embolism
The nurse working in an outpatient clinic admits a client who is diagnosed with a sprained ankle. The nurse teaches the client to:
a. Keep the ankle off the floor
b. Keep ice on the ankle for the next week
c. Keep an ace bandage wrapped around the ankle, especially when walking
d. Avoid weight bearing for two weeks
c. Keep an ace bandage wrapped around the ankle, especially when walking
The nurse is working in the Emergency Department admits a client whose left arm hangs lower than the right arm and who is reporting severe left shoulder pain. The nurse’s care, until the client is seen by the physician, is aimed at:
a. Reducing anxiety
b. Preventing movement of the right arm
c. Preventing movement of the left arm
d. Knowledge deficit
c. Preventing movement of the left arm
The nurse working on a postpartum unit includes teaching on osteoporosis prevention for which of the following clients at greatest risk?
a. Asian-American mother of three
b. German-American mother of two who smokes
c. African-American mother of one who is a dietician
d. The Latina other of two who is a recovering alcoholic
b. German-American mother of two who smokes
The nurse working on an acute pediatric unit is caring for an 8-year-old child who is profoundly mentally retarded with significant developmental delays and cerebral palsy that limits the child to a wheelchair. The child was admitted for a significant scoliosis, and has had surgery to fuse the spine, with insertion of rods on both sides of the spinal column. In addition to preventing infection and pain management, the nurse’s priority of care is:
a. Careful movement and repositioning of the client
b. Supporting family coping measures
c. Providing respite care for the primary caregiver
d. Encourage ambulation as soon as possible
a. Careful movement and repositioning of the client
Which of the following client would the nurse consider at risk for use of heat or cold applications?
a. A 68-year-old client with advanced Alzheimer’s disease
b. A 42-year-old client recently diagnosed with diabetes mellitus
c. A 24-year-old client with rheumatoid arthritis
d. A 12-year-old diagnosed with a newly fractures right humerus
a. A 68-year-old client with advanced Alzheimer’s disease
Which of the following are manifestations that are characteristics of rheumatoid arthritis and help distinguish it from osteoarthritis? (Select all that apply)
a. Activity increases pain
b. Autoimmune disease
c. Early morning stiffness
d. Low-grade fever
e. Heberden’s nodes
f. Involvement of other major organs
b. Autoimmune disease
c. Early morning stiffness
d. Low-grade fever
f. Involvement of other major organs
The nurse is collecting data for a client suspected of developing a fat embolus from a fracture of the right femur. Which of these manifestations would the nurse expect? (Select all that apply)
a. Muscle spasms in the right thigh
b. Numbness in the right leg
c. Tachycardia
d. Mental confusion
e. A migraine
f. Feeling short of breath
c. Tachycardia
d. Mental confusion
f. Feeling short of breath
The nurse is caring for a client in traction. What nursing action would be appropriate in caring for the traction weights? (Select all that apply)
a. Use assistance to reposition the patient in bed
b. Allow weights to hang freely in place
c. Lighten weights for short periods if the patient reports pain
d. Hold weights up if the patient is shifting position in bed
e. Remove weights if the patient is being moved up in bed
a. Use assistance to reposition the patient in bed
b. Allow weights to hang freely in place
The nurse is assisting with admitting a client who is diabetic and scheduled for an arthroscopy of the right knee at 8 a.m. What would be the expected actions of the nurse for preoperative care for this client? (Select all that apply)
a. Reviewing the surgical procedure details
b. Maintaining NPO status
c. Explaining the anesthetic agents
d. Witnessing signature on surgical consent
e. Providing a liquid breakfast
f. Obtaining blood glucose
b. Maintaining NPO status
d. Witnessing signature on surgical consent
f. Obtaining blood glucose
The nurse is caring for a client who was an unrestrained passenger in a motor vehicle accident. The client’s leg was also fractured. Which areas should be included in this client’s neurovascular check? (Select all that apply)
a. Level of conscience
b. Sensation
c. Pulses
d. Movement
e. Orientation
f. Pupil reaction
b. Sensation
c. Pulses
d. Movement