Você está na página 1de 35

MUSCULOSKELETAL EXAM 3

1. Based on the nurse's understanding of the physiology of bone and cartilage, the injury that the
nurse would expect to heal most rapidly is a
a. fracture of the midhumerus.
b. torn knee cruciate ligament.
c. fractured nose.
d. severely sprained ankle.

Answer: A
Rationale: Bone is dynamic tissue that is continually growing. Nasal fracture, sprains, and ligament
tears injure cartilage, tendons, and ligaments, which are slower to heal.

2. The nurse is assessing the passive range of motion of a patient's shoulder. The patient complains
of pain during circumduction when the nurse moves the arm behind the patient. Which question
should the nurse ask?
a. "Do you ever have trouble making it to the toilet?"
b. "Do you have difficulty in putting on a jacket?"
c. "Are you able to feed yourself without difficulty?"
d. "How well are you able to sleep at night?"

Answer: B
Rationale: The patient's pain will make it more difficult to accomplish tasks like putting on a shirt or
jacket. This pain should not impact the patient's ability to feed himself or herself or use the toilet
because these tasks do not involve moving the arm behind the patient. The arm will not usually be
positioned behind the patient during sleeping.

3. When the health care provider tells a patient that the pain in the patient's knee is caused by
bursitis, the patient asks the nurse to explain just what bursitis is. The nurse's best response would
be to tell the patient bursitis is an inflammation of
a. the fibrocartilage that acts as a shock absorber in the knee joint.
b. a small, fluid-filled sac found at many joints.
c. any connective tissue that is found supporting the joints of the body.
d. the synovial membrane that lines the area between two bones of a joint.

Answer: B
Rationale: Bursae are fluid-filled sacs that cushion joints and bony prominences. Fibrocartilage is a
solid tissue that cushions some joints. Bursae are a specific type of connective tissue. The synovial
membrane lines many joints but is not a bursa.

4. During assessment of the musculoskeletal system of a 74-year-old woman, the nurse notes that
the patient has lost 1 inch in height since the previous visit two years ago. The nurse will plan to
teach the patient about
a. diskography studies.
b. magnetic resonance imaging (MRI).
c. dual-energy x-ray absorptiometry (DEXA).
d. myelographic testing.

Answer: C
Rationale: The decreased height and the patient's age suggest that the patient may have
osteoporosis and that bone density testing is needed. Diskography, MRI, and myelography are
typically done for patients with current symptoms caused by musculoskeletal dysfunction and are
not the initial diagnostic test for osteoporosis.

5. When taking a patient history during assessment of the musculoskeletal system, the nurse
identifies an increased risk for the patient who reports
a. that a parent became much shorter with aging.
b. a sprained ankle 2 years previously.
c. a family history of tuberculosis.
d. taking over-the-counter (OTC) ibuprofen (Advil) for occasional aches.

Answer: A
Rationale: A family history of height loss with aging may indicate osteoporosis, and the patient may
need to consider preventative actions, such as calcium supplements. A sprained ankle 2 years
previously will not cause any current or future musculoskeletal problems. A family history of
tuberculosis is not a risk factor. Occasional nonsteroidal antiinflammatory drug (NSAID) use does not
indicate any increased musculoskeletal risk.

6. Which information obtained during the nurse's assessment of the patient's nutritional-metabolic
pattern may indicate the risk for musculoskeletal problems?
a. The patient is 5 ft 2 in and weighs 180 lb.
b. The patient prefers whole milk to nonfat milk.
c. The patient dislikes fruits and vegetables.
d. The patient takes a multivitamin daily.

Answer: A
Rationale: The patient's height and weight indicate obesity, which places stress on weight-bearing
joints. The use of whole milk, avoiding fruits and vegetables, and use of a daily multivitamin are not
risk factors for musculoskeletal problems.

7. When the nurse is assessing a new patient in the clinic, which information about the patient's
medications will be of most concern?
a. The patient takes hormone replacement therapy (HRT) to prevent "hot flashes."
b. The patient takes a daily multivitamin and calcium supplement.
c. The patient has severe asthma and requires frequent therapy with steroids.
d. The patient has migraine headaches which are treated with NSAIDs.

Answer: C
Rationale: Corticosteroid use may lead to skeletal problems such as avascular necrosis and
osteoporosis. The use of HRT and calcium supplements will help prevent osteoporosis. NSAID use
does not increase the risk for musculoskeletal problems.

8. While testing the patient's muscle strength, the nurse finds that the patient can flex the arms
when no resistance is applied but is unable to flex when the nurse applies light resistance. The nurse
should documents the patient's muscle strength as level
a. 1.
b. 2.
c. 3.
d. 4.
Answer: C
Rationale: A level 3 indicates that the patient is unable to move against resistance but can move
against gravity. Level 1 indicates minimal muscle contraction, level 2 indicates that the arm can move
when gravity is eliminated, and level 4 indicates active movement with some resistance.

9. When assessing the musculoskeletal system, the nurse's initial action will usually be to
a. have the patient move the extremities against resistance.
b. feel for the presence of crepitus during joint movement.
c. observe the patient's body build and muscle configuration.
d. check active and passive range of motion for the extremities.

Answer: C
Rationale: The usual technique in the physical assessment is to begin with inspection. Abnormalities
in muscle mass or configuration will allow the nurse to perform a more focused assessment of
abnormal areas. The other assessments are also included in the assessment but are usually done
after inspection.

10. A patient is seen at the urgent care center following a blunt injury to the left knee. The knee is
grossly swollen and very painful, but the skin is intact. During an arthrocentesis on the patient's
knee, the nurse would expect the aspirated fluid to appear
a. sanguineous.
b. purulent and thick.
c. straw colored.
d. white, thick, and ropelike.

Answer: A
Rationale: The patient's clinical manifestations suggest hemarthrosis, and the appearance of blood in
the synovial fluid is expected. Purulent fluid occurs when there is a joint infection. Straw-colored fluid
is normal and will not be expected when the knee is swollen and painful. Thick fluid suggests
infection.

11. A patient suffers an injury to the shoulder while playing football. To identify abnormalities of
cartilage and soft tissue surrounding the joint, the nurse would expect the patient to be evaluated
with
a. radioisotope bone scanning.
b. arthroscopy.
c. standard x-rays.
d. magnetic resonance imaging (MRI).

Answer: D
Rationale: MRI is most useful in assessing for soft tissue injuries. Bone scanning and standard
radiographs are used to assess for injures or lesions of bone. Arthroscopy is used for visualizing the
joints.

12. A patient with kyphosis is scheduled for dual-energy x-ray absorptiometry (DEXA) testing. The
nurse will plan to
a. start an intravenous line.
b. screen the patient for shellfish allergies.
c. teach the patient that DEXA is noninvasive.
d. give an oral sedative.

Answer: C
Rationale: DEXA testing is painless and noninvasive. No IV access is necessary. Contrast medium is
not used. Because the procedure is painless, no antianxiety medications are required.

13. A patient has a new order for open magnetic resonance imaging (MRI) to evaluate for right femur
osteomyelitis. Which information obtained by the nurse indicates that the nurse should consult with
the health care provider before scheduling an MRI?
a. The patient is claustrophobic.
b. The patient wears a hearing aid.
c. The patient is allergic to shellfish.
d. The patient has a pacemaker.

Answer: D
Rationale: Patients with permanent pacemakers cannot have MRI. An open MRI will not cause
claustrophobia. The patient will need to be instructed to remove the hearing aid before the MRI, but
this does not require consultation with the health care provider. Contrast medium will not be used,
so shellfish allergy is not a contraindication to MRI.

A nurse is performing a musculoskeletal assessment on an older adult. What physiologic changes of


aging will the nurse expect? (select all)
A. scoliosis
B. Muscle Atrophy
C. Slowed Movement
D. Rheumatoid Arthritis
E. Antalgic gait

A client returns to PACU after an arthroscopy to repair several knee ligaments. What is the nurse's
priority when caring for this client?
A. Take vitals every hour
B. Check for swelling & bleeding
C. Perform frequent neurovascular assessments
D. Ensure that the surgical dressing is intact

Which statement by the client regarding lifestyle changes to prevent osteoporosis indicates a need
for further teaching by the nurse?
A. "I need to eat more green, leafy veggies and dairy."
B. "I will cut down the amount of wine I drink each night."
C. "I plan to begin smoking cessation classes at the hospital."
D. "I am going to want to work out 3 days/week at the gym."

A client is starting on alendronate (Fosamax) for prevention of osteoporosis. What precaution will the
nurse include in the clients health teaching about this drug?
A. "Take food or milk to prevent stomach upset."
B. "Monitor the drug injection site for redness or itching."
C. "Take the drug at night before you go to bed."
D. "Do not lie down for at least 30 minutes after the drug."

A client has a new synthetic arm cast for a radial fracture. What health care teaching does the nurse
include for the clients home care? (Select all)
A. "Apply heat on the cast for the first 24 hours to increase blood flow for healing."
B. "keep your arm elevated, preferably above your heart, as much as possible."
C. "Report severe numbness or inability to move your fingers to your physician."
D. "Don't cover the cast with anything because it will stay wet for 24 hours."

A client who had an elective below-the-knee amputation reports pain in the part of his leg that was
amputated. What is the nurse's best response to his pain?
A. "the pain will go away in a few days or so."
B. "that's phantom limb pain and every amputee has that."
C. "on a scale of 0-10, how would you rate your pain?"
D. "the pain is not real, so we don't treat it."

The nurse is concerned that a client who had an open reduction, internal fixation of his tibia and
fibula is at risk for complex regional pain syndrome. What assessment findings at the affected area
are common when a client has this complication? (select all)
A. Dull, aching pain
B. Decrease in sweating
C. Muscle spasms
D. Skin discoloration
E. paresis
F. Edema

C,D,E,F

An older woman had a left total hip arthroplasty yesterday afternoon mom which precautions will
the nurse teach before helping the client transfer from the bed to the chair? (Select all)
A. "Stand on your left leg and pivot to the chair. "
B. "Do not hyper flex your hips when sitting."
C. "Cross your legs to be more comfortable."
D. "Avoid twisting your body when moving."
E. "Use your cane to help move into the chair. "

B,D,E

A nursing assistant is assigned to care for a client who has a CPM machine in place after a total knee
arthroplasty. Which statement by the NA indicates a need for further teaching and supervision?
A. "I will turn off the machine if the client has any pain."
B. "I will turn off the machine when the client wants to eat."
C. "I will store the machine on a chair when not used."
D. "I will check to make sure the clients leg is correctly placed."

A
Which assessment findings will the nurse expect for the client with late stage rheumatoid arthritis
(select all)
A. Heberdens nodes
B. High erythrocyte sedimentation values
C. Positive antinuclear antibody titer
D. Subcutaneous nodules
E. Anemia
F. Red, swollen joints

B,C,D,E,F

What health teaching by the nurse is the most important for clients diagnosed with discoid lupus
erythematosus and managing the disease using topical steroid cream?
A."take calcium supplements to prevent osteoporosis from the steroid. "
B. "Stay away from crowds and people with infections."
C. "Avoid being in the sun to prevent flare ups."
D. "Use heavy powder makeup to cover skin lesions. "

Which drug is not appropriate to treat the disease with which it is matched?
A. RA-zyloprim
B. Osteoarthritis- Celebrex
C. Acute gout- colsalide
D. Lupus- deltasone

Which finding will the nurse expect when assessing a 60-year-old patient who has osteoarthritis (OA)
of the left knee?
a. Heberden's nodules
b. Pain upon joint movement
c. Redness and swelling of the knee joint
d. Stiffness that increases with movement

ANS: B
Initial symptoms of OA include pain with joint movement. Heberden's nodules occur on the fingers.
Redness of the joint is more strongly associated with rheumatoid arthritis (RA), and stiffness in OA is
worse right after the patient rests and decreases with joint movement.

Which assessment finding about a patient who has been using naproxen (Naprosyn) for 3 weeks to
treat osteoarthritis is most important for the nurse to report to the health care provider?
a. The patient has dark colored stools.
b. The patient's pain has not improved.
c. The patient is using capsaicin cream (Zostrix).
d. The patient has gained 3 pounds over 3 weeks.

ANS: A
Dark colored stools may indicate that the patient is experiencing gastrointestinal bleeding caused by
the naproxen. The information about the patient's ongoing pain and weight gain also will be reported
and may indicate a need for a different treatment and/or counseling about avoiding weight gain, but
these are not as large a concern as the possibility of gastrointestinal bleeding. Use of capsaicin cream
with oral medications is appropriate.

After the nurse has finished teaching a patient with osteoarthritis (OA) of the left hip and knee about
how to manage the OA, which patient statement indicates a need for more education?
a. "I can take glucosamine to help decrease my knee pain."
b. "I will take 1 g of acetaminophen (Tylenol) every 4 hours."
c. "I will take a shower in the morning to help relieve stiffness."
d. "I can use a cane to decrease the pressure and pain in my hip."

ANS: B
No more than 4 g of acetaminophen should be taken daily to avoid liver damage. The other patient
statements are correct and indicate good understanding of OA management.

When caring for a patient who has osteoarthritis, the nurse will anticipate the need to teach the
patient about which of these medications?
a. Adalimumab (Humira)
b. Prednisone (Deltasone)
c. Capsaicin cream (Zostrix)
d. Sulfasalazine (Azulfidine)

ANS: C
Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating
OA. The other medications would be used for patients with RA.

A patient who has rheumatoid arthritis is seen in the outpatient clinic and the nurse notes that
rheumatoid nodules are present on the patient's elbows. Which action will the nurse take?
a. Draw blood for rheumatoid factor analysis.
b. Teach the patient about injection of the nodule.
c. Assess the nodules for skin breakdown or infection.
d. Discuss the need for surgical removal of the nodule.

ANS: C
Rheumatoid nodules can break down or become infected. They are not associated with changes in
rheumatoid factor and injection is not needed. Rheumatoid nodules are usually not removed
surgically because of a high probability of recurrence

When caring for a patient with a new diagnosis of rheumatoid arthritis, which action will the nurse
include in the plan of care?
a. Instruct the patient to purchase a soft mattress.
b. Teach patient to use lukewarm water when bathing.
c. Suggest that the patient take a nap in the afternoon.
d. Suggest exercise with light weights several times daily.

ANS: C
Adequate rest helps decrease the fatigue and pain that are associated with rheumatoid arthritis.
Patients are taught to avoid stressing joints, to use warm baths to relieve stiffness, and to use a firm
mattress.

A home health patient with rheumatoid arthritis (RA) complains to the nurse about having
chronically dry eyes. Which action by the nurse is most appropriate?
a. Reassure the patient that dry eyes are a common problem with RA.
b. Teach the patient more about adverse affects of the RA medications.
c. Suggest that the patient start using over-the-counter (OTC) artificial tears.
d. Ask the health care provider about lowering the methotrexate (Rheumatrex) dose.

ANS: C
The patient's dry eyes are consistent with Sjgren's syndrome, a common extraarticular
manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes are not
a side effect of methotrexate. Although dry eyes are common in RA, it is more helpful to offer a
suggestion to relieve these symptoms than to offer reassurance. The dry eyes are not caused by RA
treatment, but by the disease itself.

Which information will the nurse include when teaching range-of-motion exercises to a patient with
an exacerbation of rheumatoid arthritis?
a. Affected joints should not be exercised when pain is present.
b. Application of cold packs before exercise may decrease joint pain.
c. Exercises should be performed passively by someone other than the patient.
d. Walking may substitute for range-of-motion (ROM) exercises on some days.

ANS: B
Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint
pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are
intended to strengthen joints as well as improve flexibility, so passive ROM alone is not sufficient.
Recreational exercise is encouraged but is not a replacement for ROM exercises.

Prednisone (Deltasone) is prescribed for a patient with an acute exacerbation of rheumatoid


arthritis. Which laboratory result will the nurse monitor to determine whether the medication has
been effective?
a. Blood glucose test
b. Liver function tests
c. C-reactive protein level
d. Serum electrolyte levels

ANS: C
C-reactive protein is a marker for inflammation, and a decrease would indicate that the
corticosteroid therapy was effective. Blood glucose and serum electrolyte levels also will be
monitored to check for side effects of prednisone. Liver function is not routinely monitored for
patients receiving steroids.

When teaching a patient who has rheumatoid arthritis (RA) about how to manage activities of daily
living, the nurse instructs the patient to
a. stand rather than sit when performing household chores.
b. avoid activities that require continuous use of the same muscles.
c. strengthen small hand muscles by wringing sponges or washcloths.
d. protect the knee joints by sleeping with a small pillow under the knees.

ANS: B
Patients are advised to avoid repetitious movements. Sitting during household chores is
recommended to decrease stress on joints. Wringing water out of sponges would increase the joint
stress. Patients are encouraged to position joints in the extended position, and sleeping with a pillow
behind the knees would decrease the ability of the knee to extend and also decrease knee range of
motion (ROM).
When helping a patient with rheumatoid arthritis (RA) plan a daily routine, the nurse informs the
patient that it is most helpful to start the day with
a. a warm bath followed by a short rest.
b. a short routine of isometric exercises.
c. active range-of-motion (ROM) exercises.
d. stretching exercises to relieve joint stiffness.

ANS: A
Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the
morning. Isometric exercises would place stress on joints and would not be recommended.
Stretching and ROM should be done later in the day, when joint stiffness is decreased.

Anakinra (Kineret) is prescribed for a patient who has rheumatoid arthritis (RA). When teaching the
patient about this drug, the nurse will include information about
a. self-administration of subcutaneous injections.
b. taking the medication with at least 8 oz of fluid.
c. avoiding concurrently taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDs).
d. symptoms of gastrointestinal (GI) irritation or bleeding.

ANS: A
Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this
medication. Because the medication is injected, instructions to take it with 8 oz of fluid would not be
appropriate. The patient is likely to be concurrently taking aspirin or NSAIDs, and these should not be
discontinued.

A 35-year-old patient with three school-age children who has recently been diagnosed with
rheumatoid arthritis (RA) tells the nurse that the inability to be involved in many family activities is
causing stress at home. Which response by the nurse is most appropriate?
a. "You may need to see a family therapist for some help."
b. "Tell me more about the situations that are causing stress."
c. "Perhaps it would be helpful for you and your family to get involved in a support group."
d. "Your family may need some help to understand the impact of your rheumatoid arthritis."

ANS: B
The initial action by the nurse should be further assessment. The other three responses might be
appropriate based on the information the nurse obtains with further assessment.

Which information will the nurse include when teaching a patient with newly diagnosed ankylosing
spondylitis (AS) about the management of the condition?
a. Exercise by taking long walks.
b. Do daily deep breathing exercises.
c. Sleep on the side with hips flexed.
d. Take frequent naps during the day.

ANS: B
Deep breathing exercises are used to decrease the risk for pulmonary complications that may occur
with the reduced chest expansion that can occur with ankylosing spondylitis (AS). Patients should
sleep on the back and avoid flexed positions. Prolonged standing and walking should be avoided.
There is no need for frequent naps.
A 22-year-old patient hospitalized with a fever and red, hot, and painful knees is suspected of having
septic arthritis. Information obtained during the nursing history that indicates a risk factor for septic
arthritis is that the patient
a. has a parent who has reactive arthritis.
b. is sexually active and has multiple partners.
c. recently returned from a trip to South America.
d. had several sports-related knee injuries as a teenager.

ANS: B
Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults.
The other information does not point to any risk for septic arthritis.

While working at a summer camp, the nurse notices a circular lesion with a red border and clear
center on the arm of a patient who is in the camp clinic complaining of chills and muscle aches.
Which action should the nurse take next?
a. Palpate the abdomen.
b. Auscultate the heart sounds.
c. Ask the patient about recent outdoor activities.
d. Question the patient about immunization history.

ANS: C
The patient's clinical manifestations suggest possible Lyme disease. A history of recent outdoor
activities such as hikes will help confirm the diagnosis. The patient's symptoms do not suggest
cardiac or abdominal problems or lack of immunization.

A 26-year-old patient with urethritis and knee pain is diagnosed with reactive arthritis. The nurse will
plan to teach the patient about the need for several months of therapy with
a. anakinra (Kineret).
b. etanercept (Enbrel).
c. doxycycline (Vibramycin).
d. methotrexate (Rheumatrex).

ANS: C
Reactive arthritis associated with urethritis is usually caused by infection with Chlamydia trachomatis
and requires 3 months of treatment with doxycycline. The other medications are used for chronic
inflammatory problems such as rheumatoid arthritis.

A patient with an acute attack of gout is treated with colchicine. The nurse determines that the drug
is effective upon finding
a. relief of joint pain.
b. increased urine output.
c. elevated serum uric acid.
d. decreased white blood cells (WBC).

ANS: A
Colchicine produces pain relief in 24 to 48 hours by decreasing inflammation. The recommended
increase in fluid intake of 2 to 3 L/day would increase urine output but would not indicate the
effectiveness of colchicine. Elevated uric acid levels would result in increased symptoms. The WBC
count might decrease with decreased inflammation, but this would not be as useful in determining
the effectiveness of colchicine as a decrease in pain.
A patient with gout tells the nurse that he takes losartan (Cozaar) for control of the condition. The
nurse will plan to monitor
a. blood glucose.
b. blood pressure.
c. erythrocyte count.
d. lymphocyte count.

ANS: B
Losartan, an angiotensin II receptor antagonist, will lower blood pressure. It does not affect blood
glucose, red blood cell count (RBC), or lymphocytes.

A long-term care patient who takes multiple medications develops acute gouty arthritis. The nurse
will consult with the health care provider before giving the prescribed dose of
a. sertraline (Zoloft).
b. famotidine (Pepcid).
c. oxycodone (Roxicodone).
d. hydrochlorothiazide (HydroDIURIL).

ANS: D
Diuretic use increases uric acid levels and can precipitate gout attacks. The other medications are
safe to administer.

Which statement by a 24-year-old woman with systemic lupus erythematosus (SLE) indicates that the
patient has understood the nurse's teaching about management of the condition?
a. "I will use a sunscreen whenever I am outside."
b. "I will try to keep exercising even if I am tired."
c. "I should take birth control pills to keep from getting pregnant."
d. "I should not take aspirin or nonsteroidal anti-inflammatory drugs."

ANS: A
Severe skin reactions can occur in patients with SLE who are exposed to the sum. Patients should
avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate
lupus. Aspirin and nonsteroidal anti-inflammatory drugs are used to treat the musculoskeletal
manifestations of SLE.

A patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse,
"I hate the way I look! I never go anywhere except here to the health clinic." An appropriate nursing
diagnosis for the patient is
a. activity intolerance related to fatigue and inactivity.
b. impaired social interaction related to lack of social skills.
c. impaired skin integrity related to itching and skin sloughing.
d. social isolation related to embarrassment about the effects of SLE.

ANS: D
The patient's statement about not going anywhere because of hating the way he or she looks
supports the diagnosis of social isolation because of embarrassment about the effects of the SLE.
Activity intolerance is a possible problem for patients with SLE, but the information about this patient
does not support this as a diagnosis. The rash with SLE is nonpruritic. There is no evidence of lack of
social skills for this patient.
To determine whether a patient with joint swelling and pain has systemic lupus erythematosus,
which test will be most useful for the nurse to review?
a. Rheumatoid factor (RF)
b. Antinuclear antibody (ANA)
c. Anti-Smith antibody (Anti-Sm)
d. Lupus erythematosus (LE) cell prep

ANS: C
The anti-Sm is antibody found almost exclusively in SLE. The other blood tests also are used in
screening but are not as specific to SLE.

When caring for a patient with gout and a red and painful left great toe, which nursing action will be
included in the plan of care?
a. Gently palpate the toe to assess swelling.
b. Use pillows to keep the left foot elevated.
c. Use a footboard to hold bedding away from the toe.
d. Teach patient to avoid use of acetaminophen (Tylenol).

ANS: C
Since any touch on the area of inflammation may increase pain, bedding should be held away from
the toe and touching the toe will be avoided. Elevation of the foot will not reduce the pain, which is
caused by the urate crystals. Acetaminophen can be used for pain relief.

The health care provider has prescribed the following collaborative interventions for a 49-year-old
who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse
question?
a. Draw anti-DNA blood titer.
b. Administer varicella vaccine.
c. Use naproxen (Aleve) 200 mg BID.
d. Take famotidine (Pepcid) 20 mg daily.

ANS: B
Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive
drugs. The other orders are appropriate for the patient.

A patient has systemic sclerosis manifested by CREST (calcinosis, Raynaud's phenomenon,


esophageal dysfunction, sclerodactyly, telangiectasia) syndrome. Which action will the nurse include
in the plan of care?
a. Avoid use of capsaicin cream on hands.
b. Keep patient's room warm and draft free.
c. Obtain capillary blood glucose before meals.
d. Assist to bathroom every 2 hours while awake.

ANS: B
Keeping the room warm will decrease the incidence of Raynaud's phenomenon, one aspect of the
CREST syndrome. Capsaicin cream may be used to improve circulation and decrease pain. There is no
need to obtain blood glucose levels or to assist the patient to the bathroom every 2 hours.

After teaching a patient diagnosed with progressive systemic sclerosis about health maintenance
activities, the nurse determines that additional instruction is needed when the patient says,
a. "I should lie down for an hour after meals."
b. "Paraffin baths can be used to help my hands."
c. "Lotions will help if I rub them in for a long time."
d. "I should perform range-of-motion exercises daily."

ANS: A
Because of the esophageal scarring, patients should sit up for 2 hours after eating. The other patient
statements are correct and indicate that the teaching has been effective.

A patient with rheumatoid arthritis refuses to take the prescribed methotrexate (Rheumatrex), telling
the nurse "That drug has too many side effects. My arthritis isn't that bad yet." The most appropriate
response by the nurse is
a. "You have the right to refuse to take the methotrexate."
b. "Methotrexate is less expensive than some of the newer drugs."
c. "It is important to start methotrexate early to decrease the extent of joint damage."
d. "Methotrexate is effective and has fewer side effects than some of the other drugs."

ANS: C
Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the joint
degeneration that occurs as soon as the first year with RA. The other statements are accurate, but
the most important point for the patient to understand is that it is important to start DMARDs as
quickly as possible.

A patient with an exacerbation of rheumatoid arthritis (RA) is taking prednisone (Deltasone) 40 mg


daily. Which of these assessment data obtained by the nurse indicate that the patient is experiencing
a side effect of the medication?
a. The patient's blood glucose is 165 mg/dL.
b. The patient has no improvement in symptoms.
c. The patient has experienced a recent 5-pound weight loss.
d. The patient's erythrocyte sedimentation rate (ESR) has increased.

ANS: A
Corticosteroids have the potential to cause diabetes mellitus. The finding of an elevated blood
glucose reflects this side effect of prednisone. Corticosteroids increase appetite and lead to weight
gain. An elevated ESR and no improvement in symptoms would indicate that the prednisone was not
effective but would not be side effects of the medication

The home health nurse is doing a follow-up visit to a patient with recently diagnosed rheumatoid
arthritis (RA). Which assessment made by the nurse indicates that more patient teaching is needed?
a. The patient requires a 2-hour midday nap.
b. The patient has been taking 16 aspirins daily.
c. The patient sits on a stool when preparing meals.
d. The patient sleeps with two pillows under the head.

ANS: D
The joints should be maintained in an extended position to avoid contractures, so patients should
use a small, flat pillow for sleeping. The other information is appropriate for a patient with RA and
indicates that teaching has been effective.

A patient with an acute attack of gout in the left great toe has a new prescription for probenecid
(Benemid). Which information about the patient's home routine indicates a need for teaching
regarding gout management?
a. The patient sleeps about 8 to 10 hours every night.
b. The patient usually eats beef once or twice a week.
c. The patient generally drinks about 3 quarts of juice and water daily.
d. The patient takes one aspirin a day prophylactically to prevent angina.

ANS: D
Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is
taking probenecid. The patient's sleep pattern will not affect gout management. Drinking 3 quarts of
water and eating beef only once or twice a week are appropriate for the patient with gout.

When the nurse is reviewing laboratory results for a patient with systemic lupus erythematosus
(SLE), which result is most important to communicate to the health care provider?
a. Decreased C-reactive protein (CRP)
b. Elevated blood urea nitrogen (BUN)
c. Positive antinuclear antibodies (ANA)
d. Positive lupus erythematosus cell prep

ANS: B
The elevated BUN and creatinine levels indicate possible lupus nephritis and a need for a change in
therapy to avoid further renal damage. The positive lupus erythematosus (LE) cell prep and ANA
would be expected in a patient with SLE. A drop in CRP shows an improvement in the inflammatory
process.

The nurse obtains this information when assessing a patient who is taking hydroxychloroquine
(Plaquenil) to treat rheumatoid arthritis. Which symptom is most important to report to the health
care provider?
a. Abdominal cramping
b. Complaint of blurry vision
c. Phalangeal joint tenderness
d. Blood pressure 170/84 mm Hg

ANS: B
Plaquenil can cause retinopathy; the medication should be stopped. The other findings are not
related to the medication, although they also will be reported.

After obtaining the health history from a 28-year-old woman who is taking methotrexate
(Rheumatrex) to treat rheumatoid arthritis, which information about the patient is most important
for the nurse to report to the health care provider?
a. The patient had a history of infectious mononucleosis as a teenager.
b. The patient is trying to have a baby before her disease becomes more severe.
c. The patient has a family history of age-related macular degeneration of the retina.
d. The patient has been using large doses of vitamins and health foods to treat the RA.

ANS: B
Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate
therapy. The other information will not impact the choice of methotrexate as therapy.

When the nurse is reviewing laboratory data for a patient who is taking methotrexate (Rheumatrex)
to treat rheumatoid arthritis, which information is most important to communicate to the health
care provider?
a. The blood glucose is 75 mg/dL.
b. The rheumatoid factor is positive.
c. The white blood cell (WBC) count is 1500/L.
d. The erythrocyte sedimentation rate is elevated.

ANS: C
Bone marrow suppression is a possible side effect of methotrexate, and the patient's low WBC count
places the patient at high risk for infection. The elevated erythrocyte sedimentation rate and positive
rheumatoid factor are expected in rheumatoid arthritis. The blood glucose is normal.

A patient who had arthroscopic surgery of the left knee 5 days ago is admitted with a red, swollen,
and hot knee. Which assessment finding by the nurse should be reported to the health care provider
immediately?
a. The blood pressure is 88/46 mm Hg.
b. The white blood cell count is 14,200/L.
c. The patient is taking ibuprofen (Motrin).
d. The patient says the knee is very painful.

ANS: A
The low blood pressure suggests that the patient may be developing septicemia as a complication of
septic arthritis. Immediate blood cultures and initiation of antibiotic therapy are indicated. The other
information is typical of septic arthritis and also should be reported to the health care provider, but it
does not indicate any immediately life-threatening problems.

A patient hospitalized with polymyositis has joint pain, an erythematosus facial rash with eyelid
edema, and a weak, hoarse voice. The priority nursing diagnosis for the patient is
a. acute pain related to inflammation.
b. risk for aspiration related to dysphagia.
c. risk for impaired skin integrity related to scratching.
d. disturbed visual perception related to eyelid swelling.

ANS: B
The patient's vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a
high risk for aspiration. The other nursing diagnoses also are appropriate but are not as high a
priority as the maintenance of the patient's airway.

A patient with dermatomyositis is receiving long-term prednisone (Deltasone) therapy. Which


assessment finding by the nurse is most important to report to the health care provider?
a. The blood glucose is 112 mg/dL.
b. The patient has painful hematuria.
c. The patient has an increased appetite.
d. Acne is noted on the back and face.

ANS: B
Corticosteroid use is associated with increased risk for infection, so the nurse should report the
urinary tract symptoms immediately to the health care provider. The increase in blood glucose,
increased appetite, and acne also are adverse effects of corticosteroid use, but do not need diagnosis
and treatment as rapidly as the probable urinary tract infection.

Which of these patients seen by the nurse in the outpatient clinic is most likely to require teaching
about ways to reduce risk for osteoarthritis (OA)?
a. A 56-year-old man who is a member of a construction crew
b. A 24-year-old man who participates in a summer softball team
c. A 49-year-old woman who works on an automotive assembly line
d. A 36-year-old woman who is newly diagnosed with diabetes mellitus

ANS: C
OA is more likely to occur in women as a result of estrogen reduction at menopause and in
individuals whose work involves repetitive movements and lifting. Moderate exercise, such as
softball, reduces risk for OA. Diabetes is not a risk factor for OA. Working on a construction crew
would involve nonrepetitive work and thus would not be as risky

During assessment of the patient with fibromyalgia syndrome (FMS), the nurse would expect the
patient to report (select all that apply)?
a. sleep disturbances.
b. multiple tender points.
c. cardiac palpitations and dizziness.
d. multijoint pain with inflammation and swelling.
e. widespread bilateral, burning musculoskeletal pain.

ANS: A, B, C, E
These symptoms are commonly described by patients with FMS. Cardiac involvement and joint
inflammation are not typical of FMS.

When counseling an older patient about ways to prevent fractures, which information will the nurse
include?
a.
Tacking down scatter rugs in the home is recommended.
b.
Occasional weight-bearing exercise will improve muscle and bone strength.
c.
Most falls happen outside the home.
d.
Buying shoes that provide good support and are comfortable to wear is recommended.

Correct Answer: D
Rationale: Comfortable shoes with good support will help to decrease the risk for falls. Scatter rugs
should be eliminated, not just tacked down. Regular weight-bearing exercise will improve strength,
but occasional exercise is not helpful in improving strength. Falls inside the home are responsible for
many injuries.

Cognitive Level: Application Text Reference: p. 1630


Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance

A patient is seen at the urgent care center after falling on the right arm and shoulder. It will be most
important for the nurse to determine
a.
whether there is bruising at the shoulder area.
b.
whether the right arm is shorter than the left.
c.
the amount of pain the patient is experiencing.
d.
how much range of motion (ROM) is present.

Correct Answer: B
Rationale: A shorter limb after a fall indicates a possible dislocation, which is an orthopedic
emergency. The nurse will expect bruising and pain at the area, even without an injury that requires
surgery. The shoulder should be immobilized until it is evaluated by the health care provider.

3. A checkout clerk in a grocery store has muscle and tendon tears that have become inflamed,
causing pain and weakness in the left hand and elbow. The nurse identifies these symptoms as
related to
a.
muscle spasms.
b.
meniscus injury.
c.
repetitive strain injury.
d.
carpal tunnel syndrome.

Correct Answer: C
Rationale: The patient's occupation and the inflammation, pain, and weakness in the elbow and hand
suggest a repetitive strain injury. Muscle spasms would be characterized by a palpable, firm muscle
mass during the spasm. Meniscus injury would affect the knee. Carpal tunnel syndrome is
characterized by weakness and numbness of the hand.

4. When working with a patient whose job involves many hours of word processing, the nurse will
teach the patient about the need to
a.
do stretching and warm-up exercises before starting work.
b.
wrap the wrists with a compression bandage every morning.
c.
use acetaminophen (Tylenol) instead of NSAIDs for wrist pain.
d.
obtain a keyboard pad to support the wrist while word processing.

Correct Answer: D
Rationale: Repetitive strain injuries caused by prolonged times working at a keyboard can be
prevented by the use of a pad that will keep the wrists in a straight position. Stretching exercises
during the day may be helpful, but these would not be needed before starting. Use of a compression
bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are
appropriate to use to decrease swelling.

Cognitive Level: Application Text Reference: p. 1633


Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance
A patient arrives in the emergency department with ankle swelling and severe pain after twisting the
ankle playing soccer. All of the following orders are written by the health care provider. Which one
will the nurse act on first?
a.
Administer naproxen (Naprosyn) 500 mg PO.
b.
Wrap the ankle and apply an ice pack.
c.
Give acetaminophen with codeine (Tylenol #3).
d.
Take the patient to the radiology department for x-rays.

Correct Answer: B
Rationale: Immediate care after a sprain or strain injury includes the application of cold and
compression to the injury to minimize swelling. The other actions should be taken after the ankle is
wrapped with a compression bandage and ice is applied.

Cognitive Level: Application Text Reference: p. 1631


Nursing Process: Implementation NCLEX: Physiological Integrity

Following x-rays of an injured wrist, the patient is informed that it is badly sprained. In teaching the
patient to care for the injury, the nurse tells the patient to
a.
apply a heating pad to reduce muscle spasms.
b.
wear an elastic compression bandage continuously.
c.
use pillows to keep the arm elevated above the heart.
d.
gently exercise the joint to prevent muscle shortening.

Correct Answer: C
Rationale: Elevation of the arm will reduce the amount of swelling and pain. For the first 24 to 48
hours, cold packs are used to reduce swelling. Compression bandages are not left on continuously.
The wrist should be rested and kept immobile to prevent further swelling or injury.

7. A 22-year-old patient started an exercise regimen 2 months ago that includes running 3 to 4 miles
a day. The patient tells the nurse, "I enjoy my daily runs, but now I have shin splints." Which response
by the nurse is appropriate?
a.
"You may be increasing your running time too quickly and need to cut back a little bit."
b.
"You need to have x-rays of your lower legs to be sure you do not have stress fractures."
c.
"You should expect some leg pain while running."
d.
"You should try speed-walking rather than running."

Correct Answer: A
Rationale: The patient's information about running 3 to 4 miles daily after starting an exercise
program only 2 months previously suggests that the shin splints are caused by overuse. Radiographs
are not indicated for the type of injury described by the patient. Shin splints are not a normal or
expected response to running. Because the patient expresses enjoyment of running, it would not be
appropriate for the nurse to suggest a different sport.

Cognitive Level: Application Text Reference: p. 1630


Nursing Process: Implementation NCLEX: Physiological Integrity

A 20-year-old baseball pitcher has an arthroscopic repair of a rotator cuff injury performed in same-
day surgery. When the nurse plans postoperative teaching for the patient, which information will be
included?
a.
"You have an appointment with a physical therapist for tomorrow."
b.
"Leave the shoulder immobilizer on for the first few days to minimize pain."
c.
"The doctor will use the drop-arm test to determine the success of the procedure."
d.
"You should try to find a different position to play on the baseball team."

Correct Answer: A
Rationale: Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent
"frozen shoulder." A shoulder immobilizer is used immediately after the surgery, but leaving the arm
immobilized for several days would lead to loss of ROM. The drop-arm test is used to test for rotator
cuff injury, but not after surgery. The patient may be able to return to pitching after rehabilitation.

9. A patient with a fractured radius asks when the cast can be removed. The nurse will instruct the
patient that the cast can be removed only after the bone
a.
is strong enough to stand mild stress.
b.
union is complete on the x-ray.
c.
fragments are fully fused.
d.
healing has started.

Correct Answer: A
Rationale: The cast may be removed when callus ossification has occurred. It is not necessary to wait
until radiologic union or complete bone fusion occurs. Bone healing starts immediately after the
injury, but the cast will need to be worn at least 3 weeks.

10. A patient with a comminuted fracture of the right femur has Buck's traction in place while waiting
for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin
care, the nurse should
a.
have the patient lift the buttocks by bending and pushing with the left leg.
b.
turn the patient partially to each side with the assistance of another nurse.
c.
place a pillow between the patient's legs and turn gently to each side.
d.
loosen the traction and have the patient turn onto the unaffected side.

Correct Answer: A
Rationale: The patient can lift the buttocks off the bed by using the left leg without changing the
right-leg alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the
traction will interrupt the weight needed to immobilize and align the fracture.

11. A patient in the emergency department is diagnosed with a patellar dislocation. The initial
patient teaching by the nurse will focus on the need for
a.
conscious sedation.
b.
a knee immobilizer.
c.
gentle knee flexion.
d.
cast application.

Correct Answer: A
Rationale: The first goal of collaborative management is realignment of the knee to its original
anatomic position, which will require anesthesia or conscious sedation. Immobilization of the joint
will be done after realignment. Later, gentle ROM exercises may be started if the joint is stable.
Casting is not usually required for dislocations.

Cognitive Level: Application Text Reference: p. 1632


Nursing Process: Implementation NCLEX: Physiological Integrity

12. Following a motor-vehicle accident, a patient arrives in the emergency department with massive
right lower-leg swelling. Which action will the nurse take first?
a.
Elevate the leg on pillows.
b.
Apply a compression bandage.
c.
Place ice packs on the lower leg.
d.
Check leg pulses and sensation.

Correct Answer: D
Rationale: The initial action by the nurse will be to assess the circulation to the leg and to observe for
any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions
may be appropriate based on what is observed during the assessment.

13. Following the application of a hip spica cast for a patient with a fracture of the proximal third of
the left femur, an appropriate nursing intervention is to
a.
use the cast support bar to reposition the patient every 2 to 3 hours.
b.
ask the patient about any abdominal discomfort or nausea.
c.
discuss the reasons for remaining on bed rest for several weeks.
d.
promote drying of the cast by placing the patient in a prone position every 4 hours.

Correct Answer: B
Rationale: Assessment of bowel tones, abdominal pain, and nausea and vomiting will detect the
development of cast syndrome. To avoid breakage, the support bar should not be used for
repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical
therapy personnel. The patient should not be placed in the prone position until the cast has dried to
avoid breaking the cast.

Cognitive Level: Application Text Reference: p. 1640


Nursing Process: Implementation NCLEX: Physiological Integrity

A patient is admitted to the emergency department with possible fractures of the bones of the left
lower extremity. The initial action by the nurse should be to
a.
splint the lower leg.
b.
elevate the left leg.
c.
check the popliteal, dorsalis pedis, and posterior tibial pulses.
d.
obtain information about the patient's tetanus immunization status.

Correct Answer: C
Rationale: The initial nursing action should be assessment of the neurovascular status of the injured
leg. After assessment, the nurse may need to splint and elevate the leg, based on the assessment
data. Information about tetanus immunizations should be done if there is an open wound.

Cognitive Level: Application Text Reference: p. 1642


Nursing Process: Assessment NCLEX: Physiological Integrity

A nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a
small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse
would plan to:
1.
Try to manually reduce the fracture.

2.
Assist the person to get up and walk to the sidewalk.

3.
Leave the person for a few moments to call an ambulance.

4.
Stay with the person and encourage the person to remain still.
4.
Stay with the person and encourage the person to remain still.

A nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which
action is the priority?

1.
Take a set of vital signs.

2.
Call the radiology department.

3.
Immobilize the leg before moving the client.

4.
Reassure the client that everything will be fine.

3.
Immobilize the leg before moving the client.

A client with a hip fracture asks the nurse why Buck's extension traction is being applied before
surgery. The nurse's response is based on the understanding that Buck's extension traction primarily:

1.
Allows bony healing to begin before surgery

2.
Provides rigid immobilization of the fracture site

3.
Lengthens the fractured leg to prevent severing of blood vessels

4.
Provides comfort by reducing muscle spasms and provides fracture immobilization

4.
Provides comfort by reducing muscle spasms and provides fracture immobilization
Rationale:
Buck's extension traction is a type of skin traction often applied after hip fracture, before the fracture
is reduced in surgery. It reduces muscle spasms and helps immobilize the fracture. It does not
lengthen the leg for the purpose of preventing blood vessel severance. It also does not allow for
bony healing to begin.

A nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned
with which finding?
1.
Inflammation

2.
Serous drainage

3.
Pain at a pin site

4.
Purulent drainage

2.
Serous drainage

A nurse is caring for the client who has had skeletal traction applied to the left leg. The client is
complaining of severe left leg pain. Which action should the nurse take first?
1.
Provide pin care.

2.
Call the health care provider (HCP).

3.
Check the client's alignment in bed.

4.
Medicate the client with an analgesic.

3.
Check the client's alignment in bed.

A nurse has provided instructions regarding specific leg exercises for the client immobilized in right
skeletal lower leg traction. The nurse determines that the client needs further instruction if the nurse
observes the client:
1.
Pulling up on the trapeze

2.
Flexing and extending the feet

3.
Doing quadriceps-setting and gluteal-setting exercises

4.
Performing active range of motion (ROM) to the right ankle and knee

4.
Performing active range of motion (ROM) to the right ankle and knee

A nurse is checking the casted extremity of a client. The nurse would check for which of the following
signs and symptoms indicative of infection?
1.
Dependent edema
2.
Diminished distal pulse

3.
Presence of a "hot spot" on the cast

4.
Coolness and pallor of the extremity

3.
Presence of a "hot spot" on the cast

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client
is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered
an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be
caused by:

1.
Infection under the cast

2.
The anxiety of the client

3.
Impaired tissue perfusion

4.
The newness of the fracture

3.
Impaired tissue perfusion

A nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The
client has a leg fracture, and a plaster cast has been applied. In positioning the casted leg, the nurse
should:
1.
Keep the leg in a level position.

2.
Elevate the leg for 3 hours, and put it flat for 1 hour.

3.
Keep the leg level for 3 hours, and elevate it for 1 hour.

4.
Elevate the leg on pillows continuously for 24 to 48 hours.

4.
Elevate the leg on pillows continuously for 24 to 48 hours.
A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse
should plan for which of the following actions?
1.
Massaging the skin at the rim of the cast

2.
Petaling the cast edges with adhesive tape

3.
Using a rough file to smooth the cast edges

4.
Applying lotion to the skin at the rim of the cast

2.
Petaling the cast edges with adhesive tape

A client is being discharged home after application of a plaster leg cast. The nurse determines that
the client understands proper care of the cast if the client states to:
1.
Avoid getting the cast wet.

2.
Cover the casted leg with warm blankets.

3.
Use the fingertips to lift and move the leg.

4.
Use a padded coat hanger end to scratch under the cast.

1.
Avoid getting the cast wet.

A nurse is planning to provide instructions to the client about how to stand on crutches. In the
instructions, the nurse plans to tell the client to place the crutches:

1.
3 inches to the front and side of the client's toes

2.
8 inches to the front and side of the client's toes

3.
20 inches to the front and side of the client's toes

4.
15 inches to the front and side of the client's toes
2.
8 inches to the front and side of the client's toes

Rationale:
The classic tripod position is taught to the client before giving instructions on gait. The crutches are
placed anywhere from 6 to 10 inches in front and to the side of the client, depending on the client's
body size. This provides a wide enough base of support to the client and improves balance.

A nurse is evaluating the client's use of a cane for left-sided weakness. The nurse would intervene
and correct the client if the nurse observed that the client:
1.
Holds the cane on the right side

2.
Moves the cane when the right leg is moved

3.
Leans on the cane when the right leg swings through

4.
Keeps the cane 6 inches out to the side of the right foot

2.
Moves the cane when the right leg is moved

Rationale:
The cane is held on the stronger side to minimize stress on the affected extremity and provide a wide
base of support. The cane is held 6 inches lateral to the fifth great toe. The cane is moved forward
with the affected leg. The client leans on the cane for added support while the stronger side swings
through.

A nurse is caring for a client with fresh application of a plaster leg cast. The nurse plans to prevent
the development of compartment syndrome by:

1.
Elevating the limb and applying ice to the affected leg

2.
Elevating the limb and covering the limb with bath blankets

3.
Keeping the leg horizontal and applying ice to the affected leg

4.
Placing the leg in a slightly dependent position and applying ice

1.
Elevating the limb and applying ice to the affected leg
A nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to
his right forearm. Which instructions should the nurse include on the list? Select all that apply.
1.
Keep the cast and extremity elevated.

2.
The cast needs to be kept clean and dry.

3.
Allow the wet cast 24 to 72 hours to dry.

4.
Expect tingling and numbness in the extremity.

5.
Use a hair dryer set on a warm to hot setting to dry the cast.

6.
Use a soft padded object that will fit under the cast to scratch the skin under the cast.

1.
Keep the cast and extremity elevated.

2.
The cast needs to be kept clean and dry.

3.
Allow the wet cast 24 to 72 hours to dry.

Which data would indicate a potential complication associated with age-related changes in the
musculoskeletal system?

1.
Decrease in height

2.
Overall sclerotic lesions

3.
Diminished lean body mass

4.
Changes in structural bone tissue

2.
Overall sclerotic lesions

Rationale:
Sclerotic lesions occur as bone resorption increases and results in replacement of original bone with
fibrous material. This condition occurs in Paget's disease, an age-related disorder. Options 1, 3, and 4
identify normal age-related changes in the musculoskeletal system.

A client has just had a cast removed and the underlying skin is yellow-brown and crusted. The nurse
determines that further skin care instructions are required when the client states:

1.
"I will soak the skin and then wash it gently."

2.
"I need to scrub the skin vigorously with soap and water."

3.
"I need to apply an emollient lotion to enhance softening."

4.
"I need to use a sunscreen on the skin if it's exposed for a period of time."

2.
"I need to scrub the skin vigorously with soap and water."

A client has had skeletal traction applied to the right leg and has an overhead trapeze available for
use. The nurse should monitor which of the following as a high-risk area for pressure and
breakdown?

1.
Scapulae

2.
Left heel

3.
Right heel

4.
Back of the head

2.
Left heel

A client has been placed in Buck's extension traction. The nurse can provide for countertraction by:

1.
Using a footboard

2.
Providing an overhead trapeze

3.
Slightly elevating the foot of the bed
4.
Slightly elevating the head of the bed

3.
Slightly elevating the foot of the bed

A client with diabetes mellitus has had a right below-knee amputation. The nurse would be especially
vigilant in monitoring for which of the following because of the client's history of diabetes mellitus?
1.
Hemorrhage

2.
Edema of residual limb

3.
Slight redness of incision

4.
Separation of wound edges

4.
Separation of wound edges

A client is admitted to the nursing unit after a left below-knee amputation following a crush injury to
the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot
itching." The nurse interprets the client's statement to be:
1.
A normal response and indicates the presence of phantom limb pain

2.
A normal response and indicates the presence of phantom limb sensation

3.
An abnormal response and indicates that the client is in denial about the limb loss

4.
An abnormal response and indicates that the client needs more psychological support

2.
A normal response and indicates the presence of phantom limb sensation

A nurse has provided instructions to a client with a herniated lumbar disk about proper body
mechanics and other items pertinent to low back care. The nurse determines that the client needs
further instructions if the client verbalizes that he or she will:

1.
Increase fiber and fluids in the diet.

2.
Bend at the knees to pick up objects.

3.
Strengthen the back muscles by swimming or walking.

4.
Get out of bed by sitting straight up and swinging the legs over the side of the bed.

4.
Get out of bed by sitting straight up and swinging the legs over the side of the bed.

A client with a left arm fracture exhibits loss of sensation in the left fingers, pallor, slow refill, and
diminished left radial pulse. The nurse should take which of the following actions?

Submit

1.
Administer an analgesic.

2.
Notify the registered nurse.

3.
Check the circulation again in 30 minutes.

4.
Provide range-of-motion exercises to the fingers of the left hand.

2.
Notify the registered nurse.

A client is complaining of pain underneath a cast in the area of a bony prominence. The nurse
interprets that this client may need to have:
1.
The cast bivalved

2.
A window cut in the cast

3.
The cast replaced with an air splint

4.
Extra padding put over this area of the cast

2.
A window cut in the cast
A nursing instructor asks a nursing student about the risk factors associated with osteoporosis. The
instructor tells the student that she needs to read and learn about this disorder if the student states
that which of the following is an associated risk factor?
1.
Postmenopausal age

2.
Family history of osteoporosis

3.
High-calcium diet consumption

4.
Long-term use of corticosteroids

3.
High-calcium diet consumption

A nurse is providing instructions to a client with osteoporosis regarding appropriate food items to
include in the diet. The nurse tells the client that which food item would provide the least amount of
calcium?

1.
Pork

2.
Seafood

3.
Sardines

4.
Plain yogurt

1.
Pork

A nurse is caring for a client with osteoarthritis. The nurse collects data, knowing that which of the
following is a clinical manifestation associated with the disorder?

Submit

1.
Morning stiffness

2.
Positive rheumatoid factor
3.
An elevated sedimentation rate

4.
Dull aching pain in the affected joints

4.
Dull aching pain in the affected joints

A client is treated in the health care provider's office after a fall, which sprained an ankle.
Radiography has ruled out fracture. Before sending the client home, the nurse would plan to teach
the client about which item that is to be avoided in the next 24 hours?
1.
Resting the foot

2.
Application of an Ace wrap

3.
Application of a heating pad

4.
Elevating the ankle on a pillow while sitting or lying down

3.
Application of a heating pad

A nurse has provided instructions to the client returning home after arthroscopy of the knee. The
nurse determines that the client understands the instructions if the client states that he or she will:
1.
Resume regular exercise the following day.

2.
Stay off of the leg entirely for the rest of the day.

3.
Refrain from eating food for the remainder of the day.

4.
Report fever or site inflammation to the health care provider.

4.
Report fever or site inflammation to the health care provider.

A nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a
posterior approach. The client has been prescribed hip precautions. The nurse plans to implement
which of the following in the care of the client? Select all that apply.

1.
Ensure the client doesn't bend the hips beyond 120 degrees.
2.
Ensure the client doesn't sit or stand for long periods of time.

3.
Ensure the client engages in rigorous exercise to maintain strength.

4.
Ensure the client doesn't cross the legs past the midline of the body.

5.
Ensure the client uses assistive/adaptive devices with activities of daily living.

2.
Ensure the client doesn't sit or stand for long periods of time.

4.
Ensure the client doesn't cross the legs past the midline of the body.

5.
Ensure the client uses assistive/adaptive devices with activities of daily living.

A nurse is collecting physical data of the musculoskeletal system on an assigned client. The nurse
should document the presence of which of the following as a normal finding?
1.
Presence of fasciculations

2.
Atrophy on the client's dominant side

3.
Atrophy on the client's nondominant side

4.
Hypertrophy on the client's dominant side

4.
Hypertrophy on the client's dominant side

Rationale:
Hypertrophy, or increased muscle size on the client's dominant side of up to 1 cm, is considered
normal. Atrophy on either side is considered an abnormal finding. Fasciculations are fine muscle
twitches that are not normally present.

A nurse is providing care of the client following a bone biopsy. Which action by the nurse is
unnecessary in the care of this client?

1.
Elevating the limb for 24 hours
2.
Monitoring vital signs every 4 hours

3.
Administering intramuscular opioid analgesics

4.
Monitoring the site for swelling, bleeding, hematoma

3.
Administering intramuscular opioid analgesics

A nurse is caring for the client who is going to have an arthrogram using a contrast medium. Which of
the following data collected by the nurse would be of highest priority?

1.
Allergy to iodine or shellfish

2.
Whether the client needs to void before the procedure

3.
Ability of the client to remain still during the procedure

4.
Whether the client has any remaining questions about the procedure

1.
Allergy to iodine or shellfish

A client with possible rib fracture has never had a chest x-ray. The nurse would plan to tell the client
which of the following items about the procedure?
1."The x-ray stimulates a small amount of pain."

2."It is necessary to remove jewelry and any other metal objects."

3."The client will be asked to breathe in and out during the x-ray."

4."The x-ray technologist will stand next to the client during the x-ray."

2."It is necessary to remove jewelry and any other metal objects."

A nurse is teaching a client who is to have a gallium scan about the procedure. The nurse should
include which of the following items as part of the instructions?

1.
The client must stand erect during the filming.

2.
The procedure takes about 15 minutes to perform.

3.
The gallium will be injected intravenously 2 to 3 hours before the procedure.

4.
The client should remain on bedrest for the remainder of the day after the scan.

3.
The gallium will be injected intravenously 2 to 3 hours before the procedure.