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