Module 13

Question 1

An adult client is diagnosed with a degenerative bone disease that is impairing mobility. Based on this information alone, which of the following actions should be the nurse’s first priority? A) Implementing a low-level exercise program for the client B) Assessing the client’s pain management C) Teaching the client relaxation techniques D) Referring the client to a dietitian

Answer 1

Answer: B Rationale: When caring for a client with a degenerative bone disease that is impairing mobility, the nurse should assess pain management prior to implementing an exercise program, teaching relaxation exercises, or referring to a dietitian.

Question 2

A preadolescent client who fell from a balance beam in physical education class injured her ankle. Given this information, which action by the nurse is appropriate? A) Referring the client to physical therapy B) Placing an ice pack on the client’s ankle C) Planning for a corticosteroid injection D) Ordering an x-ray of the ankle

Answer 2

Answer: B Rationale: An appropriate intervention for a client who experiences an ankle injury is placing ice on the ankle to limit swelling. If physical therapy is needed, the referral would be given after the ankle has had time to heal. A corticosteroid injection would be more appropriate for a client with osteoarthritis, not an acute ankle injury. Ordering an x-ray of the ankle is outside the nurse’s scope of practice.

Question 3

The nurse is conducting a gait and posture assessment for a client who is experiencing mobility issues. Which action by the nurse is appropriate during this assessment? A) Assessing the client’s muscle mass and strength B) Measuring the length and circumference of the client’s extremities C) Inspecting the client’s spine for curvature D) Palpating the client for tenderness and pain

Answer 3

Answer: C Rationale: When assessing a client’s gait and posture, the nurse should be sure to inspect the client’s spine for curvature. Assessing muscle mass and strength, measuring the length and circumference of the extremities, and palpating for tenderness and pain are part of the physical assessment performed by the nurse for clients who are experiencing mobility issues.

Question 4

The nurse is caring for a client who is experiencing limited mobility related to a musculoskeletal alteration. Which laboratory tests would be useful to diagnose the client appropriately? Select all that apply. A) Magnetic resonance imaging (MRI) B) Alkaline phosphatase (ALP) C) Human leukocyte antigen-B27 (HLA-B27) D) Rheumatoid factor (RF) E) Electromyography (EMG)

Answer 4

Answer: B, C, D Rationale: ALP, HLA-B27, and RF are all laboratory tests that are used to diagnose clients with musculoskeletal disorders that can cause alterations in mobility. ALP is produced by bone and other organs. Increased ALP may indicate bone disease, bone fracture, bone tumors, osteomalacia, Paget disease, or rickets. Decreased ALP may indicate Wilson disease. The presence of HLA-B27 indicates an increased risk for ankylosing spondylitis and arthritis. Elevated levels of RF may indicate rheumatoid arthritis, scleroderma, lupus erythematosus, and adult Still disease. MRI and EMG are both diagnostic, not laboratory, tests use to diagnose the cause of alterations in mobility.

Question 5

The nurse is caring for a client who is 28 weeks pregnant. The client says she has recently begun to experience frequent lower back pain and asks the nurse what can be done to control this pain. What is the nurse’s best response? A) “Back pain is common during pregnancy and can usually be managed by taking nonsteroidal anti-inflammatory drugs (NSAIDs).” B) “Let’s talk about some postural adjustments that might help alleviate your pain.” C) “Back pain during pregnancy is often related to kidney infection. Have you experienced any recent urinary problems, including pain when voiding?” D) “The physician will likely order an x-ray to investigate potential causes of your pain.”

Answer 5

Answer: B Rationale: Back pain is common during pregnancy due to strain on the back from the growing uterus and fetus; abdominal weakness from stretched abdominal muscles; and hormonal changes that loosen the ligaments in the joints of the pelvis. Kidney infection is not a leading cause of back pain in pregnant women. Pregnancy-related back pain is usually managed conservatively. Postural changes or other adaptations can help increase mobility and decrease discomfort. The recommended pain medication is acetaminophen, because NSAIDs are contraindicated during pregnancy. Although diagnostic imaging may be useful, x-rays should be avoided because they deliver ionizing radiation to the fetus.

Question 6

The nurse is caring for a preadolescent male client who is accompanied by his mother. Which statement by the mother would be consistent with the client experiencing growing pains? A) “My son often complains that his arms and legs feel sore.” B) “My son seems to get injured very easily, especially broken bones.” C) “My son often doesn’t want to walk because his knees hurt.” D) “My son occasionally complains of pain in his lower back.”

Answer 6

Answer: A Rationale: Long bones of children contain an epiphyseal plate that serves as a location for bone growth. Rapid bone growth in these long bones may produce growing pains as the lengthening bones pull on the muscles. Because this only occurs in the long bones, growing pains are most likely to be felt in the arms and legs. Growing pains would not cause joint pain or lower back pain. Growing pains are also not associated specifically with fractured bones.

Question 7

The nurse is planning care for a client who is experiencing an alteration in mobility. Which would the nurse include as an independent nursing intervention? A) Instructing on the importance of proper nutrition and an active lifestyle B) Administering a prescribed nonsteroidal anti-inflammatory drug (NSAID) C) Identifying necessary modifications to the home environment D) Prescribing a skeletal muscle relaxant

Answer 7

Answer: A Rationale: An appropriate independent nursing intervention for a client who is experiencing an alteration in mobility is providing instruction on the importance of proper nutrition and an active lifestyle. Administering a prescribed NSAID is an example of a collaborative intervention that the nurse can implement. Identifying necessary modifications for the home environment is a collaborative intervention often implemented by the occupational therapist. Although it is appropriate for the nurse to administer a skeletal muscle relaxant, it is outside the scope of nursing practice to prescribe this medication.

Question 8

The nurse is providing care for a client who is experiencing subjective symptoms of carpal tunnel syndrome. Which test should the nurse anticipate being performed by a provider during the physical assessment of this client? A) Bulge test B) Ballottement test C) Phalen test D) McMurray test

Answer 8

Answer: C Rationale: Phalen test is a special assessment to determine whether the client is experiencing carpal tunnel syndrome. With this test, the wrists are held in acute flexion for 60 seconds. Numbness, tingling, or pain may indicate carpal tunnel syndrome. All of the other tests listed here are used to assess the knee.

Question 9

The nurse is caring for an adult client who sustained a right distal radial fracture and a left tibia fracture. Which mobility aid does the nurse anticipate being used for this client? A) Lofstrand crutches B) Platform crutches C) Walker D) Axillary crutches

Answer 9

Answer: B Rationale: This client has fractures in both the leg and wrist. Platform crutches are used for clients who are unable to bear weight on their wrists. A walker, axillary crutches, and Lofstrand crutches all require use of the wrists.

Question 10

The nurse is providing care for several clients. For which client should the nurse anticipate an order for administering 1000 mg of aspirin? A) A 68-year-old client with rheumatoid arthritis who is experiencing hand pain B) A 5-year-old client who is experiencing ankle pain after a fall from a horse C) A 38-year-old client who is experiencing headache pain after a skiing accident D) A 70-year-old client who is experiencing back pain after laminectomy

Answer 10

Answer: A Rationale: Aspirin is appropriate for the client with rheumatoid arthritis who is experiencing hand pain, assuming there are no other contraindications. This medication is not appropriate for the other clients, however. Aspirin therapy is not recommended for children because it is associated with an increased risk of Reye syndrome, and it may contribute to bleeding in adult clients who have sustained physical injury.

Question 11

The cells that produce the matrix for bone formation are known as A) osteoclasts. B) sarcomeres. C) osteoblasts. D) epiphyseal plates.

Answer 11

Answer: C Rationale: Osteoblasts are the cells that produce the matrix for bone formation, whereas osteoclasts are cells that break down bone tissue. Sarcomeres are filaments made of actin or myosin that are found within muscle. Epiphyseal plates are areas of cartilage located between the epiphysis and diaphysis of a child’s long bones.

Question 12

Which score would a nurse select from the muscle function grading scale if the client has full strength and range of motion in a given joint? A) 0 B) 5 C) 8 D) 10

Answer 12

Answer: B Rationale: The muscle function grading scale ranges from 0 to 5. A score of 0 indicates paralysis, meaning that the client cannot contract the muscles associated with a given joint. In contrast, a score of 5 indicates that the client can move a joint through the full range of motion under full resistance.

Question 13

Within the human body, which type of connective tissue connects bones to other bones to form a joint? A) Tendon B) Ligament C) Cartilage D) Myelin

Answer 13

Answer: B Rationale: Ligaments, tendons, and cartilage are all connective tissues. Ligaments connect bones to other bones to form a joint. Tendons connect bones to muscles and carry the contractile forces from the muscle to the bone to cause movement. Cartilage is a type of flexible connective tissue found in many locations throughout the body. Myelin is not a type of connective tissue but rather a fatty substance that insulates neuronal axons and promotes faster signal transmission.

Question 14

A client presents with an alteration in mobility. Which finding would suggest damage to the muscle? A) Increased PTH levels B) Decreased PTH levels C) Decreased CK levels D) Increased CK levels

Answer 14

Answer: D Rationale: Creatine kinase (CK) is used to detect muscle damage, muscle inflammation, rhabdomyolysis, polymyositis, and muscular dystrophy. Thus, increased CK levels are suggestive of increased muscle inflammation. Parathyroid hormone (PTH) levels are not linked to muscle inflammation but rather to osteoporosis, kidney disease, parathyroid gland tumors, lack of calcium, and vitamin D disorders.

Question 15

The nurse is providing care to a client who is experiencing back pain. Which of the following items in the client’s history is a known risk factor for disc herniation? A) 49 years of age B) Female gender C) Short stature D) Anorexia

Answer 15

Answer: A Rationale: The client’s age is a known risk factor; herniated discs are most common between the ages of 30 and 50, because discs naturally degenerate with age. Other risk factors include male gender, tall height, and excess weight (which is extremely uncommon in clients with anorexia).

Question 16

Which of the clients described below are at increased risk for back problems? Select all that apply. A) A 45-year-old man who has played golf three times a week for the past 20 years B) An 18-year-old woman who has been a distance runner since middle school C) A 62-year-old man who is a heavy truck mechanic and has a body mass index (BMI) of 30 D) A 12-year-old boy who has a history of cerebral palsy and a current BMI of 21 E) A 78-year-old man with a 40 pack-year smoking history who was recently widowed

Answer 16

Answer: C, D, E Rationale: Factors that increase the risk of herniated intervertebral discs include male gender, age (clients over 30 are at higher risk), obesity, history of smoking, and regularly engaging in heavy lifting. This means both the 62-year-old client and the 78-year-old client have multiple traits that put them at elevated risk of disc herniation. Risk factors for scoliosis include age of between 9 and 15 and history of cerebral palsy; thus, the 12-year-old client is at elevated risk for this condition. Neither playing golf nor running track causes a high risk of back problems.

Question 17

A preadolescent client is recovering from spinal fusion surgery for scoliosis. Which nursing interventions should the nurse carry out to address comfort and mobility? Select all that apply. A) Reposition every 2 hours. B) Monitor intake and output. C) Encourage and assist with range of motion (ROM) exercises every 4 hours while awake. D) Administer pain medication around the clock. E) Encourage incentive spirometer use every 4 hours while awake.

Answer 17

Answer: A, C, D Rationale: Interventions that address movement restrictions and/or pain in a preadolescent client recovering from spinal fusion include repositioning every 2 hours, encouraging and assisting with ROM exercises every 4 hours while awake, and administering pain medication around the clock. All of these interventions relate to a diagnosis of Impaired Physical Mobility. The use of an incentive spirometer may be appropriate after surgery, but it would relate to a diagnosis of Impaired Tissue Perfusion and not a diagnosis involving pain or restricted movement. Monitoring intake and output would be applicable for a diagnosis of Fluid Volume Excess or Fluid Volume Deficit.

Question 18

The nurse is providing care to a client who returns to the medical-surgical unit after herniated disc surgery. The client’s vitals are as follows: HR 100, RR 22, BP 130/86 mmHg, T 98.8°F, and pain rating of 7 on a scale of 0 to 10. Which nursing diagnosis is the highest priority for this client based on these assessment data? A) Impaired Physical Mobility B) Acute Pain C) Activity Intolerance D) Chronic Pain

Answer 18

Answer: B Rationale: The client is currently experiencing acute pain as evidenced by elevated vital signs and a pain rating of 7 on a 0-to-10 scale. Thus, the priority nursing diagnosis is Acute Pain. Impaired Physical Mobility and Activity Intolerance are appropriate diagnoses in light of the client’s surgical procedure, but they are not the highest priority. The client was likely experiencing chronic pain prior to the surgery, and it probably contributed to the need for the procedure.

Question 19

The nurse is planning care for a client with acute back pain who is a single mother of two small children and works part-time as a receptionist. Based on this information, which nursing intervention is the highest priority? A) Instructing the client in appropriate body mechanics for lifting and ways to modify her work environment B) Suggesting that the client take time off from work until her back is healed C) Obtaining an order for nonsteroidal anti-inflammatory drugs (NSAIDs) from the client’s healthcare provider D) Suggesting that the client’s children be taken care of by an extended family member until the client’s back is healed

Answer 19

Answer: A Rationale: The client is at risk for Ineffective Health Management, given that she has two small children who need care and a part-time job that is sedentary. To help the client better manage her health, the nurse should provide instruction on appropriate body mechanics for lifting and ways to modify her work environment. The client may or may not be prescribed NSAIDs. Suggesting that the client take time off from work or have extended family members care for her children may or may not be appropriate and should not be included in the plan of care.

Question 20

The nurse is planning care for a client who is 1 day postoperative after spinal fusion surgery. Which of the following is an appropriate outcome for this client? A) The client will remain in prone position. B) The client will maintain urine output at 20 mL per hour. C) The client will use the incentive spirometer every 2 hours. D) The client will void 12 hours after surgery.

Answer 20

Answer: C Rationale: An appropriate outcome for this client is the use of an incentive spirometer every 2 hours. The client is not expected to remain in a prone position, urine output should be at least 30 mL per hour, and the client should void within 8 hours of surgery.

Question 21

The nurse is documenting the interdisciplinary team report on an adolescent client who has a 35-degree Cobb angle confirmed by x-ray. What interventions should the nurse anticipate being included in the collaborative plan of care for this client? Select all that apply. A) Obtaining a physical therapy consult prior to surgical intervention B) Maintaining the existing curvature with no increase C) Bracing for 12-23 hours per day and providing a support group referral D) Administering nonopioid analgesics and a TLSO or Milwaukee brace E) Instructing the client on exercises and appropriate support groups

Answer 21

Answer: C, D, E Rationale: Treatment of children with a Cobb angle between 25 and 45 degrees consists of bracing for 12-23 hours per day with a TLSO or Milwaukee brace, mild pain medication, counseling or support group referral, and exercise to improve posture and maintain or increase spine flexibility. Mild scoliosis requires observation every 3-6 months. Severe scoliosis requires surgical intervention and subsequent physical therapy.

Question 22

The nurse is planning care for the client with chronic pain from herniated intervertebral discs who is also experiencing constipation. Which intervention should the nurse carry out to address constipation? A) Restrict foods high in fiber. B) Avoid the use of stool softeners. C) Encourage fluid intake of 2500-3000 mL each day. D) Medicate for pain around the clock.

Answer 22

Answer: C Rationale: A client with a herniated intervertebral disc could have problems with constipation because of reduced mobility. Interventions to alleviate and prevent constipation include encouraging fluid intake of 2500-3000 mL each day, encouraging foods high in fiber, and administering stool softeners to clients who cannot tolerate a high-fiber diet. Medicating for pain around the clock should be avoided if possible, because most pain medications have constipation as a side effect.

Question 23

Which region of the spine is the most common location of herniated discs? A) Cervical region B) Thoracic region C) Lumbar region D) Sacral region

Answer 23

Answer: C Rationale: The most common location of herniated discs is the lumbar region (L4-L5 and L5-S1), followed by the cervical region (C5-C6 and C6-C7).

Question 24

On the first postoperative day after spinal fusion, the nurse assesses a client and notes the following vital signs: T 39.2°C, BP 100/50 mmHg, HR 118, and RR 23. Drainage at the client’s incision site is clear and tests positive for glucose. Which assessment parameter indicates the highest risk for surgical wound infection? A) Temperature B) Incisional drainage positive for glucose C) Heart rate 118 bpm D) Presence of incisional drainage

Answer 24

Answer: B Rationale: Incisional drainage isn’t necessarily problematic; however, the presence of glucose in this drainage is indicative of cerebrospinal fluid (CSF). A CSF leak increases the risk of infection of the surgical site and meninges. Temperature above 38°C is a fever. Fever may be a sign of infection anywhere in the body, not just at the surgical wound site. Similarly, the client’s heart rate could be elevated for numerous reasons.

Question 25

The mother of a preadolescent client meets with the school nurse to discuss the client's recent diagnosis of scoliosis. Which interventions would be appropriate for the nursing diagnosis of Disturbed Body Image related to deformity and brace? Select all that apply. A) Including the student and family in a meeting to elicit her feelings about scoliosis and wearing a brace B) Offering to arrange a meeting for the student with an 8th grader who has scoliosis C) Encouraging the student and family to register for home schooling to minimize the risk of ridicule D) Teaching the student and family about clothing that will hide the brace E) Suggesting that the pediatrician prescribe an anti-anxiety agent for the student

Answer 25

Answer: A, B, D Rationale: In this scenario, important interventions related to a diagnosis of Disturbed Body Image include attentive listening, offering a support group or person, and teaching the student and family about clothes that will hide the brace. Avoiding other children and community encounters will increase the client's risk of social isolation. There is not enough information to indicate a problem that requires pharmacologic management.

Question 26

During a home care visit, an older adult client begins to cry softly when asked about coping with back pain. The client states, "My back hurts bad all the time. I am so confused about all these tests and scared that the doctor wants me to have surgery." In this scenario, which of the following nursing interventions is the highest priority? A) Asking the client to rate the pain on a scale of 0 to 10 B) Explaining potential procedures in a way the client will understand C) Administering all pain medication as ordered D) Attentively listening to the client's thoughts and fears

Answer 26

Answer: D Rationale: The priority nursing intervention for a client who is ready to disclose emotions is to attentively listen to the client's thoughts and fears. If the nurse is asking about coping, a general back pain assessment and medication administration has already likely been completed. Explaining potential procedures will be done after the assessment is complete and the plan of care is set in place.

Question 27

An adolescent client with scoliosis has a Cobb angle of 32 degrees. Given this information, what treatment will the nurse likely need to prepare the client for? A) This client will not need specific treatment. B) The nurse will prepare the client for physical therapy. C) The nurse will prepare the client for wearing a brace. D) The nurse will prepare the client for undergoing spinal fusion surgery.

Answer 27

Answer: C Rationale: Typically, clients with Cobb angles less than 15 degrees do not require treatment. Clients with Cobb angles of 15 to 25 degrees are treated conservatively with physical therapy, whereas clients with Cobb angles between 25 and 40 degrees are advised to wear a corrective brace. For clients with Cobb angles in excess of 40 degrees, spinal fusion surgery is the most effective option.

Question 28

Which condition or symptom is most common in clients with a herniated cervical disc? A) Sciatica B) Stiff neck and shoulder pain C) Changes in knee and ankle reflexes D) Cauda equina syndrome

Answer 28

Answer: B Rationale: Sciatica, cauda equina syndrome, and changes in knee and ankle reflexes are all symptoms associated with lumbar disc herniation. Herniation of the cervical discs is more commonly associated with numbness, tingling, muscle spasms, and weakness in the upper body, as well as stiff neck and shoulder pain that radiates to the arms and fingers.

Question 29

A client sustained multiple fractures in a motor vehicle crash. Of the various fracture types sustained by the client, which places the client at highest risk for osteomyelitis? A) Avulsion fracture B) Open fracture C) Comminuted fracture D) Depression fracture

Answer 29

Answer: B Ratioanle: The risk for osteomyelitis, or bone infection, is highest with an open fracture, in which the bone breaks through the skin. Comminuted, avulsion, and depression fractures are closed from the environment and present a lower risk of infection.

Question 30

The nurse is caring for clients in an assisted living facility. Which resident would the nurse identify as being at the highest risk for the development of fractures from a fall? A) A resident who participates in resistance training exercises three times a week and takes a calcium supplement B) A resident who hikes in the woods once a week and smokes 14 cigarettes per day C) A resident who line dances twice per week and has a glass of wine with dinner D) A resident who teaches yoga four times per week and is lactose intolerant

Answer 30

Answer: B Rationale: Among older adult clients, smoking is the highest-risk behavior. Although exercise helps prevent fractures, hiking on an uneven surface can be a risk. Resistance training, line dancing, yoga, and taking a calcium supplement all decrease the risk of fracture with a fall. Consuming one glass of wine each day is not a risk factor for fractures from a fall. Lactose intolerance can lower calcium intake, although there are other sources of dietary or supplemental calcium that lactose-intolerant clients can use to reduce their fracture risk.

Question 31

The nurse is teaching an older adult client and caregiver about appropriate ways to decrease the client's risk for falls. Which interventions are appropriate for the nurse to include in this teaching session? Select all that apply. A) Start walking for exercise several times per week. B) Wear sensible shoes with good support when shopping. C) Wear socks when walking in the kitchen. D) Encourage the use of throw rugs throughout the home. E) Make sure hallways and stairways have adequate lighting, even at night.

Answer 31

Answer: A, B, E Rationale: Interventions that are appropriate to decrease this client's risk for falls include wearing sensible shoes with good support when shopping and making sure hallways and stairways have adequate lighting, even at night. A mild to moderate exercise program is also beneficial, as it helps improve balance and strength, thus reducing the likelihood of falls. Nonslip footwear should be encouraged. Throw rugs should be discouraged.

Question 32

A nurse is teaching a mother warning signs and symptoms to watch for in her child, who will be discharged with a full leg cast. Which statements by the mother indicate the need for further instruction? Select all that apply. A) "If her foot turns white and cold, I should call the physical therapist." B) "I can expect that my child will have some pain, but the medicine should help." C) "We can use a blow dryer on warm to help with the itching that my child will experience." D) "We can cut a hole in the cast if my child's foot swells until we get to the doctor's office." E) "It is okay if the plaster cast gets damp as long as I blow dry it."

Answer 32

Answer: A, C, D, E Rationale: The only option that indicates appropriate understanding of cast care is the mother's statement that her child may have pain that will be relieved by medication. All of the other statements indicate a need for further instruction. If the child's foot turns white and cold, the family should contact the physician. Itching may be helped by use of a blow dryer on the cool setting. Holes should not be cut in the cast, and the plaster should stay dry at all times.

Question 33

The x-ray of a client 14 weeks post-ulnar fracture exhibits no callus formation. Based on this data, which collaborative intervention should the nurse anticipate? A) The physical therapist will set up Buck traction. B) The surgeon will schedule a consultation with the client. C) The pharmacist will educate the client on antibiotics. D) The nurse will counsel the client on starting range-of-motion exercise.

Answer 33

Answer: B Rationale: An ulnar fracture that does not show callus formation after 14 weeks would be classified as experiencing nonunion. Nonunions frequently require surgical correction. Buck traction, antibiotics, and exercise are not indicated for nonunion of a fracture.

Question 34

The nurse is providing care for a client who experienced a fracture requiring a plaster cast. Which nursing intervention is appropriate for this client? A) Prescribing opioid pain medication B) Assessing the client's neurovascular status C) Discouraging client ambulation D) Encouraging the client to keep the cast damp

Answer 34

Answer: B Rationale: It is appropriate for the nurse to assess the client's neurovascular status to monitor for compartment syndrome related to the fracture. The nurse can administer an opioid pain medication but cannot prescribe one. The nurse should encourage the client to ambulate and to keep the plaster cast dry.

Question 35

The nurse in an orthopedic outpatient clinic expects to see several clients with fractures for follow-up. Based on the information provided below, which of the nurse's clients is at highest risk for a delayed union? A) A 20-year-old college student with type I diabetes mellitus who sustained a fractured tibia in a bicycle accident. The nutrition recall tool completed during the client's last visit was consistent with American Diabetic Association (ADA) guidelines. B) A 62-year-old bartender with a history of peptic ulcer disease who sustained a fractured clavicle breaking up a fight at work. During his prior visit, the client stated he was upset that his injury required him to abstain from upper body resistance training. C) A 49-year-old teacher with osteoporosis who sustained an open ulnar fracture in a motor vehicle crash. At her last visit, the client reported that she had cut down smoking to 10 cigarettes per day. D) A 55-year-old accountant who sustained fractures to the 4th and 5th right metatarsals. The client has a history of hypertension that is well controlled with medication.

Answer 35

Answer: C Rationale: Evaluating the risk of delayed union requires knowledge of the factors that impact bone healing. The client at greatest risk of delayed union has two factors that decrease the likelihood of proper healing: an open fracture and osteoporosis. This client also uses tobacco, which decreases blood supply to the healing bone. Although diabetes does increase the risk of delayed union, this client is young and exercised on a bicycle prior to the crash. If the client is following an ADA diet, there is adequate intake of vitamin D and calcium, which fosters bone healing. Neither peptic ulcer disease nor controlled hypertension are risks for delayed bone healing.

Question 36

A client hospitalized with an open reduction and internal fixation of a fractured femur reports right calf pain. The nurse notes that the client's right calf is 3.5 cm larger than the left calf with generalized posterior erythema. The right calf is tender to touch, and the dorsalis pedis pulse is 3/4+ bilaterally. Which of the following is the priority action by the nurse? A) Use a Doppler stethoscope to confirm pedal pulses. B) Notify the healthcare provider of the findings. C) Prepare to apply a cast to the right leg. D) Prepare to administer intravenous heparin.

Answer 36

Answer: B Rationale: These findings indicate possible deep vein thrombosis (DVT). The nurse's first action upon assessing these signs and symptoms should be to notify the healthcare provider immediately. If a pedal pulse can be palpated, then a Doppler stethoscope is not needed; however, a Doppler ultrasound test may be ordered by the provider. A cast is not indicated with internal fixation. Intravenous heparin will likely be ordered after the condition is confirmed by the provider.

Question 37

A client who is hospitalized after a left hip fracture is scheduled for surgery late this afternoon. After receiving report, the nurse evaluates the Buck traction applied by a new physical therapist. Which finding would indicate that the traction is correctly applied? A) A foam boot covers the right lower leg from the knee down. B) Twenty-pound weights are connected to the bottom of a foam boot. C) Weights are supported by a stool at the end of the bed. D) The left knee and hip are in alignment above a foam boot.

Answer 37

Answer: D Rationale: The correct placement of Buck traction permits the client's left knee and hip to align. Because Buck traction is a type of skin traction, it does not involve heavy weights; usually, 5-pound weights are used. The weights always hang free from a pulley and are never supported by a stool at the end of the bed. Also, a foam boot covers the affected leg—in this case, the left leg, not the right.

Question 38

During which phase of the fracture healing process is woven bone replaced by lamellar bone? A) Reactive phase B) Reparative phase C) Remodeling phase D) Inflammatory phase

Answer 38

Answer: C Rationale: In the reactive or inflammatory phase of fracture healing, a hematoma forms around the injury. Inflammatory cells then enter the wound and degrade debris and bacteria in the area. Next, in the reparative phase, fibroblasts, osteoblasts, and chondroblasts begin to secrete collagen to form fibrocartilage, which develops into a soft callus that joins the fractured bone. Once the soft callus is formed, it is replaced by woven bone through endochondral ossification, which forms a hard callus. Finally, during the remodeling phase, woven bone is replaced by highly organized lamellar bone.

Question 39

Which of the following fractures presents the greatest risk for development of fat embolism syndrome? A) Open fracture of the fibula B) Closed fracture of the femur C) Open fracture of the humerus D) Closed fracture of the clavicle

Answer 39

Answer: B Rationale: Fat embolism syndrome may occur in conjunction with closed fractures of the long bones or pelvis. Of the closed fractures listed here, only the fracture of the femur involves a long bone, so this is the injury that presents the greatest risk for development of fat embolism syndrome.

Question 40

The nurse is presenting a program at a senior center on how to survive a fall. Which statement by a program participant indicates that this person needs clarification about what emergency actions to take after a fall? A) "I should crawl to a phone on the affected side to keep it stable against a hard surface." B) "I should try to cover myself with a blanket while I wait for help to arrive." C) "To call for help, I can scoot on my bottom to a low wall-mounted phone." D) "If possible, I can crawl to a stairway and use the stairs to lift up to a standing position."

Answer 40

Answer: A Rationale: Clients at risk for falls and hip fractures should be taught how to notify emergency services in the event of a fall and injury. These clients should be instructed to turn onto the stomach and crawl to the phone, or to scoot to the phone using the buttocks on the uninjured side. And another option is to crawl to a stairway and use the stairs to gradually lift the body to a standing position. While waiting for help to arrive, clients should cover themselves with a blanket if possible to help prevent shock.

Question 41

The nurse is assessing an older adult client in a long-term care facility after a fall. Which finding requires priority action? A) The injured leg is shortened and externally rotated. B) Redness and severe swelling are found at the hip joint. C) Pain is relieved by moving the affected extremity. D) The client is repeatedly flexing the injured leg at the hip.

Answer 41

Answer: A Rationale: The client with a fractured hip is often in extreme pain and assumes a position with the leg on the affected side shortened and externally rotated because of gravity and the pull of the muscles. Any movement of the leg on the side of the affected hip is likely to cause severe muscle spasms and further pain. Redness and swelling are the classic signs of inflammation not immediately present after hip fracture. Extreme pain associated with hip fracture prevents any voluntary movement in the leg.

Question 42

A postmenopausal client asks the nurse what she can do to prevent fracturing her hips, as her mother and grandmother both experienced this health problem. Which response by the nurse is most appropriate? A) "You should avoid all types of exercise." B) "You should consider a smoking cessation program." C) "You should limit your exposure to the sun." D) "You should use throw rugs throughout your home."

Answer 42

Answer: B Rationale: One modifiable risk factor for hip fractures is smoking. Women who smoke have a greater risk of fracture because smoking reduces bone density in menopausal and postmenopausal women. The client should not be instructed to avoid exercise; exercise will enhance the client's gait, balance, and musculoskeletal strength. Limiting sun exposure will not impact the client's risk of experiencing a hip fracture. The nurse should not instruct the client to use throw rugs throughout the home because this could cause tripping, leading to a fall.

Question 43

The first day after surgery to repair a fractured hip sustained from a fall, an older adult client refuses to ambulate but states, "I will consider it tomorrow." In this situation, which is the priority action by the nurse? A) Coordinate personnel to assist with ambulation B) Document the client's refusal C) Assess why the client is refusing to ambulate D) Notify the healthcare provider

Answer 43

Answer: C Rationale: The first thing the nurse should do is assess why the client is refusing to ambulate. The client might be fearful of falling, given that a prior fall resulted in a fractured hip. Following this assessment, the nurse could plan interventions that would facilitate ambulation, such as controlling pain and reducing the fear of falling. It is premature to notify the healthcare provider. The nurse should not force the client to get out of bed. Documenting the client's refusal is appropriate, but after determining the reason for the refusal.

Question 44

A client with a BMI of 35 is recovering from total hip replacement surgery and experiencing pain that is exacerbated with movement. The client says to the nurse, "I live alone. How will I ever be able to return to my home?" Based on this information, which is the priority nursing diagnosis for this client? A) Overweight B) Acute Pain C) Impaired Physical Mobility D) Ineffective Coping

Answer 44

Answer: B Rationale: The priority nursing diagnosis is Acute Pain. Unless this pain is controlled, the client will not be able to participate in interventions to address the nursing diagnosis of Impaired Physical Mobility. The diagnoses of Ineffective Coping and Overweight can be addressed after Acute Pain and Impaired Physical Mobility have been addressed.

Question 45

The nurse is providing discharge instructions to an older adult client who is recovering from a fractured hip. The client is planning to stay with an adult child, who is included in the discharge teaching. Which statements on the part of the client indicate appropriate understanding of the information presented by the nurse? Select all that apply. A) "I have signed a contract with Lifeline." B) "We are removing the area rugs in the hallway." C) "I've borrowed a toilet seat riser from the equipment closet." D) "I will be sure to take oxycodone before I go downstairs in the morning." E) "I can help with housework while I'm staying at my child's house."

Answer 45

Answer: A, B, C Rationale: Statements regarding the use of an emergency alert service and a toilet seat riser indicate appropriate understanding of the information presented. Picking up loose area rugs can help decrease the risk of falls. Pain medication should not be taken when there is a risk of a fall, particularly prior to going down a set of stairs. The nurse should assess the housework that the client wants to help with while living with the adult child. Many housework tasks will be inappropriate.

Question 46

The nurse is evaluating care provided to a client recovering from hip replacement surgery. Which piece of documentation in the medical record indicates that the client has achieved the expected outcome for pain management? A) The client states pain is a 6 on a numeric pain scale of 0 to 10 prior to evening care. B) The client is crying and requesting pain medication prior to morning care. C) The client is using a PCA pump around the clock and rates pain as a 2 on a numeric pain scale of 0 to 10. D) The client refuses pain medication prior to physical therapy. Pain is rated as a 7 on a numeric pain scale of 0 to 10.

Answer 46

Answer: C Rationale: Expected outcomes for pain management following hip replacement surgery are to minimize pain to a client rating of 3 or lower via medication administration, including use of patient-controlled analgesia (PCA) as appropriate. Completely eliminating pain is an unrealistic goal. Thus, only the client who is using the PCA pump and has a pain rating of 2 on a 0-to-10 scale has achieved an expected outcome for pain management.

Question 47

An older adult client experiences a hip fracture. Prior to the injury, the client had an active lifestyle. Based on this information, which surgical procedure should the nurse anticipate? A) Total hip replacement B) Open reduction and external fixation C) Arthroplasty D) Open reduction and internal fixation

Answer 47

Answer: D Rationale: Open reduction and internal fixation is the preferred surgical procedure to repair a fractured hip for older adult clients who are active and will be able to use crutches with partial weight bearing following surgery. A total hip replacement, also called arthroplasty, is generally performed only when severe arthritis or an underlying bone condition is present, which does not appear to be the case given this client's activity level prior to the injury. Open reduction and external fixation is not a surgical option for a fractured hip.

Question 48

A client is recovering from surgery to repair a fractured hip. Which actions by the nurse may reduce this client's risk for osteomyelitis in the postoperative period? Select all that apply. A) Assess for pain every 1-2 hours. B) Use sterile technique for dressing changes. C) Assess wound for size, color, and drainage. D) Administer antibiotics as prescribed. E) Administer anticoagulants as prescribed.

Answer 48

Answer: B, C, D Rationale: Interventions that can reduce the client's risk for infection include using sterile technique for dressing changes; assessing the wound for size, color, and drainage; and administering antibiotics as prescribed. Assessing for pain every 1-2 hours is appropriate for the nursing diagnosis of Acute Pain, but it does not help reduce the risk of osteomyelitis. Administering anticoagulants per order is appropriate for the client who is at risk for deep vein thrombosis (DVT), but again, it does not help reduce the risk of osteomyelitis.

Question 49

A client is undergoing surgery for a fractured hip. The surgeon has stated that careful attention will be paid to preserving the epiphyseal plate. Which client will require this precaution during surgery? A) A postmenopausal woman with paraplegia B) A 32-year-old man who is a competitive body builder C) A prepubescent girl who is a vegetarian D) An 85-year-old woman with osteoporosis

Answer 49

Answer: C Rationale: Epiphyseal plates are unique joints that produce growth of bone length in children. There is an epiphyseal plate that lies between the head and neck of the femur that must be preserved during hip surgery in pediatric clients to prevent obstruction of bone growth. Of the clients listed here, only the prepubescent girl is young enough to have an epiphyseal plate. All of the other clients are older than 18-25 years of age, when the epiphyseal plate closes.

Question 50

The nurse gives discharge instructions to an adult client who sustained a bicycle fall and underwent open reduction and internal fixation of a fractured hip. After the teaching is complete, which statements by the client indicate appropriate understanding of the information presented? Select all that apply. A) "I will use my abduction pillow while sleeping to maintain proper hip alignment." B) "I will use a high toilet seat to prevent excess flexion of my hip." C) "I only need to use my walker during physical therapy appointments." D) "I will take my prescribed ibuprofen to decrease the risk for deep vein thrombosis." E) "I might experience bruising because of the warfarin I've been prescribed."

Answer 50

Answer: A, B, E Rationale: Statements regarding use of an abduction pillow to maintain proper hip alignment; use of a high toilet seat to prevent excess flexion of the hip; and awareness that warfarin presents an increased risk for bruising all indicate client adequate understanding. The nurse should remind the client to use the walker at all times until told otherwise. The nurse should also explain that warfarin, not ibuprofen, is prescribed to decrease the risk for deep vein thrombosis.

Question 51

A hip fracture that occurs in the trochanter region would be classified as a(n) A) intracapsular fracture. B) intercapsular fracture. C) extracapsular fracture. D) subcapsular fracture.

Answer 51

Answer: C Rationale: Hip fractures are broadly classified as either intracapsular or extracapsular. Intracapsular hip fractures occur at the head or neck of the femur within the capsule of the hip joint. Extracapsular hip fractures occur within the trochanter region, which is between the neck and diaphysis of the femur. Extracapsular fractures can be further divided into intertrochanteric or subtrochanteric. The terms intercapsular and subcapsular are not used to describe fractures of the hip.

Question 52

For non-elderly adult clients who fracture a hip, why is internal fixation or casting of the fracture generally preferred over hip replacement? A) Internal fixation or casting is preferred because it does not disturb the client's epiphyseal plate. B) Internal fixation or casting is preferred because of the lower risk of deep vein thrombosis. C) Internal fixation or casting is preferred because of the shorter recovery time. D) Internal fixation or casting is preferred because of the limited longevity of hip prostheses.

Answer 52

Answer: D Rationale: Non-elderly adults are likely to live beyond the decade or so anticipated lifespan of a replacement hip. Internal fixation and casting are the preferred treatment methods for these clients because hip replacement may eventually necessitate revision surgery, which carries a greater level of risk than the initial hip replacement surgery. Protection of the epiphyseal plate is not a concern in adult clients, because they no longer have epiphyseal plates. Internal fixation, casting, and hip replacement all carry a similar risk of deep vein thrombosis, and none of these methods offers a definitive benefit in terms of recovery time.

Question 53

A client diagnosed with multiple sclerosis has an acute onset of visual changes, fatigue, and leg weakness. The client states that the last time this happened, she recovered in a few weeks. Which classification of multiple sclerosis is the client experiencing? A) Progressive-relapsing B) Secondary-progressive C) Relapsing-remitting D) Primary-progressive

Answer 53

Answer: C Rationale: There are four classifications of multiple sclerosis (MS). This client is affected by relapsing-remitting MS, which is characterized by clearly defined flare-ups with worsening neurological function followed by periods of partial or complete remission with few or no symptoms. In comparison, primary-progressive MS involves slow but nearly continuous worsening of the disease from the time of onset with no distinct remissions; secondary-progressive MS begins as relapsing-remitting but becomes worse between exacerbations; and progressive-relapsing MS involves a steady worsening of disease with acute relapses.

Question 54

A young adult client complains of blurred vision and muscle spasms that have come and gone over the past several months. The physician suspects that the client has multiple sclerosis. What in the client's history would the nurse recognize as a risk factor for MS? A) The client is a male. B) The client is of Native American descent. C) The client is of European descent. D) The client takes a vitamin D supplement daily.

Answer 54

Answer: C Rationale: Risk factors for MS include being female, having a European ancestry, and being between the ages of 20 and 40. Smoking also increases the risk for MS, but taking a vitamin D supplement may decrease the risk.

Question 55

A client with a history of relapsing-remitting multiple sclerosis (MS) is expecting her first child. Which of the following nursing interventions would be indicated for this client? A) Suggest the client seek reproductive counseling. B) Tell the client to expect a period of remission after delivery. C) Instruct the client to expect an exacerbation of symptoms while pregnant. D) Discuss the client's options for pain control during labor, as her contractions will be especially severe.

Answer 55

Answer: A Rationale: A definite genetic cause of MS has not been established; however, studies suggest that genetic factors make some individuals more susceptible to the disorder than others. Also, some medications used in the treatment of MS can be harmful to a fetus. Thus, reproductive counseling would be recommended for this client. Pregnancy often brings about remission (not exacerbation) of MS, and there is a slightly increased relapse rate postpartum. The strength of uterine contractions in a client with MS is not severe, and because clients often have lessened sensation, labor may be almost painless.

Question 56

A client with relapsing-remitting multiple sclerosis (MS) tells the nurse that even though her primary symptoms of exacerbation are leg spasms and blurred vision, her greatest struggle is getting through the day because she is always tired. Which diagnosis should the nurse identify as a priority for this client? A) Fatigue B) Disturbed Sensory Perception C) Impaired Physical Mobility D) Self-Care Deficit

Answer 56

Answer: A Rationale: The client states that the worst part of her disease exacerbations is being tired, even though leg spasms and blurred vision are present. Therefore, the nurse should identify the diagnosis of Fatigue as a priority for this client. The diagnoses of Impaired Physical Mobility because of the leg spasms and Disturbed Sensory Perception because of the blurred vision are additional nursing diagnoses applicable for this client, but they are not the priority based on the client's statement. The client may or may not have a Self-Care Deficit.

Question 57

The nurse is caring for a client admitted with an exacerbation of multiple sclerosis (MS). The client is demonstrating frustration with eating because he is experiencing hand and arm spasms that prevent the proper use of utensils. Which intervention should the nurse implement to best assist this client? A) Consult with the occupational therapist regarding assistive devices for meals. B) Counsel the client to select finger foods for meals. C) Plan time to feed the client. D) Consult with the physical therapist regarding hand and arm exercises.

Answer 57

Answer: A Rationale: Because the ability to feed oneself is essential to positive self-concept and self-esteem, the nurse should consult with the occupational therapist regarding devices the client can use to maintain independence at mealtimes. The nurse should not counsel the client to select finger foods for meals, nor should the nurse feed the client. Neither of these actions would support the client's self-concept and self-esteem needs. The nurse might consult the physical therapist regarding hand splints, but hand and arm exercises might not be beneficial for this client.

Question 58

) A client with multiple sclerosis (MS) is observed transferring from the bed to a motorized wheelchair and applying splints to the lower extremities before entering the bathroom to perform morning self-care. What could the nurse conclude regarding this observation? A) The client uses assistive devices to optimize autonomy. B) The client should be instructed to conduct morning care before applying splints to the lower extremities. C) The client is dependent on assistive devices. D) The client should be advised to avoid use of a motorized wheelchair when possible.

Answer 58

Answer: A Rationale: The nurse observed the client independently transfer from the bed to a motorized wheelchair, apply splints, and enter the bathroom to perform morning self-care. This is evidence that the client uses assistive devices to optimize autonomy. The nurse should not conclude that the client is dependent on assistive devices, because this conclusion suggests that the client is not autonomous. Similarly, the nurse should not conclude that the client requires instruction regarding wheelchair avoidance or when to apply splints, because this conclusion does not take the client's preferences into consideration.

Question 59

A client with multiple sclerosis is prescribed diazepam (Valium). What assessment finding indicates that this medication is effective for the client? A) Muscle spasticity is reduced. B) Blood glucose level is within normal limits. C) The client states that muscles are weak. D) Ophthalmologic examination shows no evidence of cataracts.

Answer 59

Answer: A Rationale: Diazepam (Valium) is a muscle relaxant commonly used for clients with multiple sclerosis. It does not cause muscle weakness. Evidence of medication effectiveness would be an observed reduction in muscle spasticity. Glucose intolerance would be assessed if the client were prescribed an adrenal corticosteroid. Cataract development is also a side effect of adrenal corticosteroids.

Question 60

The nurse is planning care for a client with multiple sclerosis. Which intervention would address the nursing diagnosis of Fatigue? A) Encourage increased activity. B) Schedule physical therapy three times a day. C) Plan activities with sufficient rest periods between them. D) Group activities together so care will not be interrupted.

Answer 60

Answer: C Rationale: Interventions to address the diagnosis of Fatigue include assessing the client's level of fatigue, arranging activities to include rest periods between them, and assisting the client in setting priorities regarding activities. Activities should not be grouped together. Increased activity will not help the client with fatigue. Physical therapy three times a day may be too aggressive for this client.

Question 61

The nurse is caring for several clients from various cultural backgrounds. Which client would the nurse assess as having the highest risk for multiple sclerosis? A) A Brazilian woman with chronic parasitic infestation B) A Hispanic man with colonized methicillin-resistant Staphylococcus aureus (MRSA) C) A Northern Canadian woman who has smoked for 25 years D) An African man in his 20s who has a vitamin D deficiency

Answer 61

Answer: C Rationale: The Northern Canadian woman who smokes has three risk factors for MS: female gender, living farthest from the equator, and smoking. Factors that lower the risk of MS include living closer to the equator (as is the case for the Brazilian and Hispanic clients), having a lowered immune response (as is the case for the client with chronic parasitic infestation), and being male.

Question 62

An adult client recently diagnosed with multiple sclerosis (MS) reports engaging in vigorous exercise on a regular basis. Which statements contain the correct information to give this client when answering specific questions about lifestyle? Select all that apply. A) "Hyperbaric oxygen treatment is recommended prior to vigorous physical exercise." B) "You will tolerate exercise better in an air-conditioned room." C) "Acupuncture may benefit some of your symptoms." D) "Drinking cold water is recommended during exercise." E) "You will be able to maintain your current exercise schedule."

Answer 62

Answer: B, C, D Rationale: Symptoms of MS are exacerbated by increased body temperature. Exercising in a cold room and drinking cold beverages help keep body temperature down. Acupuncture has low risk and may be beneficial for some symptoms of MS. Hyperbaric oxygen therapy carries more risk than benefit. Also, it is unlikely that a newly diagnosed client with MS will be able to tolerate regular vigorous exercise.

Question 63

During an outpatient clinic follow-up appointment, a client with multiple sclerosis (MS) has lab tests completed. The results show elevated levels of aspartate aminotransferase (AST), serum glutamic-oxaloacetic transaminase (SGOT), alanine aminotransferase (ALT), serum glutamic-pyruvic transaminase (SGPT), and alkaline phosphatase (ALP). The nurse recognizes that these elevated enzyme levels are a potential adverse effect of which medications? Select all that apply. A) Interferon beta-1a (Avonex) B) Teriflunomide (Aubagio) C) Glatiramer acetate (Copaxone) D) Mitoxantrone (Novantrone) E) Fingolimod (Gilenya)

Answer 63

Answer: A, B Rationale: AST, SGOT, ALT, SGPT, and ALP are liver enzymes that are monitored to detect adverse responses to the medications interferon beta-1a (Avonex) and teriflunomide (Aubagio). Glatiramer acetate (Copaxone), mitoxantrone (Novantrone), and fingolimod (Gilenya) are used to treat MS but do not typically cause liver damage.

Question 64

A nurse is teaching the parents of a client who was recently diagnosed with multiple sclerosis (MS) about what to expect as their child's condition progresses. Which statement by the parents indicates the need for further instruction? A) "My child is at increased risk for seizures because of the MS diagnosis." B) "It's not unusual for kids with MS to have problems with their schoolwork." C) "MS usually progresses faster in children than in adults." D) "Making friends may be more difficult for our child because of the MS."

Answer 64

Answer: C Rationale: Children with MS often experience seizures related to their diagnosis, and they may suffer from reduced academic performance and difficulty in family and peer relationships. However, MS usually progresses more slowly in children than in adults. Thus, the parents' statement about the speed of disease progression indicates the need for further instruction.

Question 65

Which category of multiple sclerosis (MS) is characterized by a slow but nearly continuous worsening of the disease from the time of onset with no distinct remissions? A) Relapsing-remitting B) Progressive-relapsing C) Primary-progressive D) Secondary-progressive

Answer 65

Answer: C Rationale: There are four classifications of multiple sclerosis (MS). Relapsing-remitting MS is characterized by clearly defined flare-ups with worsening neurological function followed by periods of partial or complete remission with few or no symptoms. Primary-progressive MS involves slow but nearly continuous worsening of the disease from the time of onset with no distinct remissions. Secondary-progressive MS begins as relapsing-remitting but becomes worse between exacerbations. Progressive-relapsing MS involves a steady worsening of disease with acute relapses.

Question 66

Which of the following would be classified as a secondary symptom of multiple sclerosis (MS)? A) Pressure sores B) Urinary retention C) Depression D) Unsteady gait

Answer 66

Answer: A Rationale: Secondary symptoms of MS result from chronic primary symptoms of the disease. Because pressure sores result from primary symptoms such as muscle weakness and inability to ambulate, they would be considered a secondary symptom. In comparison, both urinary retention and unsteady gait are primary symptoms of MS, whereas depression is a tertiary symptom (because it involves a psychosocial problem).

Question 67

A client with multiple sclerosis (MS) is said to be experiencing an exacerbation when he or she experiences symptoms that: A) last at least 1 week and are separated from a previous attack by at least 30 days. B) last at least 24 hours and are separated from a previous attack by at least 30 days. C) last at least 2 weeks and are separated from a previous attack by at least 2 months. D) last at least 30 days and are separated from a previous attack by at least 2 months.

Answer 67

Answer: B Rationale: Clients with MS who are suffering from an exacerbation may experience one or more symptoms that last from days to months, and symptoms can be different during distinct exacerbations. A true exacerbation must last at least 24 hours and must be separated from the previous attack by at least 30 days.

Question 68

Which of the following medications is used to treat tertiary symptoms of multiple sclerosis (MS)? A) Bupropion B) Ciprofloxacin C) Magnesium hydroxide D) Glatiramer acetate

Answer 68

Answer: A Rationale: Tertiary symptoms of MS relate to psychosocial problems, such as relationship difficulties, loss of a job because of decreased performance, or hopelessness. Of the medications listed here, only bupropion (an antidepressant) would be used to treat a tertiary symptom (depression). Copaxone would be used to treat the primary symptoms of MS, whereas ciprofloxacin (an antibiotic) and magnesium hydroxide (a laxative) would be used to treat the secondary symptoms of infection and constipation, respectively.

Question 69

The nurse is providing teaching to the client recently diagnosed with osteoarthritis. Which statement by the nurse is correct? A) "Osteoarthritis is most commonly seen in thin, small-built female clients." B) "Osteoarthritis is a result of joint inflammation." C) "Osteoarthritis occurs due to erosion of cartilage in the joints." D) "Osteoarthritis is a metabolic bone disease."

Answer 69

Answer: C Rationale: Osteoarthritis is characterized by progressive erosion of the cartilage within joints. It is not a metabolic bone disease; examples of such diseases include osteoporosis, osteomalacia, and Paget disease. Thin, small-built female clients are at increased risk for osteoporosis, not osteoarthritis. In fact, osteoarthritis is more commonly associated with obesity than with slight build. Finally, joint inflammation is a characteristic of rheumatoid arthritis, not osteoarthritis.

Question 70

The nurse is caring for a client with osteoarthritis. Which factor in the client's history and physical assessment would the nurse recognize as a risk factor for developing this condition? A) Body mass index of 36.5 B) History of esophageal reflux disease C) Client plays tennis three times each week D) Blood pressure of 136/78 mmHg

Answer 70

Answer: A Rationale: Obesity increases the risk of developing osteoarthritis (OA), because the added weight increases stress on weight-bearing joints, causing the joints to wear down more quickly. This client has a body mass index of 36.5, which is considered obese. Moderate recreational exercise (such as tennis three times per week) has been shown to decrease the chance of developing OA and slow the progression of manifestations when OA is present. Esophageal reflux is not associated with OA. Blood pressure is not a known risk factor for the development of OA.

Question 71

An older adult client with bilateral osteoarthritis of the knees tells the nurse, "I know I need to lose weight, but exercising makes my knees ache." What instruction should the nurse provide to this client? A) "You should discuss knee replacement surgery with your physician." B) "Exercising the muscles in your legs might be hard now, but over time, it will help protect your knees." C) "Try eating a reduced-calorie diet for several months before attempting exercise." D) "You need to stretch your muscles, because stretching is the only form of exercise that improves osteoarthritis."

Answer 71

Answer: B Rationale: Encouraging exercise is an important aspect of nursing care for clients with osteoarthritis (OA). Exercise can increase flexibility, improve blood flow, and help clients lose weight. Over time, these factors can help protect the joints against further deterioration and pain. The nurse should not counsel the client to follow a reduced-calorie eating plan for several months before attempting exercise. The client may or may not want to have knee replacement surgery. Stretching is just one type of exercise that will benefit clients with OA. The other components, strengthening and aerobic exercise, can be obtained through walking, swimming, and isometric, isotonic, and resistive exercises.

Question 72

The nurse is planning care for a client with osteoarthritis. Which nursing diagnosis would have the highest priority? A) Fatigue B) Chronic Pain C) Ineffective Coping D) Disturbed Body Image

Answer 72

Answer: B Rationale: When providing care to a client diagnosed with osteoarthritis, priority diagnoses would include Chronic Pain, Impaired Physical Mobility, and Self-Care Deficit. Thus, of the diagnoses identified for this client, Chronic Pain would be the highest priority. Once this diagnosis has been addressed, the nurse and client can focus on the lower priority diagnoses of Fatigue, Ineffective Coping, and Disturbed Body Image.

Question 73

The nurse is planning care for a client with osteoarthritis of the hip. Which intervention would be appropriate for this client? A) Provide moist heat packs to the affected joint 3 times each day. B) Instruct the client on the importance of strict bedrest. C) Provide nonsteroidal anti-inflammatory drugs (NSAIDs) when pain becomes severe. D) Provide opioid pain medication as prescribed.

Answer 73

Answer: A Rationale: Interventions appropriate for a client with osteoarthritis (OA) include NSAIDs, moist heat, active range-of-motion exercises, proper posture and body mechanics, and assistive devices to safely maintain independence with activities of daily living. Opioid medication is not typically prescribed for the treatment of OA. NSAIDs are most effective if taken before the pain is severe. The client should be encouraged to be mobile, not on strict bedrest.

Question 74

The nurse is evaluating care provided to a client with osteoarthritis (OA). Which client statement indicates to the nurse that interventions for OA have been successful? A) "I had to take early retirement and now stay at home all day and rest my legs." B) "I am sleeping throughout the night and have not missed any work because of knee pain." C) "I am moving from my two-story house into the first floor of my daughter's home so I won't have to walk steps anymore." D) "I changed my work hours so now I work part time and have a nursing assistant who helps me bathe twice a week at home."

Answer 74

Answer: B Rationale: Expected outcomes for the care of a client with OA include independence with activities of daily living, minimal lifestyle impact because of OA, and controlled pain that allows for rest and sleep. Of the client statements provided, only the one about improved sleep and pain not interfering with work indicates achievement of these outcomes. A client who changes work hours and has a nursing assistant for bathing is experiencing a reduction in activities of daily living and a significant impact in lifestyle. A client who is moving in with a daughter is experiencing significant lifestyle impact. A client who retires early and stays at home all day is also experiencing a significant impact in lifestyle.

Question 75

A client with osteoarthritis tells the nurse she has difficulty walking to the bathroom first thing in the morning. Which nursing action would assist this client? A) Suggesting a family member provide the client with a bedpan B) Discussing the option of residing in an assisted-living facility C) Consulting with physical therapy for an assistive walking device such as a walker or cane D) Suggesting the client use a bedside commode at home

Answer 75

Answer: C Rationale: Assistive devices are items used to maintain, increase, or improve function. The client describes difficulty walking to the bathroom in the morning. The best intervention to help this client would be to consult with physical therapy for an assistive walking device such as a walker or cane. The use of a bedside commode or bedpan may help with the immediate need to use the bathroom, but the client will still have difficulty ambulating in the morning. The option of residing in an assisted-living facility might be premature for this client.

Question 76

A client with chronic hip pain is diagnosed with osteoarthritis. Which instruction regarding home safety is most appropriate for the nurse to provide to this client? A) Walk up and down the steps at home as much as possible. B) Rest in a recliner. C) Place scatter rugs in high-traffic areas. D) Install grab bars in the bathroom near the commode and in the shower.

Answer 76

Answer: D Rationale: The client should be encouraged to install grab bars in the bathroom near the commode and in the shower. The client should be instructed not to overuse the affected joints with excessive stair climbing. Scatter rugs are a hazard to mobility and should be avoided. The client should also be instructed to sit in a straight-back chair, avoid slumping, and avoid use of a recliner.

Question 77

A client seeking treatment for severe knee pain has worked in a factory for 30 years in a position requiring repetitive lifting and carrying of 20- to 40-pound boxes. Based on the client's history, the nurse should anticipate which initial recommendation from the multidisciplinary healthcare team? A) Joint replacement surgery B) Pharmacologic therapy C) Referral for a disability application D) Intermittent use of a cane

Answer 77

Answer: B Rationale: Of these options, pharmacologic therapy would be the most likely initial intervention. Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and joint injections are all possible options. Joint replacement should be delayed as long as possible because artificial joints often require replacement within 15-20 years. There is not enough information to determine whether applying for disability is appropriate at this time. A cane is not indicated at this time.

Question 78

Lab results are back for a client who has limiting joint pain. Synovial fluid analysis shows no uric acid crystals or bacteria. The client asks what the test results mean. How should the nurse respond? A) "These test results mean that your joint pain is likely not caused by gout or septic arthritis." B) "These test results mean that your joint pain is likely not related to any form of arthritis." C) "These test results mean that your joint pain is likely caused by either rheumatoid arthritis or septic arthritis." D) "These test results mean that your joint pain is likely caused by either cancer of the joint or gout."

Answer 78

Answer: A Rationale: Gout is caused by the collection of uric acid crystals in a joint. The absence of uric acid crystals in the synovial fluid (joint fluid) makes gout unlikely. Septic arthritis is caused by infection, so the absence of bacteria makes sepsis unlikely. However, this test does not rule out osteoarthritis or rheumatoid arthritis, so these are still possible diagnoses. Although the nurse may provide information related to which conditions have been ruled out, providing a medical diagnosis is outside the nurse's scope of practice.

Question 79

A client with osteoarthritis (OA) of the knees and hips returns for a 3-month follow-up visit with the provider. The nurse calculates that the client's body mass index (BMI) is now 22. The client reports starting a water aerobics and running program three times per week. The client is also using hot packs for edema for 20 minutes and cold packs for pain for 40 minutes daily. After evaluating the client's actions, which follow-up interventions should the nurse plan? Select all that apply. A) Reinforce the correct use of hot packs. B) Suggest the client replace running with a lower impact exercise. C) Explain the risk of injury associated with use of cold packs. D) Advise the client to continue weight loss. E) Congratulate the client on starting water aerobics.

Answer 79

Answer: A, B, C, E Rationale: The nurse should congratulate the client on starting water aerobics because it is a low-impact exercise mode. The nurse should also congratulate the client on the weight loss. Note, however, that a BMI of 22 is ideal, so continued weight loss should not be encouraged. The client should be informed that using cold packs for more than 30 minutes may cause skin injury. The nurse should also reinforce that hot packs are used to decrease pain and ice packs are used for edema (swelling). Finally, the nurse should suggest that the client replace the high impact exercise of running with a lower impact exercise such as walking or biking.

Question 80

A nurse is teaching the parents of a client who was recently diagnosed with osteoarthritis (OA) about their child's condition. Which statement by the parents indicates the need for further instruction? A) "Our daughter's OA is likely related to a joint injury she sustained last year." B) "Most kids with OA usually have only one or two affected joints." C) "Because our daughter developed OA as a child, she is more likely to become disabled as a result of this condition." D) "Our daughter may outgrow her OA as she ages."

Answer 80

Answer: C Rationale: Juvenile OA is usually secondary to a congenital abnormality, genetic condition, or joint injury. It typically occurs only in the one or two joints affected by the abnormality or injury. Children with OA are less likely to become disabled and may outgrow the condition as they age. Thus, the parents' statement about an increased likelihood of disability indicates the need for further instruction.

Question 81

Which of the following treatment options would least likely be considered for a 71-year-old client with osteoarthritis (OA)? A) Physical therapy B) Administration of nonsteroidal anti-inflammatory drugs (NSAIDs) C) Weekly tai chi sessions D) Administration of narcotics

Answer 81

Answer: B Rationale: Acetaminophen is a first-line medication for older adults due to its efficacy and safety. Narcotics are a second-line choice, because they are safer than NSAIDs for older adults. Mindfulness exercises and complementary health approaches such as yoga or tai chi may assist older adults in increasing mobility and reducing pain levels. Physical therapy is especially important in older adults to maintain or improve mobility of joint(s).

Question 82

Which of the following procedures used in the treatment of osteoarthritis (OA) involves removing a small amount of bone at the articulating surface of the joint and fitting a metal replacement over the end of the bone? A) Osteotomy B) Arthroplasty C) Arthroscopy D) Joint resurfacing

Answer 82

Answer: D Rationale: In joint resurfacing, a small amount of bone is removed at the articulating surface of the joint and a metal replacement is fitted over the end of the bone. Osteotomy involves surgical removal of a wedge of bone above or below the joint to realign the joint and shift the weight away from the damaged portion of the joint. Arthroscopy entails insertion of a small fiber optic light source, magnifying lens, and camera into the joint to visualize the joint structures. Arthroplasty is total joint replacement, in which a surgeon removes the damaged joint surfaces and replaces them with plastic, metal, or ceramic prostheses.

Question 83

Which of the following terms is used to describe osteoarthritis (OA) that is caused by an underlying condition, such as injury, congenital malformation, or metabolic disease? A) Idiopathic B) Secondary C) Localized D) Generalized

Answer 83

Answer: B Rationale: OA can be classified as either idiopathic or secondary. Idiopathic OA has no identifiable cause. Idiopathic OA can be further divided into localized or generalized, with localized OA affecting one or two joints and generalized OA affecting three or more joints. Secondary OA is caused by an underlying condition, such as injury; congenital malformation; metabolic, endocrine, or neuropathic disease; or other medical cause.

Question 84

Which of the following procedures would be most appropriate to repair a finger joint that is affected by severe osteoarthritis (OA)? A) Osteotomy B) Joint resurfacing C) Joint fusion D) Internal fixation

Answer 84

Answer: C Rationale: Joint fusion is used to permanently fuse two or more bones together at a joint using pins, plates, screws, and rods. It is often recommended for badly damaged smaller joints, such as the spine, wrist, ankle, finger, or toe. Osteotomy is usually performed on the knee and hip and entails surgical removal of a wedge of bone above or below the joint to realign the joint and shift the weight away from the damaged portion of the joint. Joint resurfacing, which involves removing a small amount of bone at the articulating surface of the joint and fitting a metal replacement over the end of the bone, is often performed for hip and shoulder joints. Internal fixation is used to fix fractures, not to address osteoarthritis.

Question 85

Clients with osteoarthritis (OA) can reduce their risk of further joint damage by doing which of the following? A) Applying topical analgesic creams as prescribed B) Avoiding movement of affected joints C) Taking acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) before joint pain becomes severe D) Receiving cortisone injections in affected joints no more than three times per year

Answer 85

Answer: D Rationale: Because frequent use of corticosteroids can cause joint damage, clients should receive cortisone injections in affected weight-bearing joints no more than three or four times per year. Avoiding movement of affected joints does not reduce the risk of joint damage; rather, it worsens the effects of OA. Applying topical analgesics and taking acetaminophen and NSAIDs reduces the pain of OA but does not reduce the risk of further joint damage.

Question 86

A client complains of a right-hand tremor, increasing weakness, and muscles that feel tight. The nurse notes that the client has poor voice volume and facial muscles that do not move easily. The nurse recognizes that these symptoms are consistent with which condition? A) Parkinson disease B) Spinal cord injury C) Cerebrovascular accident D) Multiple sclerosis

Answer 86

Answer: A Rationale: Manifestations of Parkinson disease include unintentional tremor, slowed movements, low amplitude of speech, expressionless face, and muscle rigidity. The client is complaining of or exhibiting all these symptoms, suggesting a diagnosis of Parkinson disease. These symptoms are not manifestations of multiple sclerosis, spinal cord injury, or a cerebrovascular accident.

Question 87

A middle-aged female client states to the nurse, "I have noticed a slight tremor in my left hand when it's at rest. I think I might have Parkinson disease because my mother had it." Which response by the nurse is the most appropriate? A) "Having a close relative with Parkinson disease can increase your chance of developing it as well." B) "You shouldn't worry too much, because Parkinson disease has a higher prevalence in males." C) "It is unlikely that you have the same illness as your mother." D) "You probably don't have Parkinson disease. Your mother was probably exposed to a toxin that caused her illness."

Answer 87

Answer: A Rationale: In some individuals, Parkinson disease (PD) is inherited; approximately 15% to 25% of individuals with PD have a relative with PD. The nurse should not tell the client it is unlikely she has the same illness as her mother. Exposure to toxins is one theory for the development of the illness; however, the nurse has no way of knowing whether the client's mother was exposed to toxins or if that was the cause for her disease. Men are at higher risk for PD, with 50% more men than women developing the disease, but this does not eliminate the client's risk of having the disease, especially given her mother's diagnosis.

Question 88

A client with Parkinson disease (PD) ambulates with a shuffling gait and leans slightly forward. When seated, the client conducts a conversation, reads, and is able to self-feed without assistance. Which nursing diagnosis is a priority for this client? A) Ineffective Coping B) Impaired Physical Mobility C) Imbalanced Nutrition: More than Body Requirements D) Anxiety

Answer 88

Answer: B Rationale: The client demonstrates a shuffled gait with forward leaning when ambulating. When seated, the client is able to converse, read, and self-feed. Of the diagnoses listed, the one with the highest priority would be Impaired Physical Mobility. Imbalanced Nutrition would not be a priority, as the client can feed himself. There is no evidence to support the diagnoses of Ineffective Coping or Anxiety at this time.

Question 89

The nurse is planning care for a client with Parkinson disease (PD). Which of the following nursing interventions aimed at the client's spouse would best support the client's continued mobility? A) Suggesting that the spouse use a blender to make foods easier for the client to swallow B) Reviewing the client's medication administration schedule with the spouse C) Instructing the spouse to ambulate the client at least four times a day D) Instructing the spouse on proper turning and repositioning techniques

Answer 89

Answer: C Rationale: Because exercise fosters not just mobility but also independence and self-esteem, the intervention that would be most appropriate is for the nurse to instruct the spouse to ambulate the client at least four times a day. Instructing on turning and repositioning techniques would not support physical mobility. Blending foods to aid with swallowing would not support physical mobility. Reviewing the medication administration schedule would not support physical mobility.

Question 90

The nurse is evaluating the care of a client with Parkinson disease (PD). Which finding indicates an improvement in the client's nutritional status? A) The client filled out the menu card for each meal. B) The client coughs frequently when drinking fluids. C) The client was able to feed himself and had no weight change in 1 week. D) The client had a 4-pound weight loss in 1 week.

Answer 90

Answer: C Rationale: The finding that the client was able to feed himself and had no weight change in 1 week is indicative of an improvement in nutritional status. The client filling out the menu card does not indicate that the client actually consumed any of the meal. If the client coughs frequently when drinking fluids, it could indicate that interventions to address nutritional status have not been effective. The client's losing 4 pounds in 1 week would not support an improvement in nutritional status.

Question 91

The wife of a client with Parkinson disease (PD) expresses frustration about trying to communicate with her husband. What can the nurse do to facilitate communication between the client and spouse? A) Recommend that the client and spouse learn sign language. B) Suggest that the spouse obtain a hearing aid. C) Consult with speech therapy for exercises to aid the client with speech and language. D) Suggest the client and spouse communicating by writing.

Answer 91

Answer: C Rationale: The spouse is frustrated with the client's impaired verbal communication. The best intervention would be to consult with speech therapy for exercises to aid the client with speech and language. The spouse does not need a hearing aid. The spouse and client do not need to learn sign language in order to communicate. The client may or may not be able to write because of hand tremors, so it may not be appropriate for the nurse to suggest that the client and spouse communicate via writing.

Question 92

The nurse instructs a client with Parkinson disease (PD) about levodopa/carbidopa. Which client statement indicates that this teaching has been effective? A) "I should eat a high-protein diet when taking this medication." B) "When taking this medication, I should sit up for several minutes before going from lying down to standing up." C) "This medication will not affect my blood pressure medications." D) "Given enough time, this medication will cure my Parkinson disease."

Answer 92

Answer: B Rationale: Levodopa/carbidopa is a medication that boosts dopamine levels in clients with PD. This medication commonly causes orthostatic hypotension, so clients must take care when changing positions from lying to standing. Clients should also avoid eating protein-rich meals when taking this medication, as a high-protein diet may interfere with levodopa absorption from the GI tract. There is no medication that is known to cure Parkinson disease. Care must be taken if clients are also taking medications to lower their blood pressure because a cumulative effect may occur, leading to hypotension and increased risk for falling.

Question 93

The nurse completes a teaching session for a young adult client who was recently diagnosed with Parkinson disease (PD). Which client statement indicates this teaching has been effective? A) "I could have prevented PD with diet and exercise." B) "I probably have a genetic mutation that caused my PD." C) "My brain contains too much of a chemical called dopamine." D) "Most people with PD first experience symptoms when they are about my age."

Answer 93

Answer: B Rationale: Early-onset PD is likely due to a genetic mutation. Increasing age is a risk factor for the disease, and diagnosis as a young adult is uncommon. PD is associated with decreased dopamine levels in the brain, not an excess of dopamine. Although consuming a healthy, pesticide-free diet is recommended, dietary intake has not been definitively linked to development of PD.

Question 94

A client is being evaluated for Parkinson disease (PD). Which findings on the Unified Parkinson Disease Rating Scale (UPDRS) would be considered positive for PD? Select all that apply. A) Diarrhea B) Dystonia C) Retropulsion D) Hyperphonia E) Festination

Answer 94

Answer: B, C, E Rationale: The UPDRS rates clients in 42 different areas of function. Positive findings for PD include retropulsion (the tendency to fall backward), festination (rapid walking as if trying to run), and dystonia (twisting and repetitive movements). Diarrhea and hyperphonia (loud voice) are not symptoms of PD. Constipation and hypophonia (soft voice) are symptoms of PD.

Question 95

The interdisciplinary treatment team proposes interventions to improve and maintain physical function for an adult client with Parkinson disease (PD). Which of the following interventions are supported by research? Select all that apply. A) Low-intensity treadmill training B) Walking barefoot indoors C) Use of resistance bands D) Active and passive range-of-motion exercises E) High-intensity treadmill training

Answer 95

Answer: A, C, D, E Rationale: Research studies have shown improvements on the 6-minute walk test of individuals with PD after participation in low-intensity and high-intensity treadmill training, strength training (such as with resistance bands), and range-of-motion exercises. Use of shoes with non-slip soles is advised.

Question 96

The nurse is caring for a 30-year-old female client who was recently diagnosed with Parkinson disease (PD). Which of the following statements should the nurse include in the teaching for this client? A) "Having the early-onset form of PD puts you at greater risk for dementia." B) "If you get pregnant, it is highly unlikely that you will be able to carry the baby to term." C) "Given your age, your PD is likely to progress more slowly than it does for people who develop the condition later in life." D) "You can continue using birth control pills, because PD medications do not have an impact on their efficacy."

Answer 96

Answer: C Rationale: Clients with early-onset PD generally have a slower disease progression and a lower rate of dementia than clients who develop the disease later in life. The effect of PD medication on the efficacy of birth control pills is not known, so clients should be urged to consider other forms of contraception. Many women with PD have successfully carried healthy babies to full term.

Question 97

Which of the following is not a common clinical manifestation of Parkinson disease (PD)? A) Restless leg syndrome B) Cogwheel rigidity C) Malignant hypertension D) Pill-rolling

Answer 97

Answer: C Rationale: Malignant hypertension is not a clinical manifestation of PD; orthostatic hypotension is more commonly associated with this disease. All of the other conditions listed here (restless leg syndrome, cogwheel rigidity, and pill-rolling) are frequently observed in clients with PD.

Question 98

In clients with Parkinson disease, increasing doses of and long-term exposure to levodopa can cause which of the following conditions? A) Dyskinesia B) Insomnia C) Hypertension D) Compulsive behavior

Answer 98

Answer: A Rationale: With increasing doses and long-term exposure, levodopa usually causes dyskinesia, which may become less tolerable for the client than the symptoms of PD. Insomnia and hypertension are not side effects of levodopa. Compulsive behavior is a side effect of dopamine antagonists, not levodopa.

Question 99

Why do clients with Parkinson disease (PD) nearly always take carbidopa in combination with levodopa? A) Carbidopa minimizes the conversion of levodopa to dopamine within the brain, thus minimizing levodopa's unwanted side effects. B) Carbidopa enhances levodopa's conversion to dopamine throughout the body, thus intensifying levodopa's effectiveness. C) Carbidopa prevents levodopa from converting to dopamine until it reaches the brain, thus minimizing levodopa's unwanted side effects. D) Carbidopa prevents levodopa's conversion to dopamine in the brain, thus intensifying levodopa's effectiveness.

Answer 99

Answer: C Rationale: Levodopa is a natural chemical that can cross the blood—brain barrier and be converted directly to dopamine in the brain. Levodopa can also be converted to dopamine outside the brain, which leads to the most common side effects of nausea and orthostatic hypotension. Therefore, levodopa is almost always given in combination with carbidopa, which prevents levodopa from converting to dopamine until it reaches the brain.

Question 100

A client in the initial stages of Parkinson disease (PD) would most likely exhibit which of the following symptoms? A) Bilateral rigidity B) Unilateral tremors C) Bilateral tremors D) Unilateral rigidity

Answer 100

Answer: B Rationale: Motor symptoms associated with PD usually begin unilaterally, not bilaterally. For most clients, the earliest motor symptom is tremors; rigidity usually develops later in the course of the disease.

Question 101

An adolescent is brought into the emergency department (ED) with injuries sustained from a motor vehicle crash. What is a priority while providing nursing care for this client? A) Adequate urine output B) Stable blood pressure C) Continued stabilization of the neck and spinal cord D) Insertion of an intravenous access line

Answer 101

Answer: C Rationale: The danger of death from a spinal cord injury is greatest when there is damage to or transection of the upper cervical region. All people who have sustained trauma to the spine should be treated as though they have a spinal cord injury by stabilizing the neck and spinal cord. Assessment of urine output can be delayed. Assessing blood pressure is an intervention for all clients brought into the emergency department. An intravenous access line is necessary, but stabilization of the neck and spinal cord is of first priority.

Question 102

A school nurse is treating a school-age client who has fallen down a flight of stairs. The client is breathing but unconscious. After calling the ambulance, which is the priority action by the nurse? A) Open the airway using the head tilt maneuver. B) Try to rouse the client by gently shaking the shoulders. C) Protect the client's neck and head from any movement. D) Place the client on the side to prevent aspiration.

Answer 102

Answer: C Rationale: Guidelines for emergency care are avoiding flexing, extending, or rotating the neck; immobilization of the neck; securing the head; maintaining the client in the supine position; and transferring the client from the stretcher to the hospital bed with backboard in place. This client is unconscious, and the nurse must protect the neck from any (or any further) damage. If the client vomits, the nurse should use the log-roll technique to turn the client while keeping the head, neck, and spine in alignment. This client is breathing; however, if a change in respirations were to occur, the airway should be opened using the jaw thrust maneuver. Rousing the client by shaking could cause damage to the spinal cord.

Question 103

A client who sustained a cervical neck injury 2 days ago is demonstrating an irregular respiratory pattern with a rate of 8-10 breaths per minute. Based on this data, which is the priority nursing diagnosis? A) Impaired Physical Mobility B) Autonomic Dysreflexia C) Ineffective Breathing Pattern D) Impaired Gas Exchange

Answer 103

Answer: C Rationale: Because the client sustained the neck injury 2 days prior, the full extent of the injuries cannot yet be determined. The client's rate of respirations should be between 12 and 20 breaths per minute. Because the client is breathing irregularly at a rate of 8-10 breaths per minute, the client may need assisted ventilation or a tracheostomy. The priority nursing diagnosis for this client would be Ineffective Breathing Pattern. A diagnosis of Impaired Gas Exchange could occur because of the Ineffective Breathing Pattern diagnosis, but it would be the second in priority for this client. The diagnoses of Impaired Physical Mobility and Autonomic Dysreflexia could both be addressed at a later time.

Question 104

The nurse is planning care for a client admitted with a high thoracic spinal cord injury. Which interventions would be appropriate for the nursing diagnosis of Ineffective Peripheral Tissue Perfusion? Select all that apply. A) Discuss future care needs when the client is discharged. B) Increase fluids to 3000 mL per day. C) Turn and reposition the client every 2 hours. D) Assess for a full bladder. E) Assess blood pressure every 2-3 minutes.

Answer 104

Answer: D, E Rationale: Ineffective perfusion can be caused by autonomic dysreflexia, which is an emergency that requires immediate assessment and intervention. The nurse should continue to assess the client's blood pressure every 2-3 minutes in addition to elevating the head of the bed and removing tight clothing to encourage the pooling of blood in the extremities and decrease the blood pressure. Once the client's blood pressure has stabilized or decreased, the nurse can then assess for the stimuli that caused the episode, such as a full bladder. Discussing future care needs when discharged is not a priority at this time, nor is it an intervention for Ineffective Peripheral Tissue Perfusion. Turning the client every 2 hours is not a priority at this time, nor is it an intervention for Ineffective Peripheral Tissue Perfusion.

Question 105

The nurse is evaluating the effectiveness of interventions to address a client's bowel and bladder dysfunction as a result of a spinal cord injury. Which finding would indicate that these interventions have been successful? A) The client had two episodes of impacted stool over the last week. B) The client is improving in ability to perform self-urinary catheterization. C) The client is limiting fluids to reduce need to void. D) The client has an indwelling urinary catheter and is provided with stool softeners every morning.

Answer 105

Answer: B Rationale: An ideal outcome for the client with bowel and bladder dysfunction as a result of a spinal cord injury would be for the client to attain appropriate bowel and bladder elimination habits. If the client's ability to perform self-urinary catheterization is improving, the interventions can be considered successful. A client with an indwelling urinary catheter who is receiving stool softeners every morning is not progressing toward appropriate bowel and bladder elimination habits. A client who had two episodes of impacted stool over the last week is not progressing in bowel elimination habits. A client who is limiting fluids to reduce the need to void is possibly hindering his health in order to avoid having to perform self-urinary catheterization.

Question 106

The nurse in the emergency department is preparing to administer methylprednisone to a client with a spinal cord injury. What does the nurse recognize as the intended therapeutic effect of the medication? A) To increase blood glucose level B) To improve the client's level of consciousness C) To prevent cord damage from ischemia and edema D) To improve the client's ability to be adequately ventilated

Answer 106

Answer: C Rationale: High-dose steroid protocol using methylprednisone must be implemented within 8 hours of spinal cord injury to improve neurologic recovery. Clinical research indicates that use of this medication is effective in preventing secondary spinal cord damage from edema and ischemia. Methylprednisone may cause hyperglycemia if the client also has a diagnosis of diabetes. This medication is not provided to improve respirations or improve the level of consciousness.

Question 107

The nurse is evaluating the success of a bowel and bladder retraining program with a client who is recovering from a lower motor neuron spinal cord injury. Which observations indicate that this teaching has been successful? Select all that apply. A) One episode of bladder incontinence in 8 hours B) Client performs self-urinary catheterization every 4 hours while awake C) Client transfers to use bedside commode after breakfast to evacuate bowels D) Two episodes of impacted stool in 1 week E) Client maintains a high-fluid, high-fiber diet

Answer 107

Answer: B, C, E Rationale: Evidence that a bowel and bladder retraining program for a client with a spinal cord injury has been successful includes the client performing self-urinary catheterization every 4 hours while awake, transferring to the bedside commode to evacuate bowels after breakfast, and maintaining a high-fluid and high-fiber diet to prevent constipation. Evidence that this training has not been successful includes an episode of bladder incontinence and the need to have impacted stool removed twice in 1 week.

Question 108

The nurse is caring for a client who sustained a gunshot wound below the level of T12, resulting in ipsilateral motor paralysis, ipsilateral loss of proprioception and vibratory sense, and contralateral loss of pain and temperature sensation. When planning care for this client, which interpretations of this data by the nurse are likely to be correct? Select all that apply. A) The client's American Spinal Injury Association Impairment Scale score is A. B) The spinal cord injury is incomplete. C) These findings are consistent with Brown-Sequard syndrome. D) Hemisection of the spinal cord is likely. E) Some recovery of sensory function is likely.

Answer 108

Answer: B, C, D, E Rationale: Hemisection of the spinal cord, usually caused by a penetrating trauma (gunshot, knife), causes sensory and motor deficits on opposite sides of the body because the spinal cord injury is incomplete. These findings are consistent with Brown-Sequard syndrome, which has the best prognosis of all the incomplete spinal cord syndromes. An American Spinal Injury Association (ASIA) Impairment Scale (AIS) score of A indicates a complete spinal cord injury where no sensory or motor function is preserved in the sacral segments S4-S5.

Question 109

The nurse is presenting a talk on spinal cord injury for a community health fair. Which statement on the part of the attendees indicates that they understand the risk factors and prevention methods associated with spinal cord injury? A) "There isn't much I can do to prevent a head injury when another vehicle hits my car." B) "As long as my grandson wears a helmet, he will be safe on his motorcycle." C) "I'm going to spend extra time discussing this talk with my college-age son because of his higher risk for spinal cord injury." D) "Due to their elevated risk, I'd like you to present this talk to members of the local Native American population."

Answer 109

Answer: C Rationale: The highest-risk population for spinal cord injuries is young adult males, including college-age men. Riding motorcycles increases the risk of spinal cord injuries, even when helmets are used. Native Americans are the ethnic group with the lowest risk of spinal cord injury. Using a seat belt is a major preventive action for individuals who are involved in motor vehicle crashes.

Question 110

The nurse assesses a young adult client who was involved in a swimming accident that resulted in tetraplegia. The client makes eye contact with the nurse and states, "I'm going to beat this and walk out of here." Based on this statement, which nursing diagnosis is most appropriate for this client? A) Risk for Post-Trauma Syndrome B) Impaired Physical Mobility C) Self-Care Deficit D) Noncompliance

Answer 110

Answer: A Rationale: The client's statement is unrealistic and evidence of Risk for Post-Trauma Syndrome. Although the diagnoses of Impaired Physical Mobility and Self-Care Deficit are appropriate for a client with tetraplegia, this statement is not evidence of those nursing diagnoses. There is no indication of Noncompliance.

Question 111

A female client who sustained a spinal cord injury (SCI) several years ago tells the nurse she is interested in becoming pregnant. She asks the nurse for more information about how her SCI might impact a potential pregnancy. Which of the following statements should the nurse include in her response to the client? A) "Women with SCI should avoid pregnancy, because it puts too much stress on their bodies and can exacerbate their injuries." B) "If you become pregnant, your risk for autonomic dysreflexia will likely decrease." C) "The good news is that none of the medications used in the treatment of SCI are known to have detrimental effects on the fetus." D) "Should you have a baby and opt to breastfeed, you may experience an increase in muscle spasticity."

Answer 111

Answer: D Rationale: Women with SCI are considered to be "high risk" during pregnancy, but that does not mean pregnancy should be avoided. Instead, the woman will need to work closely with a team of healthcare professionals to prevent complications and prepare for pregnancy, labor, and delivery. Pregnant women are at higher risk for autonomic dysreflexia, especially during labor and delivery. Many women are unable to continue taking prescribed medications during pregnancy due to the potential harm they pose to the fetus. New mothers must also consider the effects of their SCI on breastfeeding; muscle spasticity may increase during breastfeeding, and women with limited sensation in their breasts may have reduced milk production.

Question 112

Which of the following clients is at highest risk for autonomic dysreflexia? A) A client with an injury to T9 B) A client with an injury to C7 C) A client with an injury to L2 D) A client with an injury to S1

Answer 112

Answer: B Rationale: Autonomic dysreflexia is the abrupt onset of excessively high blood pressure as the result of an overactive autonomic nervous system; it usually occurs in clients who have injuries above T5. Of the spinal segments listed here, only C7 is located above T5.

Question 113

A client with permanent paralysis of the trunk, arms, and legs would be said to be experiencing which of the following conditions? A) Tetraplegia B) Paraplegia C) Spinal shock D) Complete spinal cord injury (SCI)

Answer 113

Answer: A Rationale: Tetraplegia (also called quadriplegia) is paralysis of the upper and lower limbs and trunk. Paraplegia is paralysis of all or part of the trunk, legs, and pelvic organs. Spinal shock is a temporary condition characterized by spinal cord swelling; decreased blood flow and blood pressure; and complete loss of motor function, spinal reflexes, and autonomic function below the level of injury. Complete SCIs involve a total loss of all sensory and motor function below the level of the injury. Depending on its location, a complete SCI could results in either tetraplegia or paraplegia.