51.You are caring for a client experiencing spinal shock after a spinal cord injury.

What clinical manifestation would indicate the resolution of spinal shock?

a. The return of reflex activity
b. Normalization of the pupillary reflex
c. Return of bowel and bladder continence
d. Tingling in the extremities below the lesion
RATIONALIZATION:
Spinal shock occurs in about half of all people with acute spinal cord
injury. In spinal shock, the entire cord below the level of the lesion fails to
function, resulting in a flaccid paralysis and hypomotility of most
processes without any reflex activity. Return of reflex activity signals the
end of spinal shock. Sympathetic function is impaired below the level of
the injury because sympathetic nerves leave the spinal cord at the
thoracic and lumbar areas, and cranial parasympathetic nerves
predominate in control over respirations, heart, and all vessels and organ
below the injury. A neurogenic shock result from loss of vascular tone
caused by the injury and is manifested by hypotension, peripheral
vasodilation, and decreased CO. Rehab activities are not contraindicated
during spainl shock and should be instituted if the patient's
cardiopulmonary status is stable.
52.Which clinical manifestations would serve to alert you to the early onset of
multiple sclerosis (MS)?
a. Hyperresponsive reflexes
b. Excessive somnolence
c. Nystagmus and ataxia
d. Heat intolerance
RATIONALIZATION:
Early signs and symptoms of MS include changes in motor skills, vision,
and sensation. Hyper responsive reflexes, excessive somnolence, and heat
intolerance are later manifestations of MS.
53.A client presents with an acute exacerbation of multiple sclerosis. Which drug
should you be prepared to administer?
a. Baclofen
b. Betaseron
c. Dantrolene sodium
d. Methylprednisolone

RATIONALIZATION:

Methylprednisolone is the drug of choice for acute exacerbations of the

disease. The other drugs are not used to treat acute exacerbations of MS.
Interferon beta-1b is used to treat and control MS, decrease specific
symptoms, and slow the progression of the disease. Baclofen and
dantrolene sodium are prescribed to lessen muscle spasticity associated
with MS.
54.Which statement regarding the pathophysiology of myasthenia gravis is true?
a. The myelin sheath is destroyed by the immune system.
b. Myasthenia gravis is caused by antibodies to dopamine receptors.
c. There is evidence of both central and peripheral nervous system disease.
d. There is a defect in transmission of nerve impulses to the skeletal
muscles.

RATIONALIZATION:
Myasthenia gravis is an autoimmune disease in which the immune
system gradually destroys the
receptors for acetylcholine at the neuromuscular junction.
55.When the nurse asks the client to raise the eyebrows and grimace or puff the
cheeks, the nurse would be assessing the function of cranial nerve
a. VII
b. VIII
c. IX
d. X
RATIONALIZATION:
CN VII controls facial expressions and symmetry of the facial features. CN
VI moves the eyes in all six directions. CN IX (glossopharyngeal nerve)
controls swallow and gag reflexes and supplies some taste. CN XII allows
skeletal movement of the tongue

56.The nurse clarifies that the term for the chronic form of confusion is _______.
a Dementia
b Multiple Sclerosis
c Myasthenia Gravis
d Delirium

Rationale: Dementia is a syndrome usually of a chronic or progressive

nature in which there is deterioration in cognitive function (i.e. the ability to
process thought) beyond what might be expected from normal ageing. It
affects memory, thinking, orientation, comprehension, calculation, learning
capacity, language, and judgement. Dementia is a chronic form of confusion.
(Reference: http://www.who.int/mediacentre/factsheets/fs362/en/)
57.The nursing action that is important to prevent complications from
nasogastric feeding in a comatose client receiving tube feedings is to
a check residual volume every 4 hours.
b feed the client in the supine position.
c feed only small amounts every hour.
d stimulate the gag reflex every 8 hours.
Rationale: Feeding should be done more often but in smaller quantities
for stroke patients. This is because they are not capable of digesting food
normally. Therefore, you need to space out the feeding in a way that their
body will be able to cope with the slow digestion. Take note that you have
to see as well if the patient is showing some signs of bloating. If there is,
you may want to do it every 4-5 hours instead.
(Reference: http://visihow.com/Give_Food_via_Nasogastric_Tube)
58.The nurse who is beginning oral feedings on a client who is returning to
consciousness will
a begin feedings with water.
b stroke the posterior neck to promote swallowing.
c place about 1 teaspoonful of liquid in the front of the mouth.
d position the client upright.
Rationale: Stroke is the most common etiology of dysphagia. Following
nasogastric tube removal, stroke patients must be engaged or swallowing
ability must always be checked. Enabling patients to eat by rehabilitating
their swallowing function is important not just to ensure the medical
safety and functional activities of those patients, but also to maintain their
quality of life.
(Reference: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2593402/)
59.When a comatose patient receiving nasogastric (NG) feedings is scheduled to
have a gastrostomy tube inserted, the nurse informs the family that the
advantage of this feeding tube over nasogastric tubes is
a decreased risk of infection.
b decreased risk of aspiration.
c less complicated feeding procedure.
d increased access for mouth care.

Rationale: The G-tube can be useful where there is difficulty with

swallowing because of neurologic or anatomic disorders (stroke,
esophageal atresia, tracheoesophageal fistula, radiotherapy for head and
neck cancer), and to avoid the risk of aspiration pneumonia.
(Reference: http://patient.info/doctor/enteral-feeding)
60.When communicating with a client who has aphasia, which of the following
nursing interventions is inappropriate?
a Present one thought at a time.
b Encourage the client not to write messages.
c Speak with normal volume.
d Make use of gestures.
Rationale: Asking the patient to write a name or short sentences could
assess the ability to write and correct deficiencies in reading, which is also
part of the sensory aphasia and motor aphasia.
(Reference: http://nandanursinginterventions.blogspot.com/2012/05/impaired-verbalcommunication-related.html)

61.
Based on the nurses knowledge of thrombolytic therapy, what is the expected
outcome of this drug therapy?
a. Increased vascular permeability.
c. Dissolved emboli.
b. Vasoconstriction.
d. Prevention of hemorrhage.
Rationale: Thrombolytic therapy is the administration of drugs called lytics or clot busters to
dissolve blood clots that have acutely (suddenly) blocked your major arteries or veins and pose
potentially serious or life-threatening implications. (https://vascular.org/patientresources/vascular-treatments/thrombolytic-therapy)
62. Which of the following is an initial sign of Parkinsons disease?
a. Rigidity
c. Bradykinesia
b. Tremor
d. Akinesia
Rationale: Parkinson's disease is a progressive disorder of the nervous system that affects
movement. It develops gradually, sometimes starting with a barely noticeable tremor in just one
hand. But while a tremor may be the most well-known sign of Parkinson's disease, the disorder
also commonly causes stiffness or slowing of movement. (http://www.mayoclinic.org/diseasesconditions/parkinsons-disease/basics/definition/con-20028488)
63. The nurse develops a teaching plan for a client newly diagnosed with Parkinsons
disease. Which of the following topics that the nurse plans to discuss is the most
important?

a. Maintaining a balanced nutritional diet. c. Maintaining a safe environment.

b. Enhancing the immune system.
d. Engaging in diversional activity
Rationale: Although all options are correct, C is the most important because you may fall more
easily. In fact, you may be thrown off balance by just a small push or bump.
(http://www.mayoclinic.org/diseases-conditions/parkinsons-disease/basics/lifestyle-homeremedies/con-20028488)
64. Which goal is the most realistic and appropriate for a client diagnosed with Parkinsons
disease?
a. To cure the disease.
c. To begin preparations for terminal care.
b. To stop progression of the disease.
d. To maintain optimal body function.
c.
Rationale: Parkinson's disease is a progressive disorder of the nervous system that affects
movement and it can't be cured. Because it is a progressive disease, the best option is to prepare
for terminal care. (http://www.mayoclinic.org/diseases-conditions/parkinsonsdisease/basics/treatment/con-20028488)

65. What is the primary goal collaboratively established by the nurse, the physical therapist,
and the client with Parkinsons disease?
a. To maintain joint flexibility.
c. To improve muscle endurance.
b. To build muscle strength.
d. To reduce ataxia.
Rationale: PD affects your ability to control your movements.Ataxia is a term for a group of
disorders that affect co-ordination, balance and speech. The goal of physical therapy is to
improve your independence and quality of life by improving movement and function and
relieving pain. (http://www.webmd.com/parkinsons-disease/guide/physical-occupationaltherapy)

66.A client with Parkinsons disease is prescribed Levodopa (L-dopa) therapy. The
nurse determines that the drug is effective when the client experiences an
improvement in which of the following?
a Mood
c. Appetite
b Muscle rigidity
d. Alertness
RATIONALIZATION: Giving dopamine directly is ineffective, because the brain's
natural defense blocks it from being used by the body.
67.Which of the following is not a typical clinical manifestation of multiple
sclerosis (MS)?
a Double vision
c. Weakness in the
extremities

Sudden bursts of energy

d. Muscle tremors

RATIONALIZATION: Optic neuritis (ON) can be the first demyelinating event in

approximately 20% of patients with MS. ON develops in approximately 40% of
MS patients during the course of their disease. ON is characterized by loss of
vision (or loss of color vision) in the affected eye and pain on movement of the
eye. Much less commonly, patients with ON may describe phosphenes (transient
flashes of light or black squares) lasting from hours to months. Phosphenes may
occur before or during an ON event or even several months following recovery.
68.When the nurse talks with a client with MS who has slurred speech, which
nursing intervention is contraindicated?
a Encouraging the client to speak slowly.
b Encouraging the client to speak distinctly.
c Asking the client to repeat indistinguishable words.
d Asking the client to speak louder when tired.
RATIONALIZATION: It will affect the patient condition.
69.A client with multiple sclerosis is experiencing bowel incontinence and is
starting a bowel retraining program. Which strategy is in appropriate?
a Eating a diet high in fiber.
c. Using an elevated toilet
seat.
b Setting a regular time for elimination.
d. Limiting fluid intake to
1000 ml/day.
RATIONALIZATION: It would not be helpful to limit the fluid intake of a client
during bowel retraining.
70.Which of the following is an inappropriate goal to establish with a client who
has Multiple Sclerosis?
a The client will develop joint mobility.
c. The client will develop
cognition.
b The client will develop muscle strength. d. The client will develop mood
elevation.
RATIONALIZATION: It takes to develop client cognition if he/she has MS.
71.The nurse is preparing a client with Multiple Sclerosis for discharge from the
hospital to home. Which of the following instructions is appropriate?
a. You will need to accept the necessity for a quiet and inactive lifestyle.
b. Keep active, use stress reduction strategies, and avoid fatigue.
c. Follow good health habits to change the course of the disease.
d. Practice using the mechanical aids that you will need when future
disabilities arise.

: The nurse most positive approach is to encourage the client with

multiple sclerosis to stay active, use stress reduction techniques and avoid
fatigue because it is important to support the immune system while
remaining active
Try to stay as active as you can. Ask your health care provider what kind of
activity and exercise are right for you. Try walking or jogging. Stationary
bicycle riding is also good exercise.
Benefits of exercise include:

Helps your muscles stay loose

Helps you keep your balance

Good for your heart

Helps you sleep better

Helps you have regular bowel movements

https://medlineplus.gov/ency/patientinstructions/000129.htm
72.Which intervention should the nurse suggest to help a client with Multiple
Sclerosis avoid episodes of urinary incontinence?
a. Limit fluid intake to 1000 ml/ day.
b. Insert an indwelling urinary catheter.
c. Establish a regular voiding schedule.
d. Administer prophylactic antibiotics, as ordered.
: Encouraging the patient to void regularly every 2 hours. Teach the
patient to practice relaxation techniques, such as deep breathing, which
helps decrease the sense of urgency.
Handbook of Geriatric Nursing Care, Volume 236
73.An unconscious client has been positioned on one side. The nurse anticipates
that which of the following anatomic areas is a pressure point in this position?
a. Sacrum
c. Ankles
b. Occiput
d. Heels

: For the unconscious patient who has been positioned on one side
may develop pressure point on ankle which is for side lying position.
Usually, mobile individuals, when either conscious or unconscious, will
receive nerve signals from the compressed part of the body and will
automatically move to relieve the pressure. Pressure sores do not usually
develop in people with normal mobility and mental alertness. However,
people compromised through acute illness, heavy sedation,
unconsciousness, or diminished mental functioning, may not receive
signals to move, and as a result of the constant pressure, tissue damage
may progress to bedsores in these individuals.
http://www.surgeryencyclopedia.com/A-Ce/Bedsores.html#ixzz4K27YtDKA
74.What is the intended outcome for the nursing intervention of performing
passive range of motion exercises on an unconscious client?
a. Preservation of muscle mass.
c. Increase in muscle
tone.
b. Prevention of bone demineralization.
d. Maintenance of joint
mobility.
: Instruct patient or assist with active and passive ROM exercises of
affected and unaffected extremities. Increases blood flow to muscles and
bone to improve muscle tone, maintain joint mobility; prevent
contractures or atrophy and calcium resorption from disuse
http://nurseslabs.com/osteoporosis-nursing-care-plans/
75.When the nurse performs oral hygiene for a comatose client, which nursing
intervention is the priority?
a. Keep a suction machine available.
b. Place the client in a prone position.
c. Wear sterile gloves while brushing the clients teeth.
d. Use gauze wrapped around the fingers to cleanse the clients gums.
: Because unconscious patients are at risk for aspirating during oral
hygiene, you must always have suction set up at the bedside and ready to
be used before you begin providing oral hygiene.
http://www.atitesting.com/ati_next_gen/skillsmodules/content/personalhygiene/equipment/oral-hygiene2.html
76.The nurse is testing the coordinated functioning of the cranial nerves III,
IV, and VI. To do this correctly, the nurse would test the
a. Corneal reflex
c. Pupil response to light

b. Six cardinal fields of gaze

and accommodation

d. Pupil response to light

RATIONALIZATION: The six cardinal fields of gaze are tested are

evaluated to determine any paralysis or weakness of the ocular muscles
(oculomotor nerve, trochlear nerve, abducent nerve).
77.The nurse is caring for the client who begins to experience seizure activity
while in bed. Which of the following actions by the nurse would be
contraindicated?
a. Loosening restrictive clothing
c.
Restraining the clients limbs.
b. Removing the pillow and raising padded side rails
d. Positioning
RATIONALIZATION: Restraining the clients limbs-nursing actions during a
seizure include providing for privacy, loosening restrictive clothing,
removing the pillow and raising side rails in the bed, and placing the client
on one side with the head flexed forward, if possible, to allow the tongue
to fall forward and facilitate drainage. The limbs are never restrained
because the strong muscle contractions could cause the client harm. if the
client is not in bed when seizure activity begins, the nurse lowers the
client to the floor, if possible, protects the head from injury, and moves
furniture that may injure the client. Other aspects of care are as described
for the client who is in bed.
78.A nursing student is caring for a client with a cerebrovascular accident
who is experiencing unilateral neglect. The nurse would intervene if the
student planned to use which of the following strategies to help the client
adapt to this deficit?
a. Move the commode and chair to the affected side.
b. Place the bedside articles on the affected side.
c. Approach the client from the unaffected side.
d. Tell the client to scan the environment.
RATIONALIZATION: Unilateral neglect is an unawareness of the
paralyzed side of the body, which increases the clients risk for injury. The
nurses role is to refocus the clients attention to the affected side. The
nurse moves personal care items and belongings to the affected side, as
well as the bedside chair and commode. The nurse teaches the client to
scan the environment to become aware of that half of the body and
approaches the client from the affected side to increase awareness
further.
79.The client with Bells palsy asks the nurse what caused this problem to
occur. The nurses response is based on an understanding that the cause
is
a. Unknown, but possibly includes ischemia, viral infection, or an
autoimmune problem.
b. Unknown, but possibly includes long-term tissue malnutrition and cellular
hypoxia.

c. Primarily genetic in origin and is triggered by exposure to neurotoxins.

d. Primarily genetic in origin and is triggered by exposure to meningitis.
RATIONALIZATION: Bells palsy is a one-sided facial paralysis from
compression of the facial nerve. The exact cause is unknown, but may
include vascular ischemia, infection, exposure to viruses such as herpes
zoster or herpes simplex, autoimmune disease, or a combination of these
factors.
80.The nurse has given the client with Bells palsy instructions on preserving
muscle tone in the face and preventing denervation. The nurse
determines that the client needs additional information if the client stated
to
a. Expose the face to cold air
b. Massage the face with a gentle upward motion
c. Wrinkle the forehead, blow out the cheeks, and whistle
d. Use a device for electrical stimulation of the face
RATIONALIZATION: Physical therapy to stimulate the facial nerve and
help maintain muscle tone may be beneficial to some. Facial massage and
exercises may help prevent permanent contractures (shrinkage or
shortening of muscles) of the paralyzed muscles before recovery takes
place. Moist heat applied to the affected side of the face may help reduce
pain. Electrical stimulation may help nerve regrowth.

81.The nurse is admitting a client with Guillain- Barre syndrome to the nursing
unit. The client has an ascending paralysis to the level of the waist. Knowing
the complications of the disorder, the nurse brings which of the following
items into the clients room?
a) Nebulizer and pulse oximeter
b) Flashlight and incentive spirometer
c) Electrocardiogram monitoring electrodes and intubation tray
d) Blood pressure cuff and flashlight
Guillain- Barre Syndome affects your nerves. Because nerves
control your moveents and body functions people with Guillain- Barre
Syndome may experience: Breathing Difficulties; The weakness or
paralysis can spread to the muscles that control your breathing, a
potentially fatalcomplication. Up to 30 percent of people with such
disease need TEMPORARY HELP FROM MACHINE TO BRATHE when
they are hospitalized for treatment
1998-2016 Mayo Foundation for Medical Education and Research//
http.www.mayoclinic.or.com
82. Basal skull fracture commonly involved in head injury
a)
Temporal
c) Frontal lobe
b)Parietal lobe
d) Occipital lobe

Basilar Skull Fracture or the Basal Skull Fracture is a fracture of

the base of the skull, typically involving the TEMPORAL BONE
Pathology of Brain Damage after Head Injury pg. 133- 154
83.A 2 year old child is admitted to the neurosurgical unit following a head injury.
The nurse is using
the Glasgow Coma Scale to measure neurological functioning. Which of the
following assessment findings indicate the lowest level of functioning for this
child?
a)
Confusion
c)
Eyes open only to
pain
b)
Irritable and cries
d) No response to
painful stimuli
The Glasgowcoma scale (GCS) is used to describe the general level
of consciousness in patients with traumatic brain injury. Assessment
findings indicating the lowest level of functioning for a child aged 0-2
YEARS OLD IS NO RESPONSE
Http:// www. glasgowcomascale/emdecicine.medscape.com/

84.Following a spinal cord injury the physician indicates that a client is

paraplegic. The family asks
the nurse what this means. The nurse explains that
a) Upper extremities are paralyzed
b) Lower extremities are paralyzed
c) One side of the body is paralyzed
d) Both lower and upper extremities are paralyzed
Paraplegia; is a paralysis of the lower half of the body with
involvement of both legs
http://www.merriam.com/

85.A client with myasthenia gravis continues to become weaker despite

treatment with
neostigmine. Endrophonium HCl (Tensilon) is ordered to
a) Rule in myasthenic crisis
c. To differentiate crisis
b) Rule in cholinergic crisis
d. All of the above

Endrophonium HCl (Tensilon) is ordered to prolonging the action of

a neurotransmitter called acetylcholine which is found naturally in the
body. It does this by inhibiting the action of the enzyme
acetylcholinesterase. Acetylcholine stimulates nicotinic and muscarinic
receptors.
https://pubchem.ncbi.nlm.nih.gov/compound/edrophonium
86.A
a.
b.
c.
d.

client with a hemiparesis uses a cane specifically to:

Maintain balance and improve stability
Relieve pressure on weight bearing joints
Prevent further injury to weakened muscles
Aid in controlling involuntary muscle movements

Rationale: Hemiparesis is the weakness of entire left or right side of the

body and clients with hemiparesis has problems in balance especially when trying to
walk. https://www.askdrshah.com/hemiplegia.aspx
87.A client has paraplegia as a result of a motorcycle accident. Nursing care
should include turning the client every 1 to 2 hours primarily to:
a. Prevent pressure ulcers
b. Keep the client comfortable
c. Prevent flexion contractures of the extremities
d. Improve venous circulation in the lower extremities
Rationale: Paraplegia is impairment in motor and sensory function of the
lower extremities. Turning the patient 1 to 2 hours prevent the patient having
pressure ulcers because of the immobility of this client.
Nurse Jade Dimaguiba Sy is recently transferred to the newly opened Neurologic
Unit of the Hospital. During her everyday duty, she is assigned to take care of
clients with different needs that affect the sensory, perception, coordination and
even motor functions.
88.A patient is 1 day post-surgery for a crushed pelvis. The CNA reports that the
patient is complaining of being short of breath and demonstrating signs of
confusion and restlessness. The nurse suspects from these signs alone that the
patient has suffered:
Impending shock.

c.

Anxiety.

a.
A fat embolus.
b.

d. Neurovascular compromise

Rationale: These are the classic symptoms of a fat embolus that has
escaped from the crushed marrow
89. The nurse would teach the older patient with a newly casted Colles fracture to:

Apply cool compresses to the cast.

a.
Let the hand and arm dangle to increase the drainage.
b.
Keep the hand immobile to reduce swelling.
c.
Move the shoulders to reduce contractures.
d.

Rationale: Movement of the shoulders will help decrease the threat of

contractures from immobility
90.The patient who has osteomyelitis following multiple fractures injuires what the
physician meant when he said that surgery would follow the antibiotic therapy.
The nurses most helpful reply is to explain that the surgery will be done to:

a.

Remove dead bone.

casting material.
Close the open draining wound.

b.

c.

Close the area with

d. Amputate.

Rationale: After the antibiotic has controlled the infection in the bone,
the surgery will
be done to remove the dead bone.

91. The patient with the crushed forearm cannot get pain relief with
opioids. The injury is swollen, cool, and cyanotic, with weak distal
pulses. The nurse assesses that this is a(n):
Compartment syndrome.

c.

Fat embolus

a.
Overwhelming infection.

d.

Osteomyelitis

b.
Rationalization: A compartment syndrome may occur following
massive injury or an inappropriately tight cast. The tissues become
swollen to the point that they cut off their own circulation.
Reference: https://www.coursehero.com/file/11508446/chapter-42/

92.The patient who sustained a simple fracture of the left fibula 7

days ago asks in what stage of bone healing he might be? The
nurse replies that at 7 days, the patient would be in the stage of:
Hematoma formation.

c.

Callus formation.

Ossification.

d. Fibrocartilage formation

a.

b.
Rationalization: Callus formation occurs at the end of the first week
after injury.
Reference: https://www.coursehero.com/file/11508446/chapter-42/

93.In caring for a patient just admitted with a pelvic fracture, the
assessment that would cause the most concern is:
a.A pain level rating of 8 on a 1 to 10 scale.
No urinary output for 8 hours.
b.
c.Evidence of bruising along the patients hips and buttocks.
d.Complaints of need for back care from resting in bed.

Rationalization: The absence of urinary output could indicate a

perforated bladder.
Reference: https://www.coursehero.com/file/11508446/chapter-42/

94.When an older woman falls down at church and immediately

complains of severe pain in her left hip, the choir director

recognizes the cardinal sign of a fractured hip when he sees:

a.

The left leg is shorter than the right.

left leg
Downward curled toes.

b.

c.

Internal rotation of the

d. Hematoma on the left hip.

Rationalization: The classic sign of a fractured hip is a shortened limb on

the affected side, with an externally rotated limb.
Reference: https://www.coursehero.com/file/11508446/chapter-42/

95.The patient has just had a plaster of Paris upper extremity cast
placed because of a fractured radius. The statement indicating
that the patient understands the discharge teaching related to
cast care is:
a. When I get home, I will remove some of the padding if it feels tight so my
fingers dont swell.
b. When I get home, I will wrap the cast in plastic so it will conserve the heat.
c.

When I get home, I will use a spoon handle to scratch inside if my arm
itches.

d. When I get home, I am going to rest in bed with my arm elevated

above my head.
Rationalization: Resting with the limb elevated above the head helps prevent
swelling
Reference: https://www.coursehero.com/file/11508446/chapter-42/

96 The nurse assisting with the application of a short arm plaster cast
application would take special care to:
a. Dampen the skin to make the stockinette adhere.
b. Tape the arm prior to application of the stockinette.
c. Smooth the stockinette to prevent a pressure ulcer.

d. Roll the stockinette tightly above and below the margins of the cast

Ratio: Forearm or wrist fractures. Also used to hold the forearm or wrist
muscles and tendons in place
after surgery.

97. The older patient who sustained a fractured hip and femur in a motor
vehicle accident is to be in Russells traction for several weeks, the nurse
will focus care on:
a. Offering frequent distractions.
b. Encouraging nutrition.

c. Pain relief.

d. Prevention of deep venous thrombos

Ratio:
Russell's traction is applied as adhesive or nonadhesive skin
a sling to relieve the weight ofthe lower extremities subjected
A jacket restraint is often incorporated to help immobilize the

98 The nurse performing a neurovascular assessment of the patient in

skeletal traction assesses the abnormal sign of:
a. Delayed capillary refill
b. Bilateral equal pulses
c. Absence of pain and swelling
d. Area is same color as the unaffected side

Ratio: The most important indicator of neurovascular compromise is pain

disproportionate to the injury. Pain associated with compartment syndrome i
generally constant however worse with passive movement to extension and
not relieved with opioid analgesia.
Indication of pain in non-verbal patients includes restlessness, grimacing,
guarding, tachycardia, hypotension, tachypnea or diaphoresis

99 When the nurse is told that a patient has a compound comminuted

fracture, the nurse is concerned because this type of fracture is one in

which the bone is:

a.

Bent but not completely broken, and the bent piece protrudes through the
skin.

b.

Compressed, and bone pieces protrude through the skin.

c.

Twisted, and the fragments are separated.

d.

Broken into two or more pieces, and bone fragments protrude through the
skin.

Ratio: A transverse fracture is when the broken piece of bone is at a right

angle to the bone's axis. An oblique fracture is when the break has a curved
or sloped pattern. A comminuted fracture is when the bone breaks into
several pieces

100. A patient with bilateral avascular necrosis of the hips is to walk with
crutches using a
four-point gait for 6 weeks after her bone decompression surgeries.
Which statement
would indicate that the patient understands this technique?

a. The axillary bars on the crutches should support my weight

when I walk.
b. I will move both crutches and then swing my legs to the crutches2
and 2 equals 4!

c. I will move my right crutch and then my left leg and then the left crut
and my right leg.

d. I will move both crutches and then swing my legs through the crutche
together.
Ratio: Avascular necrosis (AVN) is defined as cellular death of bone
components due to interruption of the blood supply; the bone structures
then collapse, resulting in bone destruction, pain, and loss of joint function.