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The Client with Musculoskeletal Health ProblemsThe Client with Rheumatoid Arthritis■ The Client with Osteoarthritis■ The Client with a Hip Fracture■ The Client having Joint Replacement Surgery■ The Client with a Herniated Disk■ The Client with an Amputation due to Peripheral Vascular Disease■ The Client with Fractures■ The Client with a Femoral Fracture■ The Client with a Spinal Cord Injury■ Managing Care Quality and Safety■ Answers, Rationales, and Test Taking StrategiesThe Client with Rheumatoid Arthritis1. On a visit to the clinic, a client reports theonset of early symptoms of rheumatoid arthritis.The nurse should conduct a focused assessment for:■ 1. Limited motion of joints.■ 2. Deformed joints of the hands.■ 3. Early morning stiffness.■ 4. Rheumatoid nodules.2. A client with rheumatoid arthritis states, “Ican’t do my household chores without becomingtired. My knees hurt whenever I walk.” Which nursingdiagnosis would be most appropriate?■ 1. Activity intolerance related to fatigue andpain.■ 2. Self-care defi cit related to increasing jointpain.■ 3. Ineffective coping related to chronic pain.■ 4. Disturbed body image related to fatigue andjoint pain.3. Of the clients listed below, who is at risk fordeveloping rheumatoid arthritis (RA)? Select all thatapply.■ 1. Adults between the ages of 20 and 50 years.■ 2. Adults who have had an infectious diseasewith the Epstein-Barr virus.■ 3. Adults that are of the male gender.■ 4. Adults who possess the genetic link, specifi -cally HLA-DR4.■ 5. Adults who also have osteoarthritis.4. A client is in the acute phase of rheumatoidarthritis. Which of the following should the nurseidentify as lowest priority in the plan of care?■ 1. Relieving pain.■ 2. Preserving joint function.■ 3. Maintaining usual ways of accomplishingtasks.■ 4. Preventing joint deformity.5. The nurse teaches a client about heat andcold treatments to manage arthritis pain. Which ofthe following client statements indicates that the clientstill has a knowledge defi cit?■ 1. “I can use heat and cold as often as I want.”■ 2. “With heat, I should apply it for no longerthan 20 minutes at a time.”■ 3. “Heat-producing liniments can be used withother heat devices.”■ 4. “Ten to 15 minutes per application is themaximum time for cold applications.”6. The client with rheumatoid arthritis tells thenurse, “I have a friend who took gold shots and hada wonderful response. Why didn’t my physician letme try that?” Which of the following responses bythe nurse would be most appropriate?■ 1. “It’s the physician’s prerogative to decide howto treat you. The physician has chosen whatis best for your situation.”■ 2. “Tell me more about your friend’s arthriticcondition. Maybe I can answer that questionfor you.”■ 3. “That drug is used for cases that are worsethan yours. It wouldn’t help you, so don’tworry about it.”■ 4. “Every person is different. What works for oneclient may not always be effective for another.”7. The teaching plan for the client with rheumatoidarthritis includes rest promotion. Which ofthe following would the nurse expect to instruct theclient to avoid during rest periods?■ 1. Proper body alignment.■ 2. Elevating the part.■ 3. Prone lying positions.■ 4. Positions of fl exion.8. After teaching the client with rheumatoidarthritis about measures to conserve energy inactivities of daily living involving the small joints,which of the following, if stated by the client, wouldindicate the need for additional teaching?■ 1. Pushing with palms when rising from a chair.■ 2. Holding packages close to the body.■ 3. Sliding objects.■ 4. Carrying a laundry basket with clinched fi ngersand fi sts.9. After teaching the client with severe rheumatoidarthritis about prescribed methotrexate (Rheumatrex),which of the following statements indicatesthe need for further teaching?■ 1. “I will take my vitamins while I’m on thisdrug.”■ 2. “I must not drink any alcohol while I’m takingthis drug.”■ 3. “I should brush my teeth after every meal.”■ 4. “I will continue taking my birth controlpills.”10. A 25-year-old client taking hydroxychloroquine(Plaquenil) for rheumatoid arthritis reportsdiffi culty seeing out of her left eye. Correct interpretationof this assessment fi nding indicates which ofthe following?■ 1. Development of a cataract.■ 2. Possible retinal degeneration.■ 3. Part of the disease process.■ 4. A coincidental occurrence.11. A client with rheumatoid arthritis tells thenurse, “I know it is important to exercise my jointsso that I won’t lose mobility, but my joints are sostiff and painful that exercising is diffi cult.” Whichof the following responses by the nurse would bemost appropriate?■ 1. “You are probably exercising too much.Decrease your exercise to every other day.”■ 2. “Tell the physician about your symptoms.Maybe your analgesic medication can beincreased.”■ 3. “Stiffness and pain are part of the disease.Learn to cope by focusing on activities youenjoy.”■ 4. “Take a warm tub bath or shower before exercising.This may help with your discomfort.”12. Which of the following statements should thenurse include in the teaching session when preparinga client for arthrocentesis? Select all that apply.■ 1. “A local anesthetic agent may be injected intothe joint site for your comfort.”■ 2. “A syringe and needle will be used to withdrawfl uid from your joint.”■ 3. “The procedure, although not painful, willprovide immediate relief.”■ 4. “We’ll want you to keep your joint active afterthe procedure to increase blood fl ow.”■ 5. “You will need to wear a compression bandagefor several days after the procedure.”The Client with Osteoarthritis13. A client with osteoarthritis will undergo anarthrocentesis on his painful edematous knee. Whatshould be included in the nursing plan of care?Select all that apply.■ 1. Explain the procedure.■ 2. Administer preoperative medication 1 hourbefore surgery.■ 3. Instruct the client to immobilize the knee for2 days after the surgery.■ 4. Assess the site for bleeding.■ 5. Offer pain medication.14. A postmenopausal client is scheduled for abone-density scan. To plan for the client’s test, whatshould the nurse communicate to the client?■ 1. Request that the client remove all metalobjects on the day of the scan.■ 2. Instruct the client to consume foods and beverageswith a high content of calcium for2 days before the test.■ 3. Inform the client that she will need to ingest600 mg of calcium gluconate by mouth for2 weeks before the test.■ 4. Tell the client that she should report any significant pain to her physician at least 2 daysbefore the test.15. A physician orders a lengthy X-ray examinationfor a client with osteoarthritis. Which of thefollowing actions by the nurse would demonstrateclient advocacy?■ 1. Contact the X-ray department and ask thetechnician if the lengthy session can bedivided into shorter sessions.■ 2. Contact the physician to determine if analternative examination could be scheduled.■ 3. Provide a dose of acetaminophen (Tylenol).■ 4. Cancel the examination because of the hardX-ray table.16. Which of the following should the nurseassess when completing the history and physicalexamination of a client diagnosed withosteoarthritis?■ 1. Anemia.■ 2. Osteoporosis.■ 3. Weight loss.■ 4. Local joint pain.17. A client with osteoporosis needs educationabout diet and ways to increase bone density. Whichof the following should be included in the teachingplan? Select all that apply.■ 1. Maintain a diet with adequate amounts ofvitamin D, as found in fortifi ed milk andcereals.■ 2. Choose good calcium sources, such as fi gs,broccoli, and almonds.■ 3. Use alcohol in moderation because a moderateintake has no known negative effects.■ 4. Try swimming as a good exercise to maintainbone mass.■ 5. Avoid the use of high-fat foods, such as avocados,salad dressings, and fried foods.18. Which of the following statements indicatesthat the client with osteoarthritis understands theeffects of capsaicin (Zostrix) cream?■ 1. “I always wash my hands right after I applythe cream.”■ 2. “After I apply the cream, I wrap my knee withan elastic bandage.”■ 3. “I keep the cream in the cabinet above thestove in the kitchen.”■ 4. “I also use the same cream when I get a cut ora burn.”19. At which of the following times should thenurse instruct the client to take ibuprofen (Motrin),prescribed for left hip pain secondary to osteoarthritis,to minimize gastric mucosal irritation?■ 1. At bedtime.■ 2. On arising.■ 3. Immediately after a meal.■ 4. On an empty stomach.20. The client diagnosed with osteoarthritisstates, “My friend takes steroid pills for her rheumatoidarthritis. Why don’t I take steroids for myosteoarthritis?” Which of the following is the bestexplanation?■ 1. Intra-articular corticosteroid injections areused to treat osteoarthritis.■ 2. Oral corticosteroids can be used in osteoarthritis.■ 3. A systemic effect is needed in osteoarthritis.■ 4. Rheumatoid arthritis and osteoarthritis aretwo similar diseases.21. After teaching a group of clients withosteoarthritis about using regular exercise, which ofthe following client statements indicates effectiveteaching?■ 1. “Performing range-of-motion exercises willincrease my joint mobility.”■ 2. “Exercise helps to drive synovial fl uidthrough the cartilage.”■ 3. “Joint swelling should determine when tostop exercising.”■ 4. “Exercising in the outdoors year-round promotesjoint relaxation.”The Client with a Hip Fracture22. A client in a double hip spica cast is constipated.The surgeon cuts a window into the cast.Which of the following outcomes should the nurseanticipate?■ 1. The window will allow the nurse to palpatethe superior mesenteric artery.■ 2. The window will allow the surgeon to manipulatethe fracture site.■ 3. The window will allow the nurses to repositionthe client.■ 4. The window will provide some relief frompressure due to abdominal distention as aresult of constipation.23. A client has an intracapsular hip fracture.The nurse should conduct a focused assessment todetect:■ 1. Internal rotation.■ 2. Muscle fl accidity.■ 3. Shortening of the affected leg.■ 4. Absence of pain in the fracture area.24. The nurse is developing the plan of care foran older adult client with a hip fracture. Which ofthe following chronic health problems would thenurse be least likely to assess in the client?■ 1. Hypertension.■ 2. Cardiac decompensation.■ 3. Pulmonary disease.■ 4. Multiple sclerosis.25. When teaching a client with an extracapsularhip fracture scheduled for surgical internalfi xation with the insertion of a pin, the nurse basesthe teaching on the understanding that this surgicalrepair is the treatment of choice. Which of the followingexplains the reason?■ 1. Hemorrhage at the fracture site is prevented.■ 2. Neurovascular impairment risk is decreased.■ 3. The risk of infection at the site is lessened.4. The client is able to be mobilized sooner.26. A client with an extracapsular hip fracturereturns to the nursing unit after internal fi xation andpin insertion with a drainage tube at the incisionsite. Her husband asks, “Why does she have thistube inserted in her hip?” Which of the followingresponses would be best?■ 1. “The tube helps us to detect a wound infectionearly on.”■ 2. “This way we won’t have to irrigate thewound.”■ 3. “Fluid won’t be allowed to accumulate at thesite.”■ 4. “We have a way to administer antibiotics intothe wound.”27. A client had a posterolateral total hipreplacement 2 days ago. What should the nurseinclude in the client’s plan of care? Select all thatapply.■ 1. When using a walker, encourage the client topoint the toes inward.■ 2. Position a pillow between the legs to maintainabduction.■ 3. Allow the client to be in the supine position orin the lateral position on the unoperated side.■ 4. Do not allow the client to bend down to tie orslip on shoes.■ 5. Place ice on the incision after physicaltherapy.28. Which information should the nurse includewhen performing discharge teaching with a clientwho had an anterolateral approach for a total hipreplacement? Select all that apply.■ 1. Avoid turning the toes or knee outward.■ 2. Use an abduction pillow between the legswhen in bed.■ 3. Use an elevated toilet seat and shower chair.■ 4. Do not extend the operative leg backwards.■ 5. Restrict motion for 2 weeks after surgery.29. The nurse is assessing a client for neurologicimpairment after a total hip replacement. Whichof the following would indicate impairment in theaffected extremity?■ 1. Decreased distal pulse.■ 2. Inability to move.■ 3. Diminished capillary refi ll.■ 4. Coolness to the touch.30. A client with a hip fracture has undergonesurgery for insertion of a femoral head prosthesis.Which of the following activities should the nurseinstruct the client to avoid?■ 1. Crossing the legs while sitting down.■ 2. Sitting on a raised commode seat.■ 3. Using an abductor splint while lying on theside.■ 4. Rising straight from a chair to a standingposition.31. The nurse advises the client who has had afemoral head prosthesis placement on the type ofchair to sit in during the fi rst 6 to 8 weeks after surgery.Which would be the correct type to recommend?■ 1. A desk-type swivel chair.■ 2. A padded upholstered chair.■ 3. A high-backed chair with armrests.■ 4. A recliner with an attached footrest.32. The nurse is assessing the home environmentof an elderly client who is using crutches duringthe postoperative recovery phase after hip pinning.Which of the following would pose the greatesthazard to the client as a risk for falling at home?■ 1. A 4-year-old cocker spaniel.■ 2. Scatter rugs.■ 3. Snack tables.■ 4. Rocking chairs.The Client Having JointReplacement Surgery33. In preparation for total knee surgery, a 200-lbclient with osteoarthritis must lose weight. Whichof the following exercises should the nurse recommendas best if the client has no contraindications?■ 1. Weight lifting.■ 2. Walking.■ 3. Aquatic exercise.■ 4. Tai chi exercise.34. Prior to surgery, the nurse is instructing a clientwho will have a total hip replacement tomorrow.Which of the following information is most importantto include in the teaching plan at this time?■ 1. Teaching how to prevent hip fl exion.■ 2. Demonstrating coughing and deep-breathingtechniques.■ 3. Showing the client what an actual hip prosthesislooks like.■ 4. Assessing the client’s fears about the procedure.35. The client has just had a total knee replacementfor severe osteoarthritis. Which of the followingassessment fi ndings should lead the nurse tosuspect possible nerve damage?■ 1. Numbness.■ 2. Bleeding.■ 3. Dislocation.■ 4. Pinkness.36. After surgery and insertion of a total jointprosthesis, a client develops severe sudden pain andan inability to move the extremity. The nurse correctlyinterprets these fi ndings as indicating whichof the following?■ 1. A developing infection.■ 2. Bleeding in the operative site.■ 3. Joint dislocation.■ 4. Glue seepage into soft tissue.37. A client who had a total hip replacement2 days ago has developed an infection with a fever.The nursing diagnosis of fl uid volume defi cit relatedto diaphoresis is made. Which of the following isthe most appropriate outcome?■ 1. The client drinks 2,000 mL of fl uid per day.■ 2. The client understands how to manage theincision.■ 3. The client’s bed linens are changed asneeded.■ 4. The client’s skin remains cool throughouthospitalization.38. After knee arthroplasty, the client has asequential compression device (SCD). The nurseshould do which of the following?■ 1. Elevate the sequential compression device(SCD) on two pillows.■ 2. Change the settings on the SCD to make theclient more comfortable.■ 3. Stop the SCD to remove dressings and bathethe leg.■ 4. Discontinue the SCD when the client is ambulatory.39. The nurse is preparing the discharge ofa client who has had a knee replacement with ametal joint. The nurse should instruct the clientabout which of the following? Select all thatapply.■ 1. Notify health care providers about the jointprior to invasive procedures.■ 2. Avoid use of Magnetic Resonance Imaging(MRI) scans.■ 3. Notify airport security that the joint may setoff alarms on metal detectors.■ 4. Refrain from carrying items weighing morethan 5 lb.■ 5. Limit fl uid intake to 1,000 mL/day.40. Following a total hip replacement, the nurseshould position the client in which of the followingways?■ 1. Place weights alongside of the affectedextremity to keep the extremity fromrotating.■ 2. Elevate both feet on two pillows.■ 3. Keep the lower extremities adducted by useof an immobilization binder around bothlegs.■ 4. Keep the extremity in slight abductionusing an abduction splint or pillows placedbetween the thighs.41. Following a total hip replacement, the nurseshould do which of the following? Select all thatapply.■ 1. With the aid of a coworker, turn the clientfrom the supine to the prone position every2 hours.■ 2. Encourage the client to use the overhead trapezeto assist with position changes.■ 3. For meals, elevate the head of the bed to90 degrees.■ 4. Use a fracture bedpan when needed by theclient.■ 5. When the client is in bed, prevent thromboembolismby encouraging the client to dotoe-pointing exercises.42. A client is to have a total hip replacement.The preoperative plan should include which of thefollowing? Select all that apply.■ 1. Administer antibiotics as prescribed to ensuretherapeutic blood levels.■ 2. Apply leg compression device.■ 3. Request a trapeze be added to the bed.■ 4. Teach isometric exercises of quadriceps andgluteal muscles.■ 5. Demonstrate crutch walking with a 3-pointgait.■ 6. Place Buck’s traction on the bed.43. The nurse is teaching the client to administerenoxaparin (Lovenox) following a total hip arthroplasty?The nurse should instruct the client aboutwhich of the following? Select all that apply.■ 1. Report promptly any diffi culty breathing,rash, or itching.■ 2. Notify the health care provider of unusualbruising.■ 3. Avoid all aspirin-containing medications.■ 4. Wear or carry medical identifi cation.■ 5. Expel the air bubble from the syringe beforethe injection.■ 6. Remove needle immediately after medicationis injected.44. A client who had a total hip replacement4 days ago is worried about dislocation of the prosthesis.The nurse should respond by saying whichof the following?■ 1. “Don’t worry. Your new hip is very strong.”■ 2. “Use of a cushioned toilet seat helps to preventdislocation.”■ 3. “Activities that tend to cause adduction of thehip tend to cause dislocation, so try to avoidthem.”■ 4. “Decreasing use of the abductor pillow willstrengthen the muscles to prevent dislocation.”45. The nurse is assessing a client who had a lefthip replacement 36 hours ago. Which of the followingindicates the prosthesis is dislocated? Select allthat apply.■ 1. The client reported a “popping” sensation inthe hip.■ 2. The left leg is shorter than the right leg.■ 3. The client has sharp pain in the groin.■ 4. The client cannot move his right leg.■ 5. The client cannot wiggle the toes on the leftleg.46. A client who has had a total hip replacementhas a dislocated hip prosthesis. The nurse shouldfi rst?■ 1. Stabilize the leg with Buck’s traction.■ 2. Apply an ice pack to the affected hip.■ 3. Position the client toward the opposite side ofthe hip.■ 4. Notify the orthopedic surgeon.47. The nurse is planning care for a group ofclients who have had total hip replacement. Of theclients listed below, which is at highest risk forinfection and should be assessed fi rst?■ 1. A 55-year-old client who is 6 feet tall andweighs 180 lb.■ 2. A 90-year-old who lives alone.■ 3. A 74-year-old who has periodontal diseasewith periodontitis.■ 4. A 75-year-old who has asthma and uses aninhaler.48. The nurse has established a goal with a clientto improve mobility following hip replacement.Which of the following is a realistic outcome at thetime of discharge from the surgical unit?■ 1. The client can walk throughout the entirehospital with a walker.■ 2. The client can walk the length of a hospitalhallway with minimal pain.■ 3. The client has increased independence intransfers from bed to chair.■ 4. The client can raise the affected leg 6 incheswith assistance.49. The nurse is assessing a client’s left leg forneurovascular changes following a total left kneereplacement. Which of the following are expectednormal fi ndings? Select all that apply.■ 1. Reduced edema of the left knee.■ 2. Skin warm to touch.■ 3. Capillary refi ll response.■ 4. Moves toes.■ 5. Pain absent.■ 6. Pulse on left leg weaker than right leg.50. On the evening of surgery for total kneereplacement, a client wants to get out of bed. Tosafely assist the client the nurse should do which ofthe following?■ 1. Encourage the client to apply full weightbearing.■ 2. Order a walker for the client.■ 3. Place a straight-backed chair at the foot of thebed.■ 4. Apply a knee immobilizer.51. When preparing a client for discharge fromthe hospital after a total knee replacement, the nurseshould include which of the following informationin the discharge plan? Select all that apply.■ 1. Report signs of infection to health care provider.■ 2. Keep the affected leg and foot on the fl oorwhen sitting in a chair.■ 3. Remove anti-embolism stockings when sleeping.■ 4. The physical therapist will encourage progressiveambulation with use of assistivedevices.■ 5. Change the dressing daily.52. Following a total joint replacement, which ofthe following complications has the greatest likelihoodof occurring?■ 1. Deep vein thrombosis (DVT).■ 2. Polyuria.■ 3. Intussception of the bowel.■ 4. Wound evisceration.The Client with a Herniated Disk53. The nurse is observing a client who is recoveringfrom back strain lift a box as shown below.What should the nurse do?■ 1. Praise the client for using correct bodymechanics.■ 2. Suggest to the client that she put both kneeson the fl oor before attempting to lift the box.■ 3. Advise the client to bend from the waist ratherthan stretching her back in this position.■ 4. Inform the client that she should keep herback straight by squatting with both kneesparallel.45. The nurse is assessing a client who had a lefthip replacement 36 hours ago. Which of the followingindicates the prosthesis is dislocated? Select allthat apply.■ 1. The client reported a “popping” sensation inthe hip.■ 2. The left leg is shorter than the right leg.■ 3. The client has sharp pain in the groin.■ 4. The client cannot move his right leg.■ 5. The client cannot wiggle the toes on the leftleg.46. A client who has had a total hip replacementhas a dislocated hip prosthesis. The nurse shouldfi rst?■ 1. Stabilize the leg with Buck’s traction.■ 2. Apply an ice pack to the affected hip.■ 3. Position the client toward the opposite side ofthe hip.■ 4. Notify the orthopedic surgeon.47. The nurse is planning care for a group ofclients who have had total hip replacement. Of theclients listed below, which is at highest risk forinfection and should be assessed fi rst?■ 1. A 55-year-old client who is 6 feet tall andweighs 180 lb.■ 2. A 90-year-old who lives alone.■ 3. A 74-year-old who has periodontal diseasewith periodontitis.■ 4. A 75-year-old who has asthma and uses aninhaler.48. The nurse has established a goal with a clientto improve mobility following hip replacement.Which of the following is a realistic outcome at thetime of discharge from the surgical unit?■ 1. The client can walk throughout the entirehospital with a walker.■ 2. The client can walk the length of a hospitalhallway with minimal pain.■ 3. The client has increased independence intransfers from bed to chair.■ 4. The client can raise the affected leg 6 incheswith assistance.49. The nurse is assessing a client’s left leg forneurovascular changes following a total left kneereplacement. Which of the following are expectednormal fi ndings? Select all that apply.■ 1. Reduced edema of the left knee.■ 2. Skin warm to touch.■ 3. Capillary refi ll response.■ 4. Moves toes.■ 5. Pain absent.■ 6. Pulse on left leg weaker than right leg.54. Which of the following activities shouldthe nurse instruct the client with low back pain toavoid?■ 1. Keeping light objects below the level of theelbows when lifting.■ 2. Leaning forward while bending the knees.■ 3. Exceeding the prescribed exercise program.■ 4. Sleeping on the side with legs fl exed.55. A client attempting to get out of bed stopsmidway because of low back pain radiating downto the right heel and lateral foot. What should thenurse do in order of priority from fi rst to last?2. Notify the physician.3. Assist the client to lie down.4. Administer the prescribed celecoxib (Celebrex).1. Apply a warm compress to the client’s back.56. A client with a ruptured intervertebral discat L4–5 stands with a fl attened spine slightly tiltedforward and slightly fl exed to the affected side. Thenurse interprets this fi nding as indicating which ofthe following?■ 1. Motor changes.■ 2. Postural deformity.■ 3. Alteration of refl exes.■ 4. Sensory changes.57. Which of the following positions would bemost comfortable for a client with a ruptured disc atL5–S1 right?■ 1. Prone.■ 2. Supine with the legs fl exed.■ 3. High Fowler’s.■ 4. Right Sims.58. The client with a herniated intervertebraldisc scheduled for a myelogram asks the nurse aboutthe procedure. The nurse explains that radiographswill be taken of the client’s spine after an injectionof which of the following?■ 1. Sterile water.■ 2. Normal saline solution.■ 3. Liquid nitrogen.■ 4. Radiopaque dye.59. Which of the following would not beappropriate to include when preparing a client formagnetic resonance imaging (MRI) to evaluate aruptured disc?■ 1. Informing the client that the procedure ispainless.■ 2. Taking a thorough history of past surgeries.■ 3. Checking for previous complaints of claustrophobia.■ 4. Starting an I.V. line at keep-open rate.60. A client complaining of numbness from theback of his left buttock to the dorsum of his foot andbig toe is scheduled to undergo a laminectomy. Theoperative consent form states, “a left lumbar laminectomyof L3–4.” Which of the following should thenurse do next?■ 1. Have the client sign the consent form.■ 2. Call the surgeon.■ 3. Change the consent form.■ 4. Review the client’s history.61. Immediately after a lumbar laminectomy, thenurse administers ondansetron hydrochloride (Zofran)to the client as ordered. The nurse determinesthat the drug is effective when which of the followingis controlled?■ 1. Muscle spasms.■ 2. Nausea.■ 3. Shivering.■ 4. Dry mouth.62. After a laminectomy, the client states, “Thephysician said that I can do anything I want to.”Which of the following client-stated activities indicatesthe need for further teaching?■ 1. Drying the dishes.■ 2. Sitting outside on fi rm cushions.■ 3. Making the bed walking from side to side.■ 4. Sweeping the front porch.63. The nurse is developing the discharge teachingplan for a client after a lumbar laminectomyL4–5 who will be returning to work in 6 weeks.Which of the following actions should the nurseencourage the client to avoid?■ 1. Placing one foot on a stepstool during prolongedstanding.■ 2. Sleeping on the back with support under theknees.■ 3. Maintaining average body weight for height.■ 4. Sitting whenever possible.64. A male client underwent a spinal fusionyesterday. Which of the following nursing assessmentsshould alert the nurse to the development ofa possible complication?■ 1. Lateral rotation of the head and neck.■ 2. Clear yellowish fl uid on the dressing.■ 3. Use of the standing position to void.■ 4. Nonproductive cough.65. The nurse is assisting a client who has had aspinal fusion apply a back brace. In which order ofpriority should the nurse assist the client applyingthe brace?2. Verify the order for the settings for the brace.3. Ask the client to stand with arms held awayfrom the body.4. Assist the client to log roll and rise to a sittingposition.1. Have the client in a side-lying position.66. After the nurse teaches a client about wearinga back brace after a spinal fusion, which of the followingclient statements indicates effective teaching?■ 1. “I will apply lotion before putting on thebrace.”■ 2. “I will be sure to pad the area around my iliaccrest.”■ 3. “I can use baby powder under the brace toabsorb perspiration.”■ 4. “I should wear a thin cotton undershirt underthe brace.”67. The nurse develops a teaching plan for aclient scheduled for a spinal fusion. Which of thefollowing should the nurse expect to include?■ 1. The client typically experiences more pain atthe donor site than at the fusion site.■ 2. The surgeon will apply a simple gauze dressingto the donor site.■ 3. Neurovascular checks are unnecessary if thefi bula is the donor site.■ 4. The client’s level of activity restriction isdetermined by the amount of pain.68. A client who has had a lumbar laminectomywith a spinal fusion is sitting in a chair. In whichposition are his feet if he is complying with his postoperativeinstructions?■ 1. On the fl oor with the feet fl at.■ 2. On a low footstool.■ 3. In any comfortable position with legsuncrossed.■ 4. On a high footstool so the feet are level withthe chair seat.69. The nurse develops a plan of care for a clientin the initial postoperative period following a lumbarlaminectomy. Which of the following activitiesis contraindicated?■ 1. Assisting with her daily hygiene activities.■ 2. Lying fl at in bed.■ 3. Walking in the hall.■ 4. Sitting all afternoon in her room.70. Which of the following exercises shouldthe nurse advise the client to avoid after a lumbarlaminectomy?■ 1. Knee-to-chest lifts.■ 2. Hip tilts.■ 3. Sit-ups.■ 4. Pelvic tilts.The Client with an Amputation dueto Peripheral Vascular Disease71. Which of the following should the nurseidentify as the least likely factor contributing to aclient’s peripheral vascular disease?■ 1. Uncontrolled diabetes mellitus for 15 years.■ 2. A 20-pack-year history of cigarette smoking.■ 3. Current age of 39 years.■ 4. A serum cholesterol concentration of 275 mg/dL.72. A client has severe arterial occlusive diseaseand gangrene of the left great toe. Which of thefollowing fi ndings is expected?■ 1. Edema around the ankle.■ 2. Loss of hair on the lower leg.■ 3. Thin, soft toenails.■ 4. Warmth in the foot.73. A client with absent peripheral pulses andpain at rest is scheduled for an arterial Dopplerstudy of the affected extremity. When preparing theclient for this test, the nurse should:■ 1. Have the client sign a consent form for theprocedure.■ 2. Administer a pretest sedative as appropriate.■ 3. Keep the client tobacco-free for 30 minutesbefore the test.■ 4. Wrap the client’s affected foot with a blanket.74. The client with peripheral arterial diseasesays, “I’ve really tried to manage my conditionwell.” Which of the following should the nursedetermine as appropriate for this client?■ 1. Resting with the legs elevated above the levelof the heart.■ 2. Walking slowly but steadily for 30 minutestwice a day.■ 3. Minimizing activity as much and as often aspossible.■ 4. Wearing antiembolism stockings at all timeswhen out of bed.75. Which of the following should the nurseinclude in the teaching plan for a client with arterialinsuffi ciency to the feet that is being managedconservatively?■ 1. Daily lubrication of the feet.■ 2. Soaking the feet in warm water.■ 3. Applying antiembolism stockings.■ 4. Wearing fi rm, supportive leather shoes.76. A client says, “I hate the idea of being aninvalid after they cut off my leg.” Which of thefollowing would be the nurse’s most therapeuticresponse?■ 1. “At least you will still have one good leg touse.”■ 2. “Tell me more about how you’re feeling.”■ 3. “Let’s fi nish the preoperative teaching.”■ 4. “You’re lucky to have a wife to care for you.”77. The client asks the nurse, “Why can’t thephysician tell me exactly how much of my leg he’sgoing to take off? Don’t you think I should knowthat?” On which of the following should the nursebase the response?■ 1. The need to remove as much of the leg as possible.■ 2. The adequacy of the blood supply to the tissues.■ 3. The ease with which a prosthesis can be fi tted.■ 4. The client’s ability to walk with a prosthesis.78. A client who has had an above-the-kneeamputation develops a dime-sized bright red spoton the dressing after 45 minutes in the postanesthesiarecovery unit. The nurse should:■ 1. Elevate the stump.■ 2. Reinforce the dressing.■ 3. Call the surgeon.■ 4. Draw a mark around the site.79. A client in the postanesthesia care unit witha left below-the-knee amputation has pain in her leftbig toe. Which of the following should the nurse dofi rst?■ 1. Tell the client it is impossible to feel the pain.■ 2. Show the client that the toes are not there.■ 3. Explain to the client that her pain is real.■ 4. Give the client the prescribed opioid analgesic.80. The client with an above-the-knee amputationis to use crutches while his prosthesis is beingadjusted. In which of the following exercises shouldthe nurse instruct the client to best prepare him forusing crutches?■ 1. Abdominal exercises.■ 2. Isometric shoulder exercises.■ 3. Quadriceps setting exercises.■ 4. Triceps stretching exercises.81. The nurse teaches a client about using thecrutches, instructing the client to support her weightprimarily on which of the following body areas?■ 1. Axillae.■ 2. Elbows.■ 3. Upper arms.■ 4. Hands.82. The client is to be discharged on a low-fat,low-cholesterol, low-sodium diet. Which of the followingshould be the nurse’s fi rst step in planningthe dietary instructions?■ 1. Determining the client’s knowledge levelabout cholesterol.■ 2. Asking the client to name foods that are highin fat, cholesterol, and salt.■ 3. Explaining the importance of complying withthe diet.■ 4. Assessing the client’s and family’s typicalfood preferences.The Client with Fractures83. A client has a leg immobilized in traction.Which of the following activities demonstratedby the client indicate that the client understandsactions to take to prevent muscle atrophy?■ 1. The client adducts the affected leg every 2hours.■ 2. The client rolls the affected leg away from thebody’s midline twice per day.■ 3. The client performs isometric exercises to theaffected extremity three times per day.■ 4. The client asks the nurse to add a 5-lb weightto the traction for 30 minutes/day.84. The client with a fractured tibia has beentaking methocarbamol (Robaxin). Which of the followingindicate that the drug is having the intendedeffect?■ 1. Lack of infection.■ 2. Reduction in itching.■ 3. Relief of muscle spasms.■ 4. Decrease in nervousness.85. When developing a teaching plan for a clientwho is prescribed acetaminophen (Tylenol) formuscle pain, which information should the nurseexpect to include? Select all that apply.■ 1. The drug can be used if the person is allergicto aspirin.■ 2. Acetaminophen does not affect platelet aggregation.■ 3. This drug causes little or no gastric distress.■ 4. Acetaminophen exerts a strong antiinflammatory effect.■ 5. The client should have the International NormalizedRatio (INR) checked regularly.86. A client who has been taking carisoprodol(Soma) at home for a fractured arm is admitted witha blood pressure of 80/50 mm Hg, a pulse rate of 115bpm, and respirations of 8 breaths/minute and shallow.The nurse interprets these fi ndings as indicatingwhich of the following?■ 1. Expected common adverse effects.■ 2. Hypersensitivity reaction.■ 3. Possible habituating effect.■ 4. Hemorrhage from gastrointestinal irritation.87. When admitting a client with a fracturedextremity, the nurse should fi rst focus the assessmenton which of the following?■ 1. The area proximal to the fracture.■ 2. The actual fracture site.■ 3. The area distal to the fracture.■ 4. The opposite extremity for baseline comparison.88. Which of the following client statementsidentifi es a knowledge defi cit about cast care?■ 1. “I’ll elevate the cast above my heart initially.”■ 2. “I’ll exercise my joints above and below thecast.”■ 3. “I can pull out cast padding to scratch insidethe cast.”■ 4. “I’ll apply ice for 10 minutes to control edemafor the fi rst 24 hours.”89. Which of the following interventions wouldbe least appropriate for a client who is in a doublehip spica cast?■ 1. Encouraging the intake of cranberry juice.■ 2. Advising the client to eat large amounts ofcheese.■ 3. Establishing regular times for elimination.■ 4. Having the client dangle at the bedside.90. The nurse prepares a teaching plan for aclient about crutch walking using a two-point gaitpattern. Which of the following should the nurseinclude?■ 1. Advance a crutch on one side and thenadvance the opposite foot; repeat on theopposite side.■ 2. Advance a crutch on one side and simultaneouslyadvance and bear weight on the oppositefoot; repeat on the opposite side.■ 3. Advance both crutches together and thenfollow by lifting both lower extremities to thelevel of the crutches.■ 4. Advance both crutches together and then followby lifting both lower extremities past thelevel of the crutches.91. A client returned from surgery with a debridedopen tibial fracture and has a three-way drainagesystem. The nurse should fi rst:■ 1. Review the results of culture and sensitivitytesting of the wound.■ 2. Look for the presence of a pressure dressingover the wound.■ 3. Determine if the client has increased painfrom exposed nerve endings.■ 4. Check the client’s blood pressure for hypotensionresulting from additional vessel bleeding.92. A client has a tibial fracture that requiredcasting. Approximately 5 hours later, the clienthas increasing pain distal to the left tibial fracturedespite the morphine injection administered 30minutes previously. Which of the following shouldbe the nurse’s next assessment?■ 1. Presence of a distal pulse.■ 2. Pain with a pain rating scale.■ 3. Vital sign changes.■ 4. Potential for drug tolerance.93. A client with a fracture develops compartmentsyndrome. Which of the following signsshould alert the nurse to impending organ failure?■ 1. Crackles.■ 2. Jaundice.■ 3. Generalized edema.■ 4. Dark, scanty urine.The Client with a Femoral Fracture94. A client with a fractured right femur has nothad any immunizations since childhood. Which ofthe following biologic products should the nurseadminister to provide the client with passive immunityfor tetanus?■ 1. Tetanus toxoid.■ 2. Tetanus antigen.■ 3. Tetanus vaccine.■ 4. Tetanus antitoxin.95. After teaching the client with a femoralfracture about the purpose of treatment with skeletaltraction, which of the following, if stated by the client,would indicate the need for additional teaching?■ 1. To align injured bones.■ 2. To provide long-term pull.■ 3. To apply 25 lb of traction.■ 4. To pull weight with a boot.96. The nurse is planning care for the client witha femoral fracture who is in balanced suspensiontraction. Which of the following would the nurse beleast likely to include in the plan of care?■ 1. Use of a fracture bedpan.■ 2. Checks for redness over the ischial tuberosity.■ 3. Elevation of the head of bed no more than25 degrees.■ 4. Personal hygiene with a complete bed bath.97. A client is in balanced suspension tractionusing a half-ring Thomas splint with a Pearsonattachment that suspends the lower extremity andapplies direct skeletal traction for a hip fracture.Which of the following nursing assessments wouldnot be appropriate?■ 1. Greater trochanter skin checks.■ 2. Pin site inspection.■ 3. Neurovascular checks proximal to the splint.■ 4. Foot movement evaluation.98. The client in balanced suspension tractionis transported to surgery for closed reduction andinternal fi xation of his fractured femur. Which of thefollowing should the nurse do when transportingthe client to the operating room?■ 1. Transfer the client to a cart with manuallysuspended traction.■ 2. Call the surgeon to request an order to temporarilyremove the traction.■ 3. Send the client on his bed with extra help tostabilize the traction.■ 4. Remove the traction and send the client on acart.99. A client has a Pearson attachment on thetraction setup. Which of the following is the purposeof this attachment?■ 1. To support the lower portion of the leg.■ 2. To support the thigh and upper leg.■ 3. To allow attachment of the skeletal pin.■ 4. To prevent fl exion deformities in the ankleand foot.100. Which of the following should lead the nurseto suspect that a client with a fracture of the rightfemur may be developing a fat embolus?■ 1. Acute respiratory distress syndrome.■ 2. Migraine-like headaches.■ 3. Numbness in the right leg.■ 4. Muscle spasms in the right thigh.101. The client with a fractured femur is upset andagitated about her injury and its treatment. She says,“How can I stay like this for weeks? I can’t evenmove!” Which of the following is the most appropriatenursing diagnosis?■ 1. Impaired physical mobility related to traction.■ 2. Ineffective coping related to prolonged immobility.■ 3. Defi cient diversional activity related to prolongedhospitalization.■ 4. Activity intolerance related to impairedmobility.102. The client asks the nurse what his activitylimitations are while he is in Buck’s traction. Thenurse should tell the client:■ 1. “You can sit up whenever you want.”■ 2. “You must lie fl at on your back most of thetime.”■ 3. “You can turn your body.”■ 4. “You must lie on your stomach.”103. Because a client has a Thomas splint, thenurse should assess the client regularly for which ofthe following?■ 1. Signs of skin pressure in the groin area.■ 2. Evidence of decreased breath sounds.■ 3. Skin breakdown behind the heel.■ 4. Urine retention.104. The client has a nursing diagnosis of Self-caredefi cit related to the confi nement of traction. Whichof the following would indicate a successful outcomefor this diagnosis?■ 1. The client assists as much as possible in hiscare, demonstrating increased participationover time.■ 2. The client allows the nurse to complete hiscare in an effi cient manner without interfering.■ 3. The client allows his wife to assume totalresponsibility for his care.■ 4. The client allows his wife to complete hiscare to promote feelings of usefulness.105. The client who had an open femoral fracturewas discharged to her home where she developedfever, night sweats, chills, restlessness, and restrictivemovement of the fractured leg. Which of thefollowing refl ects the best interpretation of thesefi ndings?■ 1. Pulmonary emboli.■ 2. Osteomyelitis.■ 3. Fat emboli.■ 4. Urinary tract infection.106. The nurse is planning care for a client withosteomyelitis. The client is taking an antibiotic, butthe infection has not resolved. The nurse shouldadvise the client to do which of the following?■ 1. Use herbal supplements.■ 2. Eat a diet high in protein and vitamins C andD.■ 3. Ask the health care provider for a change ofantibiotics.■ 4. Encourage frequent passive range-of-motionto the affected extremity.The Client with a Spinal Cord Injury107. When planning to move a person with a possiblespinal cord injury, the nurse should direct theteam to:■ 1. Limit movement of the arms by wrappingthem next to the body.■ 2. Move the person gently to help reduce pain.■ 3. Immobilize the head and neck to preventfurther injury.■ 4. Cushion the back with pillows to ensure comfort.108. The nurse is taking care of a client with aspinal cord injury. The extent of the client’s injuryis shown below. Which of the following fi ndings isexpected when assessing this client?■ 1. Inability to move his arms.■ 2. Loss of sensation in his hands and fi ngers.■ 3. Dysfunction of bowel and bladder.■ 4. Diffi culty breathing109. When the client has a cord transection at T4,which of the following is the primary focus of thenursing assessment?■ 1. Renal status.■ 2. Vascular status.■ 3. Gastrointestinal function.■ 4. Biliary function.110. When assessing the client with a cord transectionabove T5 for possible complications, which ofthe following should the nurse expect as least likelyto occur?■ 1. Diarrhea.■ 2. Paralytic ileus.■ 3. Stress ulcers.■ 4. Intra-abdominal bleeding.111. The nurse is planning to teach the client withspinal cord injury and intermittent nasogastric suctioningabout interventions to protect her integumentarysystem. The nurse should tell the client to:■ 1. Eat enough calories to maintain desiredweight.■ 2. Stay in cool environments to avoid sweating.■ 3. Stay in warm environments to avoidchilling.■ 4. Eat low-sodium foods to avoid edema.112. Which of the following should the nurse useas the best method to assess for the development ofdeep vein thrombosis in a client with a spinal cordinjury?■ 1. Homans’ sign.■ 2. Pain.■ 3. Tenderness.■ 4. Leg girth.113. During the period of spinal shock, the nurseshould expect the client’s bladder function to bewhich of the following?■ 1. Spastic.■ 2. Normal.■ 3. Atonic.■ 4. Uncontrolled.114. After 1 month of therapy, the client in spinalshock begins to experience muscle spasms in hislegs. He calls the nurse in excitement to report theleg movement. Which of the following responses bythe nurse would be the most accurate?■ 1. “These movements indicate that the damagednerves are healing.”■ 2. “This is a good sign. Keep trying to move allthe affected muscles.”■ 3. “The return of movement means that eventuallyyou should be able to walk again.”■ 4. “The movements occur from muscle refl exesthat can’t be initiated or controlled by thebrain.”115. The client with a spinal cord injury asksthe nurse why the dietitian has recommended todecrease the total daily intake of calcium. Which ofthe following responses by the nurse would providethe most accurate information?■ 1. “Excessive intake of dairy products makesconstipation more common.”■ 2. “Immobility increases calcium absorptionfrom the intestine.”■ 3. “Lack of weight bearing causes demineralizationof the long bones.”■ 4. “Dairy products likely will contribute toweight gain.”116. As a fi rst step in teaching a woman with aspinal cord injury and quadriplegia about her sexualhealth, the nurse assesses her understanding of hercurrent sexual functioning. Which of the followingstatements by the client indicates she understandsher current ability?■ 1. “I won’t be able to have sexual intercourseuntil the urinary catheter is removed.”■ 2. “I can participate in sexual activity but mightnot experience orgasm.”■ 3. “I can’t have sexual intercourse because it causeshypertension, but other sexual activity is okay.”■ 4. “I should be able to participate in sexualactivity, but I will be infertile.”117. A client with a spinal cord injury who hasbeen active in sports and outdoor activities talksalmost obsessively about his past activities. In tears,one day he asks the nurse, “Why can’t I stop talkingabout these things? I know those days are goneforever.” Which of the following responses by thenurse conveys the best understanding of the client’sbehavior?■ 1. “Be patient. It takes time to adjust to such amassive loss.”■ 2. “Talking about the past is a form of denial.We have to help you focus on today.”■ 3. “Reviewing your losses is a way to help youwork through your grief and loss.”■ 4. “It’s a simple escape mechanism to go backand live again in happier times.”Managing Care Quality and Safety118. The nurse is documenting care of a clientwho is restrained in bed with bilateral wristrestraints. Following assessment of the restraints,the nurse’s documentation should include which ofthe following? Select all that apply.■ 1. Nutrition and hydration needs.■ 2. Capillary refi ll.■ 3. Continued need for restraints.■ 4. Need for medication119. The nurse on an orthopedic unit is institutinga falls prevention program. Which of the followingpersonnel should be involved in the program? Selectall that apply.■ 1. Registered nurses.■ 2. Physicians.■ 3. Unlicensed personnel.■ 4. Housekeeping services.■ 5. Family members.■ 6. Client.120. The nurse unit manager is making rounds ona team of clients and notices a client who is wearingred slipper socks and a color-coded armbandthat indicates the client is at risk for falling walkingdown the hall unassisted. The nurse should dowhich of the following fi rst?■ 1. Encourage the client to keep walking until hebecomes tired.■ 2. Walk with the client back to his room andassist him to get in bed.■ 3. Accompany the client while using the lapelmicrophone to call for the unlicensed nursingpersonnel (UAP) to walk with the client.■ 4. Instruct the client to walk only in his room.121. The physician has written an order for aclient to begin anticoagulant therapy with 5 mgCoumadin (warfarin) orally. In planning care forthis client, the nurse should verify that which of thefollowing services have been contacted? Check allthat apply.■ 1. Pharmacy.■ 2. Dietary.■ 3. Laboratory.■ 4. Discharge planning.■ 5. Chaplain.122. The nurse on the orthopedic unit is going tolunch and is conducting a “hand-off” to the chargenurse. The goal of the “hand-off” communication isto do which of the following?■ 1. To insure the charge nurse understands thatthe nurse is going to lunch.■ 2. To be sure the charge nurse assigns someoneelse to take care of the client.■ 3. To provide accurate information about client’scare to the next caregiver.■ 4. To provide in-depth information about theclient’s history.Answers, Rationales, and Test Taking StrategiesThe answers and rationales for each question followbelow, along with keys ( ) to the client need(CN) and cognitive level (CL) for each question. Usethese keys to further develop your test-taking skills.For additional information about test-taking skillsand strategies for answering questions, refer to pages10–21, and pages 25–26 in Part 1 of this book.The Client with Rheumatoid Arthritis1. 3. Initially, most clients with early symptomsof rheumatoid arthritis complain of early morningstiffness or stiffness after sitting still for a while.Later symptoms of rheumatoid arthritis includelimited joint range of motion; deformed joints, especiallyof the hand; and rheumatoid : Physiological adaptation;CL: Analyze2. 1. Based on the client’s complaints, the mostappropriate nursing diagnosis would be Activityintolerance related to fatigue and pain. Nursinginterventions would focus on helping the clientconserve energy and decrease episodes of fatigue.Although the client may develop a self-care defi -cit related to the activity intolerance and increasingjoint pain, the client is voicing concerns abouthousehold chores and diffi culty around the houseand yard, not self-care issues. Over time, the clientmay develop ineffective coping or body imagedisturbance as the disorder becomes chronic withincreasing pain and : Basic care and comfort; CL: Analyze3. 1, 2, 4. Rheumatoid arthritis (RA) affectswomen three times more often than men, betweenthe ages of 20 and 55 years. Research has determinedthat RA occurs in clients who have had infectiousdisease, such as the Epstein-Barr virus. Thegenetic link, specifi cally HLA-DR4, has been foundin 65% of clients with RA. People with osteoarthritisare not necessarily at risk for developing : Reduction of risk potential;CL: Analyze4. 3. Maintaining usual ways of accomplishingtasks would be the lowest priority during the acutephase. Rather, the focus is on developing less stressfulways of accomplishing routine tasks. Pain reliefis a high priority during the acute phase becausepain is typically severe and interferes with the client’sability to function. Preserving joint functionand preventing joint deformity are high prioritiesduring the acute phase to promote an optimal levelof functioning and reduce the risk of : Physiological adaptation;CL: Synthesize5. 3. Heat-producing liniment can producea burn if used with other heat devices that couldintensify the heat reaction. Heat and cold can beused as often as the client desires. However, eachapplication of heat should not exceed 20 minutes,and each application of cold should not exceed 10to 15 minutes. Application for longer periods resultsin the opposite of the intended effect: vasoconstrictioninstead of vasodilation with heat, and vasodilationinstead of vasoconstriction with : Reduction of risk potential;CL: Evaluate6. 4. The nurse’s most appropriate response isone that is therapeutic. The basic principle of therapeuticcommunication and a therapeutic relationshipis honesty. Therefore, the nurse needs to explaintruthfully that each client is different and that thereare various forms of arthritis and arthritis treatment.To state that it is the physician’s prerogative to decidehow to treat the client implies that the client is not amember of his or her own health care team and is nota participant in his or her care. The statement also isdefensive, which serves to block any further communicationor questions from the client about the physician.Asking the client to tell more about the friendpresumes that the client knows correct and completeinformation, which is not a valid assumption to make.The nurse does not know about the client’s friend andshould not make statements about another client’scondition. Stating that the drug is for cases that areworse than the client’s demonstrates that the nurseis making assumptions that are not necessarily validor appropriate. Also, telling the client not to worryignores the underlying emotions associated with thequestion, totally discounting the client’s : Psychosocial adaptation;CL: Synthesize7. 4. Positions of fl exion should be avoidedto prevent loss of functional ability of affectedjoints. Proper body alignment during rest periodsis encouraged to maintain correct muscle and jointplacement. Lying in the prone position is encouragedto avoid further curvature of the spine andinternal rotation of the : Physiological adaptation;CL: Synthesize8. 4. Carrying a laundry basket with clinchedfi ngers and fi sts is not an example of conservingenergy of small joints. The laundry basket shouldbe held with both hands opened as wide as possibleand with outstretched arms so that pressure is notplaced on the small joints of the fi ngers. When risingfrom a chair, the palms should be used insteadof the fi ngers so as to distribute weight over thelarger area of the palms. Holding packages close tothe body provides greater support to the shoulder,elbow, and wrist joints because muscles of the armsand hands are used to stabilize the weight againstthe body. This decreases the stress and weight orpull on small joints such as the fi ngers. Objects canbe slid with the palm of the hand, which distributesweight over the larger area of the palms instead ofstressing the small joints of the fi ngers to pick up theweight of the object to move it to another : Basic care and comfort; CL: Evaluate9. 1. Because some over-the-counter vitamin supplementscontain folic acid, the client should avoidself-medication with vitamins while taking methotrexate,a folic acid antagonist. Because methotrexateis hepatotoxic, the client should avoid the intake ofalcohol, which could increase the risk for hepatotoxicity.Methotrexate can cause bone marrow depression,placing the client at risk for infection. Therefore,meticulous mouth care is essential to minimize therisk of infection. Contraception should be used duringmethotrexate therapy and for 8 weeks after thetherapy has been discontinued because of its effect onmitosis. Methotrexate is considered : Pharmacological and parenteraltherapies; CL: Evaluate10. 2. Diffi culty seeing out of one eye, whenevaluated in conjunction with the client’s medicationtherapy regimen, leads to the suspicion of possibleretinal degeneration. The possibility of an irreversibleretinal degeneration caused by deposits ofhydroxychloroquine (Plaquenil) in the layers of theretina requires an ophthalmologic examination beforetherapy is begun and at 6-month intervals. Althoughcataracts may develop in young adults, they are lesslikely, and damage from the hydroxychloroquine isthe most obvious at-risk factor. Eyesight is not affectedby the disease process of rheumatoid : Pharmacological and parenteraltherapies; CL: Analyze11. 4. Superfi cial heat applications, such as tubbaths, showers, and warm compresses, can be helpfulin relieving pain and stiffness. Exercises can beperformed more comfortably and more effectivelyafter heat applications. The client with rheumatoidarthritis must balance rest with exercise every day,not every other day. Typically, large doses of analgesics,which can lead to hepatotoxic effects, are notnecessary. Learning to cope with the pain by refocusingis : Basic care and comfort;CL: Synthesize12. 1, 2, 5. An arthrocentesis is performed toaspirate excess synovial fl uid, pus, or blood from ajoint cavity to relieve pain or to diagnosis infl ammatorydiseases such as rheumatoid arthritis. A localagent may be used to decrease the pain of the needleinsertion through the skin and into the joint cavity.Aspiration of the fl uid into the syringe can bevery painful because of the size and infl ammationof the joint. Usually a steroid medication is injectedlocally to alleviate the infl ammation; a compressionbandage is applied to help decrease swelling; andthe client is asked to rest the joint for up to 24 hoursafterwards to help relieve the pain and promote restto the infl amed joint. The client may experiencepain during this time until the infl ammation beginsto resolve and swelling : Reduction of risk potential;CL: CreateThe Client with Osteoarthritis13. 1, 4, 5. To prepare a client for an arthrocentesis,the nurse should tell the client that a local anestheticadministered by the physician will decreasediscomfort. There may be bleeding after the procedure,so the nurse should check the dressing. Theclient may experience pain. The nurse should offerpain medication and evaluate outcomes for painrelief. Because a local anesthetic is used, the clientwill not require preoperative medication. The clientwill rest the knee for 24 hours and then shouldbegin range-of-motion and muscle : Management of care; CL: Create14. 1. Metal will interfere with the test. Metallicobjects within the examination fi eld, such as jewelry,earrings, and dental amalgams, may inhibit organvisualization and can produce unclear images. Ingestingfoods and beverages days before the test willnot affect bone mineral status. Short-term calciumgluconate intake will also not infl uence bone mineralstatus. The client may already have had chronic painas a result of a bone fracture or from : Management of care; CL: Synthesize15. 1. Shorter sessions will allow the client to restbetween the sessions. Changing the physician’s orderto a different examination will not provide the informationneeded for this client’s treatment. Acetaminophenis a nonopioid analgesic and an antipyretic,not an anti-infl ammatory agent. Thus, it would nothelp this client avoid the adverse effects of a lengthyX-ray examination. Although the X-ray table is hard,there are other options for making the client comfortable,rather than canceling the : Management of care; CL: Synthesize16. 4. Osteoarthritis is a degenerative joint diseasewith local manifestations such as local joint pain,unlike rheumatoid arthritis, which has systemicmanifestation such as anemia and osteoporosis.Weight loss occurs in rheumatoid arthritis, whereasmost clients with osteoarthritis are : Physiological adaptation;CL: Analyze17. 1, 2, 3. A diet with adequate amounts of vitaminD aids in the regulation, absorption, and subsequentutilization of calcium and phosphorus, whichare necessary for the normal calcifi cation of bone.Figs, broccoli, and almonds are very good sources ofcalcium. Moderate intake of alcohol has no knownnegative effects on bone density but excessive alcoholintake does reduce bone density. Swimming,biking, and other non–weight-bearing exercisesdo not maintain bone mass. Walking and running,which are weight-bearing exercises, do maintainbone mass. The client should eat a balanced diet butdoes not need to avoid the use of high-fat : Reduction of risk potential;CL: Create18. 1. Capsaicin cream, which produces analgesiaby preventing the reaccumulation of substance Pin the peripheral sensory neurons, is made from theactive ingredients of hot peppers. Therefore, clientsshould wash their hands immediately after applyingcapsaicin cream if they do not wear gloves, to avoidpossible contact between the cream and mucousmembranes. Clients are instructed to avoid wearingtight bandages over areas where capsaicin creamhas been applied because swelling may occur frominfl ammation of the arthritis in the joint and lead toconstriction on the peripheral neurovascular system.Capsaicin cream should be stored in areas between59° F and 86° F (15° C and 30° C). The cabinet overthe stove in the kitchen would be too warm. Capsaicincream should not come in contact with irritatedand broken skin, mucous membranes, or eyes.Therefore it should not be used on cuts or : Pharmacological and parenteraltherapies; CL: Evaluate19. 3. Drugs that cause gastric irritation, such asibuprofen, are best taken after or with a meal, whenstomach contents help minimize the local irritation.Taking the medication on an empty stomach at anytime during the day will lead to gastric irritation.Taking the drug at bedtime with food may causethe client to gain weight, possibly aggravating theosteoarthritis. When the client arises, he is stiff fromimmobility and should use warmth and stretchinguntil he gets food in his : Pharmacological and parenteraltherapies; CL: Synthesize20. 1. Corticosteroids are used for clients withosteoarthritis to obtain a local effect. Therefore, theyare given only via intra-articular injection. Oral corticosteroidsare avoided because they can cause anacceleration of osteoarthritis. Rheumatoid arthritisand osteoarthritis are two different : Pharmacological and parenteraltherapies; CL: Synthesize21. 2. Weight-bearing exercise plays a veryimportant role in stimulating regeneration of cartilage,which lacks blood vessels, by driving synovialfl uid through the joint cartilage. Joint mobility isincreased by weight-bearing exercises, not rangeof-motion exercises, because surrounding muscles,ligaments, and tendons are strengthened. Pain isan early sign of degenerative joint bone problems.Swelling may not occur for some time after pain, ifat all. Osteoarthritic pain is worsened in cold, dampweather; therefore, exercising outdoors is not recommendedyear round in all : Health promotion and maintenance;CL: EvaluateThe Client with a Hip Fracture22. 4. The hip spica cast is used for treatment offemoral fractures; it immobilizes the affected extremityand the trunk securely. It extends from above thenipple line to the base of the foot of both extremitiesin a double hip spica. Constipation, possible dueto lack of mobility, can cause abdominal distentionor bloating. When the spica cast becomes too tightdue to distention, the cast will compress the superiormesenteric artery against the duodenum. Thecompression produces abdominal pain, abdominalpressure, nausea, and vomiting. The nurse shouldassess the abdomen for decreased bowel sounds, notthe superior mesenteric artery. The surgeon cannotmanipulate a fracture through a small window ina double hip spica cast. The nurse cannot use thewindow to aid in repositioning because the windowopening can break and cause cast : Reduction of risk potential;CL: Evaluate23. 3. With an intracapsular hip fracture, theaffected leg is shorter than the unaffected legbecause of the muscle spasms and external rotation.The client also experiences severe pain in the regionof the : Physiological adaptation;CL: Analyze24. 4. Multiple sclerosis would be the least likelychronic health problem for an older client with a hipfracture. Typically, multiple sclerosis is considered a severe crippling disorder of young clients. Hypertensionis a common chronic health problem in olderclients. Cardiac decompensation is common in olderclients; it arises from cardiac musculature changesand age-related changes in the heart. This comorbidcondition can complicate the treatment and carewhen the older client experiences a hip fracture.Pulmonary disease commonly arises from age-relatedchanges in the respiratory system. These comorbidconditions can complicate the treatment and carewhen the older client experiences a hip : Reduction of risk potential;CL: Analyze25. 4. Insertion of a pin for the internal fi xationof an extracapsular fractured hip provides goodfi xation of the fracture. The fracture site is stabilizedand fractured bone ends are well approximated. Asa result, the client is able to be mobilized sooner,thus reducing the risks of complications related toimmobility. Internal fi xation with a pin insertiondoes not prevent hemorrhage or decrease the risk ofneurovascular impairment, potential complicationsassociated with any joint or bone surgery. It does notlessen the client’s risk of infection at the : Reduction of risk potential;CL: Apply26. 3. The primary purpose of the drainage tubeis to prevent fl uid accumulation in the wound.Fluid, when it accumulates, creates dead space.Elimination of the dead space by keeping the woundfree of fl uid greatly enhances wound healing andhelps prevent abscess formation. Although thecharacteristics of the drainage from the tube, suchas a change in color or appearance, may suggesta possible infection, this is not the tube’s primarypurpose. The drainage tube does not eliminate theneed for wound irrigation or provide a way to instillantibiotics into the : Reduction of risk potential;CL: Apply27. 2, 3, 4, 5. A client who has had a posterolateraltotal hip replacement should not adduct the hipjoint, which would lead to dislocation of the ball outof the socket; therefore, the client should be encouragedto keep the toes pointed slightly outwardwhen using a walker. An abduction pillow shouldbe kept between the legs to keep the hip joint in anabducted position. The client should rotate betweenlying supine and lateral on the unoperated side, butnot on the operated side. Ice is used to reduce swellingon the operative side. The client should not fl exthe operated hip beyond a 90-degree angle, such aswhen bending down to tie or slip on shoes. Doing socould lead to joint : Reduction of risk potential;CL: Create28. 1, 3, 4. A client who has had a total hipreplacement via an anterolateral approach hasalmost the opposite precautions as those for a clientwho has had a total hip replacement throughthe posterolateral approach. The hip joint shouldnot be actively abducted. The client should avoidturning the toes or knee outward. The client shouldkeep the legs side by side without a pillow orwedge. The client should use an elevated toiletseat and shower chair and should not extend theoperative leg backwards. The client should performrange-of-motion exercises as directed by the : Reduction of risk potential;CL: Create29. 2. Being unable to move the affected leg suggestsneurologic impairment. A decrease in the distalpulse, diminished capillary refi ll, and coolnessto touch of the affected extremity suggest : Reduction of risk potential;CL: Analyze30. 1. Any activity or position that causesfl exion, adduction, or internal rotation of greaterthan 90 degrees should be avoided until the softtissue surrounding the prosthesis has stabilized,at approximately 6 weeks. Crossing the legs whilesitting down can lead to dislocation of the femoralhead from the hip socket. Sitting on a raised commodeseat prevents hip fl exion and adduction.Using an abductor splint while side-lying keepsthe hip joint in abduction, thus preventing adductionand possible dislocation. Rising straight froma chair to a standing position is acceptable forthis client because this action avoids hip fl exion,adduction, and internal rotation of greater than90 : Reduction of risk potential;CL: Synthesize31. 3. A high-backed straight chair with armrestsis recommended to help keep the client in thebest possible alignment after surgery for a femoralhead prosthesis placement. Use of this type ofchair helps to prevent dislocation of the prosthesisfrom the socket. A desk-type swivel chair, paddedupholstered chair, or recliner should be avoidedbecause it does not provide for good body alignmentand can cause the overly fl exed femoral headto : Reduction of risk potential;CL: Synthesize32. 2. Although pets and furniture, such as snacktables and rocking chairs, may pose a problem, scatterrugs are the single greatest hazard in the home, especially for elderly people who are unsure andunsteady with walking. Falls have been found toaccount for almost half the accidental deaths thatoccur in the home. The risk of falls is further compoundedby the client’s need for : Safety and infection control;CL: SynthesizeThe Client Having JointReplacement Surgery33. 3. When combined with a weight loss program,aquatic exercise would be best because itcushions the joints and allows the client to burnoff calories. Aquatic exercise promotes circulation,muscle toning, and lung expansion, which promotehealthy preoperative conditioning. Weight liftingand walking are too stressful to the joints, possiblyexacerbating the client’s osteoarthritis. Although taichi exercise is designed for stretching and coordination,it would not be the best exercise for this clientto help with weight : Physiological adaptation;CL: Synthesize34. 4. Before implementing a teaching plan, thenurse should determine the client’s fears about theprocedure. Only then can the client begin to hearwhat the nurse has to share about the individualizedteaching plan designed to meet the client’s needs.In the preoperative period, the client needs to learnhow to correctly prevent hip fl exion and to demonstratecoughing and deep breathing. However, thisteaching can be effective only after the client’s fearshave been assessed and addressed. Although theclient may appreciate seeing what a hip prosthesislooks like, so as to understand the new body part,this is not a : Psychosocial adaptation;CL: Synthesize35. 1. The nurse should suspect nerve damage ifnumbness is present. However, whether the damageis short-term and related to edema or long-termand related to permanent nerve damage would notbe clear at this point. The nurse needs to continueto assess the client’s neurovascular status, includingpain, pallor, pulselessness, paresthesia, and paralysis(the fi ve P’s). Bleeding would suggest vasculardamage or hemorrhage. Dislocation would suggestmalalignment. Pink color would suggest adequatecirculation to the area. Numbness would suggestneurologic : Reduction of risk potential;CL: Analyze36. 3. The joint has dislocated when the clientwith a total joint prosthesis develops severe suddenpain and an inability to move the extremity. Clinicalmanifestations of an infection would include infl ammation,redness, erythema, and possibly drainageand separation of the wound. Bleeding could beexternal (e.g., blood visible from the wound or onthe dressing) or internal and manifested by signs ofshock (e.g., pallor, coolness, hypotension, tachycardia).The seepage of glue into soft tissue would haveoccurred in the operating room, when the glue isstill in the liquid form. The glue dries into the hard,fi xed form before the wound is : Reduction of risk potential;CL: Analyze37. 1. An average adult requires approximately1,100–1,400 mL of fl uids per day. In some instances,such as when a person has an increase in body temperatureor has increased perspiration, additionalwater may be necessary. With an increase in bodytemperature, there is also an increase in insensiblefl uid loss. The increased loss of fl uid causes anincreased need for fl uid replacement. If the loss issignifi cant and/or goes untreated, an individual’sintake will not be balanced with output. Managingthe incision, changing the bed linens, or keepingthe client’s skin cool are not outcomes indicative ofresolution of a fl uid volume defi : Physiological adaptation;CL: Synthesize38. 4. After knee arthroplasty, the knee will beextended and immobilized with a fi rm compressiondressing and an adjustable soft extension splint inplace. A sequential compression device (SCD) willbe applied. The SCD can be discontinued when theclient is ambulatory, but while the client is in bedthe SCD needs to be maintained to prevent thromboembolism.The SCD should be positioned on thebed, but not on two pillows. Settings for the SCD areordered by the orthopedic surgeon. Initial dressingchanges are completed by the orthopedic surgeonand changed as needed per physician : Reduction of risk potential;CL: Synthesize39. 1, 2, 3. The nurse should instruct the clientto notify the dentist and other health care providersof the need to take prophylactic antibiotics ifundergoing any procedure (e.g., tooth extraction)due to the potential of bacteremia. The nurse shouldalso advise the client that the metal components ofthe joint may set off the metal-detector alarms inairports. The client should also avoid MRI studiesbecause the implanted metal components will bepulled toward the large magnet core of the MRI. Anyweight bearing that is permitted is prescribed by the orthopedic surgeon and is usually not limited to5 lb. Post surgery, the client can resume a normaldiet with regular fl uid : Health promotion and maintenance;CL: Create40. 4. After total hip replacement, proper positioningby the nurse prevents dislocation of theprosthesis. The nurse should place the client in asupine position and keep the affected extremity inslight abduction using an abduction splint or pillowsor Buck’s extension traction. The client mustnot abduct or fl ex the operated hip because this mayproduce : Reduction of risk potential;CL: Synthesize41. 2, 4, 5. Following total hip replacement, theclient should use the overhead trapeze to assist withposition changes. The head of the bed should not beelevated more than 45 degrees; any height greaterthan 45 degrees puts a strain on the hip joint andmay cause dislocation. To use a fracture bedpan,instruct the client to fl ex the unoperated hip andknee to lift buttocks onto pan. Toe-pointing exercisesstimulate circulation in the lower extremitiesto prevent the formation of thrombi and potentialemboli. The prone position is avoided shortly after atotal hip : Reduction of risk potential;CL: Synthesize42. 1, 3, 4. Administration of antibiotics as prescribedwill aid in the acquisition of therapeutic bloodlevels during and immediately after surgery to preventosteomyelitis. The nurse can request that a trapeze beadded to the bed so the client can assist with liftingand turning. The nurse should also demonstrate andhave the client practice isometric exercises (musclesetting) of quadriceps and gluteal muscles. The clientwill not use crutches after surgery; a physical therapyassistant will initially assist the client with walkingby using a walker. The client will not use Buck’s traction.The client will require anti-embolism stockingsand use of a leg compression device to minimize therisk of thrombus formation and potential emboli; theleg compression device is applied during surgery andmaintained per physician : Physiological adaptation; CL: Create43. 1, 2, 3, 4. Client/family teaching shouldinclude advising the client to report any symptomsof unusual bleeding or bruising, dizziness, itching,rash, fever, swelling, or diffi culty breathing tohealthcare provider immediately. Instruct the clientnot to take aspirin or nonsteroidal anti-infl ammatorydrugs without consulting health care provider whileon therapy. A low-molecular weight heparin is conshould wear or carry medical identifi cation. Theair bubble should not be expelled from the syringebecause the bubble insures the client receives thefull dose of the medication. The client should allow5 seconds to pass before withdrawing the needle toprevent seepage of the medication out of the : Pharmacological and parenteraltherapies; CL: Create44. 3. Dislocation precautions include: avoidextremes of internal rotation, adduction, and90- degree fl exion of affected hip for at least 4 to6 weeks after the procedure. Use of an abductionpillow prevents adduction. Decreasing use of theabductor pillow does not strengthen the musclesto prevent dislocation. Informing a client to “notworry” is not therapeutic. A cushioned toilet seatdoes not prevent hip : Psychosocial adaptation;CL: Synthesize45. 1, 2, 3. Dislocation of a hip prosthesis mayoccur with positioning that exceeds the limits of theprosthesis. The nurse must recognize dislocationof the prosthesis. Signs of prosthesis dislocationinclude: acute groin pain in the affected hip, shorteningof the affected leg, restricted ability or inabilityto move the affected leg, and reported “popping”sensation in the hip. Toe wiggling is not a test forpotential hip : Reduction of risk potential;CL: Analyze46. 4. If a prosthesis becomes dislocated, thenurse should immediately notify the surgeon. Thisis done so the hip can be reduced and stabilizedpromptly to prevent nerve damage and to maintaincirculation. After closed reduction, the hip may bestabilized with Buck’s traction or a brace to preventrecurrent dislocation. If ordered by the surgeon,an ice pack may be applied post reduction to limitedema, although caution must be utilized due topotential muscle spasms. Some orthopedic surgeonsmay order the client be turned toward the side of thereduced hip but that is not the nurse’s fi rst : Reduction of risk potential;CL: Synthesize47. 3. Infection is a serious complication of totalhip replacement and may necessitate removal of theimplant. Clients who are obese, poorly nourished,elderly, have poorly controlled diabetes, rheumatoidarthritis, or concurrent infections (e.g., dental,urinary tract) are at high risk for infection. Clientswho are of normal weight and have well-controlledchronic diseases are not at risk for infection. Livingalone is not a risk factor for : Reduction of risk potential;CL: Synthesize48. 3. Expected outcomes at the time of dischargefrom the surgical unit after a hip replacementinclude the following: increased independence intransfers, participates in progressive ambulationwithout pain or assistance, and raises the affectedleg without assistance. The client will not be ableto walk throughout the hospital, walk for a distancewithout some postoperative pain, or raise theaffected leg more than several inches. The clientmay be referred to a rehabilitation unit in order toachieve the additional independence, strength, andpain : Physiological adaptation;CL: Evaluate49. 1, 2, 3, 4. Postoperatively, the knee in atotal knee replacement is dressed with a compressionbandage and ice may be applied to controledema and bleeding. Recurrent assessment by thenurse for neurovascular changes can prevent loss oflimb. Normal neurovascular fi ndings include: colornormal, extremity warm, capillary refi ll less than 3seconds, moderate edema, tissue not palpably tense,pain controllable, normal sensations, no paresthesia,normal motor abilities, no paresis or paralysis, andpulses strong and : Reduction of risk potential;CL: Analyze50. 4. The knee is usually protected with a kneeimmobilizer (splint, cast, or brace) and is elevatedwhen the client sits in a chair. Pre- and post-surgery,the physician prescribes weight-bearing limits anduse of assistive devices for progressive ambulation.Positioning a straight-backed chair at the foot of thebed is not an action conducive for getting the clientout of bed on the evening of surgery for a total : Reduction of risk potential;CL: Synthesize51. 1, 4. After a total knee replacement, effortsare directed at preventing complications, suchas thromboembolism, infection, limited range ofmotion, and peroneal nerve palsy. The nurse shouldinstruct the client to report signs of infection, suchas an increased temperature. To prevent edema, theaffected leg must remain elevated when the clientsits in a chair. After discharge, the client mayundergo physical therapy on an outpatient basis perphysician order. The client should leave the dressingin place until the follow-up visit with the : Reduction of risk potential;CL: Create52. 1. Deep vein thrombosis is a complication oftotal joint replacement and may occur during hospitalizationor develop later when the client is home.Clients who are obese or have previous history of a DVT or PE are at high risk. Immobility producesvenous stasis, increasing the client’s chance todevelop a venous thromboembolism. Signs of a DVTinclude: unilateral calf tenderness, warmth, redness,and edema (increased calf circumference). Findingsshould be reported promptly to the physicianfor defi nitive evaluation and therapy. Polyuria maybe indicative of diabetes mellitus. Intussusceptionof the bowel and wound evisceration tend to occurafter abdominal : Reduction of risk potential;CL: AnalyzeThe Client with a Herniated Disk53. 1. The client is using correct body mechanicsfor lifting because she is keeping her back as straightas possible and is holding the box close to her body.She is using her large leg muscles to lift the box.She is using a broad base of support by placing herfeet as wide apart as possible. The other suggestionswould cause the client to put a strain on her : Reduction of risk potential;CL: Synthesize54. 3. The client with low back pain should notexceed the prescribed exercises even though theymay think, “If this will make me well, double willmake me well quicker.” When exceeding prescribedexercise programs, the client’s muscle may beunconditioned and easily tired, leading to injury andincreased pain. To use proper body mechanics whenlifting light objects, the client should bring the itemclose to the center of gravity, which occurs when theobject is kept below the level of the elbows. Leaningforward while bending the knees allows for the musclesof the thigh to be used instead of those of thelower back. Sleeping on the side with the legs fl exedis appropriate because the spine is kept in a neutralposition without twisting or pulling on : Reduction of risk potential;CL: Synthesize55.4. Administer the prescribed celecoxib (Celebrex).1. Apply a warm compress to the client’s back.2. Notify the physician.3. Assist the client to lie down.When the client is not entirely able to get out of bed,the nurse should fi rst assist the client to lie down forcomfort/safety before administering the prescribed Celebrex. Applying a warm compress will furtherpromote relaxation of skeletal muscles. The physicianshould be kept informed of the client’s statusand nursing actions already : Basic care and comfort;CL: Synthesize56. 2. Standing with a fl attened spine slightlytilted forward and slightly fl exed to the affectedside indicates a postural deformity. Motor changeswould include fi ndings such as hypotonia or muscleweakness. Absent or diminished refl exes related tothe level of herniation would indicate alteration inrefl exes. Sensory changes would include fi ndingssuch as paresthesia and numbness related to thespecifi c tract of the : Physiological adaptation;CL: Analyze57. 2. A supine position with the client’s legsfl exed is the most comfortable position becauseit allows for the disc to recess off of the nerve,thus alleviating the pressure and pain. The proneposition causes hyperextension of the spine andincreased pressure of the disc on the nerve root onthe right. A ruptured disc at L5–S1 right is a termcommonly used in the analysis of a history andphysical examination, magnetic resonance image, ormyelogram to identify a ruptured disc compressingthe right nerve root exiting the L5–S1 spinous process,as opposed to the central area or the left nerveroot of that spinous process. If the ruptured areaof the disc were in the central area of the spinousprocess, the prone position and hyperextensionmight relieve the disc pressure on the nerve. A highFowler’s or sitting position increases the pressure ofthe disc on the nerve root because of gravity, as doesa right Sims : Physiological adaptation;CL: Synthesize58. 4. Myelography, used to determine the exactlocation of a herniated disk, involves the use of aradiopaque dye (usually an iodized oil, but in someinstances a water-soluble compound). In someinstances, air is used for an air-contrast : Reduction of risk potential;CL: Apply59. 4. An I.V. line is not required for an MRI. If aclient has an I.V. line, it is usually converted to anintermittent infusion device, such as a saline lock,to avoid infi ltration during transport of the clientand completion of the procedure. When a contrastagent is used, the client is moved out of the cylinder,the contrast material is injected, and the clientis moved back in. An MRI scan is painless. Typicallythe staff positions the client with pillows, blankets,earplugs, and music, to ensure client comfort, before surgeriesis important, especially if the surgery involvedimplantation of any metallic devices (e.g., implants,clips, pacemakers). Additionally, the nurse needs toassess for hearing aids, electronic devices, shrapnel,bra hooks, necklaces, jewelry, credit cards, zippers,or any type of metal that the magnet of the MRI unitwould attract. Although open MRI units are nowavailable, they are not in widespread use. Therefore,the nurse needs to determine whether the client isclaustrophobic because the unit is a closed cylinderin which the client hears pops of noise. A numberof clients develop claustrophobia that causes theprocedure to be cancelled. If the client is claustrophobic,the procedure may need to be rescheduledafter an open MRI unit is located or made : Reduction of risk potential;CL: Synthesize60. 2. Based on the client’s complaints, the nurseshould call the surgeon to verify the location of thesurgery. The client’s complaints indicate radiculopathyof L4 to L5, but the consent form states L3 to L4.Radiculopathy of L3 to L4 involves pain radiatingfrom the back to the buttocks to the posterior thigh tothe inner calf. The nurse must act as a client advocateand not ask the client to sign the consent until thecorrect procedure is identifi ed and confi rmed on theconsent. The nurse has no legal authority or responsibilityto change the consent. The history is a sourceof information, but when the client is coherent andthe history is contradictory, the physician should becontacted to clarify the situation. Ultimately, it is thesurgeon’s responsibility to identify the site of surgeryspecifi ed on the surgical consent : Management of care; CL: Synthesize61. 2. Ondansetron hydrochloride (Zofran) isa selective serotonin receptor antagonist that actscentrally to control the client’s nausea in the postoperativephase. It does not control muscle spasms,shivering, or dry : Pharmacological and parenteraltherapies; CL: Evaluate62. 4. Sweeping causes a twisting motion, whichshould be avoided because twisting can cause unduestress on the recently ruptured disc site, musclespasms, and a potential recurrent disc rupture.Although the client should not bend at the waist, suchas when washing dishes at the sink, the client can drydishes because no bending is necessary. The clientcan sit in a fi rm chair that keeps the back anatomicallyaligned. The client should not twist and pull, sowhen making the bed, the client should pull the coversup on one side and then walk around to the otherside before trying to pull the covers up : Physiological adaptation;CL: Evaluate63. 4. After a lumbar laminectomy L4–5, a clientwho is returning to work should avoid sittingwhenever possible. If the client must sit, he or sheshould sit only in chairs that allow the knees to behigher than the hips and support the arms to maintaincorrect body alignment and reduce undue stresson the spine. Maintaining good body postures ismost important after a lumbar laminectomy L4–5.By 6 weeks after the surgery, the client should haveregained stamina. To maintain correct body posture,the client should also place one foot on a stepstoolduring prolonged standing. Sleeping on the backwith a support under the knees is effective in maintainingcorrect body posture. Maintaining an averageweight for height is important in maintaining ahealthy back because carrying extra weight causesundue stress on back : Physiological adaptation;CL: Synthesize64. 2. Clear yellowish fl uid on the dressing maybe cerebrospinal fl uid (CSF). This fl uid must betested for glucose to determine whether it is CSF. Ifso, the client is at great risk for an infection of thecentral nervous system, which has a high mortalityrate. The client should be able to laterally rotate thehead and neck, which is above the surgical site inthe spinal column. During the nursing postoperativeneuromuscular-vascular assessment of movementof the head and neck, the nurse should fi nd resultsconsistent with the preoperative baseline status.Using the standing position to void is normal for amale client. Coughing is the body’s defense mechanismto help clear the lungs of the anesthetic agentsand to ventilate the lungs in response to a sustaineddeep inspiration for ventilation of the lower lobesof the lungs. A frequent cough could place a strainon the incision site and should be avoided. Also, aproductive cough of thick, yellow sputum wouldindicate the complication of a respiratory : Reduction of risk potential;CL: Analyze65.1. Have the client in a side-lying position.4. Assist the client to log roll and rise to a sittingposition.3. Ask the client to stand with arms held awayfrom the body.2. Verify the order for the settings for the brace.The nurse should fi rst verify the settings for thebrace and activity orders. Next, the client shouldbe in a side-lying position; explain that the spine should be kept aligned and in a neutral position.Teach not to pull on objects with arms. For gettingout of bed, log roll client to side, splint back, andrise to a sitting position by pushing against mattresswhile swinging legs over the side of the bed. Finally,the client should stand with the arms outstretchedso the nurse can apply the : Physiological adaptation;CL: Synthesize66. 4. The client should wear a thin cottonundershirt under the brace to prevent the bracefrom abrading directly against the skin. The cottonmaterial also aids in absorbing any moisture,such as perspiration, that could lead to skin irritationand breakdown. Applying lotion is not recommendedbefore applying the brace because furtherskin breakdown can result (related to the collectionof moisture where microorganisms can grow) andirritants from the lotion can cause further irritation.Applying extra padding (e.g., to the iliac crests) isnot recommended because the padding can becomewrinkled, producing more pressure sites and skinbreakdown. Use of baby or talcum powder is notrecommended because the irritation from the talcumalso can cause irritation and skin : Reduction of risk potential;CL: Evaluate67. 1. Typically, the donor site causes more painthan the fused site does because infl ammation,swelling, and venous oozing around the nerve endingsin the donor site, where the subcutaneous tissuewas removed, occur during the fi rst 24 to 48 hourspostoperatively. After surgery, the surgeon appliesa pressure dressing to the donor site to compressthe veins that were transected for the removal ofsubcutaneous tissue but that did not stop oozingblood after surgical cauterization during the surgicalprocedure. Pressure on a transected vein, which islow pressure, stops the oozing and loss of blood fromthe venous site. When the donor site is the fi bula,neurovascular checks must be performed every hourto ensure adequate neurologic function of and circulationto the area. The surgeon, not the degree oramount of pain, specifi es activity : Physiological adaptation;CL: Synthesize68. 1. A client who has had back surgery shouldplace his feet fl at on the fl oor to avoid strain on theincision. Placing the feet on a low or high footstoolor in any other position of comfort with the legsuncrossed increases the pressure on the suture lineand increases the infl ammation around the involvednerve root, thereby increasing the risk of possiblererupture of the disc : Reduction of risk potential;CL: Evaluate69. 4. After a lumbar laminectomy, a clientshould not sit for prolonged periods in a chairbecause of the increased pressure against the nerveroot and incision site. Assisting with daily hygieneis an appropriate activity during the initial postoperativeperiod because, as with any surgicalprocedure, the client needs to return to her optimallevel of functioning as soon as possible. There isno limitation on the client’s participation in dailyhygiene activities except for her individual responseof pain, nausea, vomiting, or weakness. Lying fl at inbed is appropriate because it does not cause stresson the spinal column where the laminectomy wasperformed and the disc tissue was removed. Positionsthat should be avoided are those that wouldcause twisting and fl exion of the spine. Walking inthe hall is an acceptable activity. It promotes goodpostoperative ventilation, circulation, and return ofperistalsis, which are needed for all surgical clients.In addition, walking provides the postoperativelumbar laminectomy client an opportunity to buildup endurance and muscle strength and to promotecirculation to the operative and incision sites forhealing without twisting or stressing : Physiological adaptation;CL: Synthesize70. 3. Sit-ups are not recommended for the clientwho has had a lumbar laminectomy because theseexercises place too great a stress on the back. Kneeto-chest lifts, hip tilts, and pelvic tilt exercises arerecommended to strengthen back and : Reduction of risk potential;CL: SynthesizeThe Client with an Amputation dueto Peripheral Vascular Disease71. 3. Typically, peripheral vascular disease isconsidered to be a disorder affecting older adults.Therefore, an age of 39 years would not be consideredas a risk factor contributing to the developmentof peripheral vascular disease. Uncontrolled diabetesmellitus is considered a risk factor for peripheralvascular disease because of the macroangiopathicand microangiopathic changes that result from poorblood glucose control. Cigarette smoking is a knownrisk factor for peripheral vascular disease. Nicotineis a potent vasoconstrictor. Serum cholesterol levelsgreater than 200 mg/dL are considered a risk factorfor peripheral vascular : Health promotion and maintenance;CL: Analyze72. 2. The client with severe arterial occlusivedisease and gangrene of the left great toe would havelost the hair on the leg due to decreased circulationto the skin. Edema around the ankle and lower legwould indicate venous insuffi ciency of the lowerextremity. Thin, soft toenails (i.e., not thickenedand brittle) are a normal fi nding. Warmth in thefoot indicates adequate circulation to the extremity.Typically, the foot would be cool to cold if a severearterial occlusion were : Physiological adaptation;CL: Analyze73. 3. The client should be tobacco-free for30 minutes before the test to avoid false readingsrelated to the vasoconstrictive effects of smoking onthe arteries. Because this test is noninvasive, the clientdoes not need to sign a consent form. The clientshould receive an opioid analgesic, not a sedative,to control the pain as the blood pressure cuffs areinfl ated during the Doppler studies to determine theankle-to-brachial pressure index. The client’s ankleshould not be covered with a blanket because theweight of the blanket on the ischemic foot will causepain. A bed cradle should be used to keep even theweight of a sheet off the affected : Reduction of risk potential;CL: Synthesize74. 2. Slow, steady walking is a recommendedactivity for the client with peripheral arterial diseasebecause it stimulates the development of collateralcirculation needed to ensure adequate tissue oxygenation.The client with peripheral arterial diseaseshould not minimize activity. Activity is necessaryto foster the development of collateral circulation.Elevating the legs above the heart is an appropriatestrategy for reducing venous congestion. Wearingantiembolism stockings promotes the return ofvenous circulation, which is important for clientswith venous insuffi ciency. However, their use inclients with peripheral arterial disease may causethe disease to : Physiological adaptation;CL: Evaluate75. 1. Daily lubrication, inspection, cleaning,and patting dry of the feet should be performed toprevent cracking of the skin and possible infection.Soaking the feet in warm water should be avoidedbecause soaking can lead to maceration and subsequentskin breakdown. Additionally, the client witharterial insuffi ciency typically experiences sensorychanges, so the client may be unable to detect waterthat is too warm, thus placing the client at risk forburns. Antiembolism stockings, appropriate forclients with venous insuffi ciency, are inappropriatefor clients with arterial insuffi ciency and could lead to a worsening of the condition. Footwear should beroomy, soft, and protective and allow air to circulate.Therefore, fi rm, supportive leather shoes wouldbe : Reduction of risk potential;CL: Synthesize76. 2. Encouraging the client who will be undergoingamputation to verbalize his feelings is themost therapeutic response. Asking the client totell more about how he is feeling helps to elicitinformation, providing insight into his view of thesituation and also providing the nurse with ideas tohelp him cope. The nurse should avoid value-ladenresponses, such as, “At least you will still have onegood leg to use,” that may make the client feel guiltyor hostile, thereby blocking further communication.Furthermore, stating that the client still has onegood leg ignores his expressed concerns. The clienthas verbalized feelings of helplessness by using theterm “invalid.” The nurse needs to focus on thisconcern and not try to complete the teaching fi rstbefore discussing what is on the client’s mind. Theclient’s needs, not the nurse’s needs, must be metfi rst. It is inappropriate for the nurse to assume toknow the relationship between the client and hiswife or the roles they now must assume as dependentclient and caregiver. Additionally, the responseabout the client’s wife caring for him may reinforcethe client’s feelings of helplessness as an : Psychosocial adaptation;CL: Synthesize77. 2. The level of amputation often cannot beaccurately determined until during surgery, whenthe surgeon can directly assess the adequacy ofthe circulation of the residual limb. From a moral,ethical, and legal viewpoint, the surgeon attemptsto remove as little of the leg as possible. Althougha longer residual limb facilitates prosthesis fi tting,unless the stump is receiving a good blood supplythe prosthesis will not function properly becausetissue necrosis will occur. Although the client’s abilityto walk with a prosthesis is important, it is not adetermining factor in the decision about the level ofamputation required. Blood supply to the tissue isthe primary : Physiological adaptation;CL: Synthesize78. 4. The priority action is to draw a markaround the site of bleeding to determine the rate ofbleeding. Once the area is marked, the nurse candetermine whether the bleeding is increasing ordecreasing by the size of the area marked. Becausethe spot is bright red, the bleeding is most likelyarterial in origin. Once the rate and source of bleedingare identifi ed, the surgeon should be notifi ed.The stump is not elevated because adhesions may occur, interfering with the ability to fi t a prosthesis.The dressing would be reinforced if the bleedingis determined to be of venous origin, characterizedby slow oozing of darker blood that ceases with theapplication of a pressure dressing. Typically, operativedressings are not changed for 24 hours. Therefore,the dressing is reinforced to prevent organismsfrom penetrating through the blood-soaked areas ofthe initial postoperative : Physiological adaptation;CL: Synthesize79. 4. The nurse’s fi rst action should be toadminister the prescribed opioid analgesic to theclient, because this phenomenon is phantom sensationand interventions should be provided to relieveit. Pain relief is the priority. Phantom sensation isa real sensation. It is incorrect and inappropriateto tell a client that it is impossible to feel the pain.Although it does relieve the client’s apprehensionsto be told that phantom sensations are a realphenomenon, the client needs prompt treatment torelieve the pain sensation. Usually phantom sensationwill go away. However, showing the client thatthe toes are not there does nothing to provide theclient with : Physiological adaptation;CL: Synthesize80. 4. Use of crutches requires signifi cantstrength from the triceps muscles. Therefore, effortsare focused on strengthening these muscles inanticipation of crutch walking. Bed and wheelchairpush-ups are excellent exercises targeted at the tricepsmuscles. Abdominal exercises, range-of-motionand isometric exercises of the shoulders, and quadricepsand gluteal setting exercises are not helpfulin preparing for crutch : Reduction of risk potential;CL: Synthesize81. 4. When using crutches, the client is taughtto support her weight primarily on the hands. Supportingbody weight on the axillae, elbows, or upperarms must be avoided to prevent nerve damage fromexcessive : Reduction of risk potential;CL: Synthesize82. 4. Before beginning dietary instructions andinterventions, the nurse must fi rst assess the client’sand family’s food preferences, such as pattern offood intake, life style, food preferences, and ethnic,cultural, and fi nancial infl uences. Once this informationis obtained, the nurse can begin teachingbased on the client’s current knowledge level andthen building on this knowledge : Physiological adaptation;CL: SynthesizeThe Client with Fractures83. 3. Isometric contractions increase the tensionwithin a muscle but do not produce movement.Repeated isometric contractions make muscles growlarger and stronger. Adduction of the leg puts workonto the hip joint as well as altering the pull of traction.Rolling the leg, or external rotation, alters thepull of traction. Additional weight should not beadded to traction unless ordered by the physician; itwill not prevent muscle : Reduction of risk potential;CL: Evaluate84. 3. Methocarbamol is a muscle relaxant andacts primarily to relieve muscle spasms. It has noeffect on microorganisms, does not reduce itching,and has no effect on : Pharmacological and parenteraltherapies; CL: Evaluate85. 1, 2, 3. Acetaminophen is an alternative fora client who is allergic to aspirin. It does not affectplatelet aggregation and the client does not need tohave coagulation studies (such as INR). Acetaminophencauses little or no gastric distress. Acetaminophenexerts no anti-infl ammatory : Pharmacological and parenteraltherapies; CL: Create86. 3. Hypotension, tachycardia, and depressedrespirations are signs of high levels of ingestion ofmuscle relaxants, and the client may be developinga habit of taking this drug for a prolonged period.The potential for abuse should be considered whenlarge doses of a muscle relaxant such as carisoprodolare taken for prolonged periods. Expectedcommon adverse effects would include drowsiness,fatigue, lassitude, blurred vision, headache, ataxia,weakness, and gastrointestinal upset. Hemorrhagefrom gastrointestinal irritation is not associatedwith this drug. Hypersensitivity reactions would bemanifested by pruritus and : Pharmacological and parenteraltherapies; CL: Evaluate87. 3. The nursing assessment is fi rst focused onthe region distal to the fracture for neurovascularinjury or compromise. When a nerve or blood vesselis severed or obstructed at the actual fracture site,innervation to the nerve or blood fl ow to the vesselis disrupted below the site; therefore, the areadistal to the fracture site is the area of compromisedneurologic input or vascular fl ow and return, not thearea above the fracture site or the fracture site itself.The nurse may assess the opposite extremity at thearea proximal to the fracture site for a baseline comparisonof pulse quality, color, temperature, size, and so on, but the comparison would be made afterthe initial neurovascular : Physiological adaptation;CL: Analyze88. 3. Clients should not pull out cast padding toscratch inside the cast because of the hazard of skinbreakdown and subsequent potential for infection.Clients are encouraged to elevate the casted extremityabove the level of the heart to reduce edema andto exercise or move the joints above and below thecast to promote and maintain fl exibility and musclestrength. Applying ice for 10 minutes during thefi rst 24 hours helps to reduce : Reduction of risk potential;CL: Evaluate89. 2. The client in a double hip spica castshould avoid eating foods that can be constipating,such as cheese. Rather, fresh fruits and vegetablesshould be encouraged and the client should beencouraged to drink at least 2,500 mL/day. Drinkingcranberry juice, which helps keep urine acidic,thereby avoiding the development of renal calculi,is encouraged. The client should be encouraged toestablish regular times for elimination to promoteregularity in bowel and bladder habits. The clientwill develop orthostatic hypotension unless thecirculatory system is reconditioned slowly throughdangling and standing : Physiological adaptation;CL: Synthesize90. 2. A two-point gait involves partial weightbearing on each foot, with each crutch advancingsimultaneously with the opposing leg. Advancing acrutch on one side and then advancing the oppositefoot, and repeating on the opposite side, illustratesthe four-point gait. When the client advances bothcrutches together and follows by lifting both lowerextremities to the same level as the crutches, the gaitis called a “swing to” gait. When the client advancesboth crutches together and follows by lifting bothlower extremities past the level of the crutches, thegait is called a “swing through” gait. The “swingthrough” gait is often used by paraplegic clientsbecause it allows them to place weight on their legswhile the crutches are moved one stride : Reduction of risk potential;CL: Synthesize91. 1. The wound was left open with a three-waydrainage system in place to irrigate the debridedwound with normal saline or an antibiotic. Beforethe debridement, a sample of the wound would betaken for culture and sensitivity testing so that anorganism-specifi c antibiotic could be administeredto prevent possible serious sequelae of osteomyelitis.Therefore, the nurse should review the results of the culture and sensitivity report. A pressure dressingwould not be applied to an open wound. Rather,a wet-to-dry dressing most likely would be used.There should not be increased pain related to theexposure of nerve endings in the subcutaneous tissueof the wound that was left open to the environment.The bleeding of vessels should be controlledas it would have been if the wound had been closed.Therefore, additional vessel bleeding should not bea : Physiological adaptation;CL: Synthesize92. 1. The nurse should assess the client’s abilityto move her toes and for the presence of distalpulses, including a neurovascular assessment ofthe area below the cast. Increasing pain unrelievedby usual analgesics and occurring 4 to 12 hoursafter the onset of casting or trauma may be the fi rstsign of compartment syndrome, which can lead topermanent damage to nerves and muscles. Althoughthe nurse can use a pain rating scale or assess forchanges in vital signs to objectively assess the client’spain, the client’s complaints suggest early andimportant signs of compartment syndrome requiringimmediate intervention. The nurse should notconfuse these signs with the potential for drug tolerance.This assessment might be appropriate once thesuspicion of compartment syndrome has been : Physiological adaptation;CL: Analyze93. 4. The client with compartment syndromemay release myoglobin from damaged muscle cellsinto the circulation. This becomes trapped in therenal tubules, resulting in dark, scanty urine, possiblyleading to acute renal failure. Crackles maysuggest respiratory complications; jaundice suggestsliver failure; and generalized edema may suggestheart failure. However, these are not associated withcompartment : Reduction of risk potential;CL: AnalyzeThe Client with a Femoral Fracture94. 4. Passive immunity for tetanus is providedin the form of tetanus antitoxin or tetanus immuneglobulin. An antitoxin is an antibody to the toxin ofan organism. Administering tetanus toxoid, antigen,or vaccine would provide active immunity bystimulating the body to produce its own : Pharmacological and parenteraltherapies; CL: Apply95. 4. Skeletal traction is not used to pull weightwith a boot. Skeletal traction involves the insertionof a wire or a pin into the bone to maintain a pull of5 to 45 lb on the area, promoting proper alignmentof the fractured bones over a long : Reduction of risk potential;CL: Evaluate96. 4. The client with a femoral fracture in balancedsuspension traction should not be given acomplete bed bath. Rather, the client is encouragedto participate in self-care and movement in bed,such as with a trapeze triangle. Use of a fracturebedpan is appropriate. A fracture bedpan is lower,and it is easier for the client to move on and off thebedpan without altering the line of traction. Checkingfor areas of redness or pressure over all areasin contact with the traction or bed, including theischial tuberosity, is important to prevent possibleskin breakdown. The client should be positionedso that the feet do not press against the footboard.Therefore, elevating the head of the bed no morethan 25 degrees is recommended to keep the clientfrom moving down in the : Reduction of risk potential;CL: Synthesize97. 3. Neurovascular checks should be performeddistal or past the site of the splint, not proximal orabove the site of the splint, at least every 4 hours.An injury or compromise to the peripheral nervousinnervation or blood fl ow will refl ect a change onthe site of the splint after the pathway from theheart and brain. Checking the skin over the greatertrochanter is appropriate because the half-ring ofthe Thomas splint can slide around the greater trochanterarea where the traction is applied; it shouldbe checked routinely along with other areas at highrisk for pressure necrosis, such as the fi bular head,ischial tuberosity, malleoli, and hamstring tendons.Inspecting the pin site is appropriate because anydrainage or redness might indicate an infection inthe bone in which the pin is inserted. Immediatetreatment is imperative to avoid osteomyelitis andpossible loss of the limb. Evaluation of the foot formovement is important to obtain neuromuscularvasculardata for assessment in comparison with thebaseline data of the affected extremity and with theopposite extremity to detect any compromise of theclient’s : Reduction of risk potential;CL: Synthesize98. 3. The nurse should send the client to theoperating room on his bed with extra help to keepthe traction from moving to maintain the femur inthe proper alignment before surgery. Transferring theclient to a cart with manually suspended traction is inappropriate because doing so places the client atrisk for additional trauma to the surrounding neurovascularand soft tissues, as would removing thetraction. The surgeon need not be called because thedecision about transferring the client is an independentnursing : Reduction of risk potential;CL: Synthesize99. 1. The Pearson attachment supports thelower leg and provides increased stability in theoverall traction setup. It also makes it easier tomaintain correct alignment. It does not support thethigh and upper leg or prevent fl exion deformities inthe ankle and foot. It is not attached to the : Reduction of risk potential;CL: Apply100. 1. Fat emboli usually result in symptoms ofacute respiratory distress syndrome, such as apprehension,chest pain, cyanosis, dyspnea, tachypnea,tachycardia, and decreased partial pressure of arterialoxygen resulting from poor oxygen exchange.Migraine-like headaches are not a symptom of a fatembolism, but mental confusion, memory loss, anda headache from poor oxygen exchange may be seenwith central nervous system involvement. Numbnessin the right leg is a peripheral neurovascularresponse that most likely is related to the femoralfracture. Muscle spasms in the right thigh are asymptom of a neuromuscular response affecting thelocal muscle around the femoral fracture : Reduction of risk potential;CL: Analyze101. 2. Based on the client’s statements, Ineffectivecoping is the most appropriate nursing diagnosisbecause the client is voicing frustration about thecurrent situation and her inability to move. Thenurse should seek ways to help the client adjustto and cope with her present state of immobility.Emphasis should be placed on what the clientcan do to care for herself, such as participating inher daily care and exercises to maintain musclestrength, to help her maintain some control over hersituation. The data do not support a diagnosis ofImpaired mobility, Defi cient diversional activities, orActivity : Psychosocial adaptation;CL: Analyze102. 1. The client can sit up in bed, remainingin the supine position so that an even, sustainedamount of traction is maintained under the bandageused in the Buck’s traction. Maintenance of even,sustained traction decreases the chance that thebandage or traction strap might slip and cause compressionor stress on the nerves or vascular tracts, resulting in permanent damage. The client does nothave to remain fl at but may adjust the head of thebed to varying degrees of elevation while remainingin the supine position. The client should not turnhis body to another position because the bandagemay : Reduction of risk potential;CL: Synthesize103. 1. The nurse should assess for signs of skinpressure in the groin area because the Thomassplint, which is a half-ring that slips over the thighand suspends the lower extremity in direct skeletaltraction, may cause discomfort, pressure, or skinirritation in the groin. The nurse always assessesrespirations as part of routine vital signs, but assessingfor evidence of decreased breath sounds is nota routine assessment related directly to the Thomassplint. The head of the bed can be elevated tofacilitate breathing, but not more than 25 degrees, toavoid continually moving the client toward the footof the bed from the weight of the traction. The nursealways assesses for pressure areas on dependentparts, but assessing for skin breakdown behind theheel is not a routine assessment related directly tothe Thomas splint, in which the heel is free of anycontact with padding or metal parts of the Pearsonattachment for the balanced suspension traction.The client who is in a Thomas splint is able to usea bedpan to urinate, especially the fracture bedpanfor a female client and the urinal for a male. Urineretention should not be a special assessment directlyrelated to the Thomas splint, but it may be a clientspecific : Reduction of risk potential;CL: Analyze104. 1. The client’s assisting as much as possiblein his care and increasing participation over timeindicate that the client has accomplished self-careby gaining a sense of control. If the client lets thenurse complete his care without interfering, hisbehavior would indicate passivity, possibly fromdenial or depression. If the client allows his wife toassume total responsibility for his care or to completehis care, he still has a self-care defi cit and asuccessful outcome has not been : Basic care and comfort; CL: Evaluate105. 2. Fever, night sweats, chills, restlessness,and restrictive movement of the fractured leg areclinical manifestations of osteomyelitis, which is apyogenic bone infection caused by bacteria (usuallystaphylococci), a virus, or a fungus. The boneis inaccessible to macrophages and antibodies forprotection against infections, so an infection in thissite can become serious quickly. The client with apulmonary or fat embolus would develop symptomsof pulmonary compromise, such as shortness of breath, chest pain, angina, and mental confusion.Signs and symptoms of urinary tract infectionwould include pain over the suprapubic, groin, orback region with fever and chills, with no restrictivemovement of the : Reduction of risk potential;CL: Analyze106. 2. The goal of care for this client is healingand tissue growth while the client continues onlong-term antibiotic therapy to clear the infection.A diet high in protein and vitamins C and D promoteshealing. Herbal supplements may potentiatebleeding (e.g., ginkgo, ginger, tumeric, chamomile,kelp, horse chestnut, garlic, and dong quai) andhave not been proven through research to promotehealing. Frequent passive motion will increase circulationbut may also aggravate localized bone pain.It is not appropriate to advise the client to changeantibiotics as treatment may take : Physiological adaptation;CL: SynthesizeThe Client with a SpinalCord Injury107. 3. The priority concern is to immobilize thehead and neck to prevent further trauma when afractured vertebra is unstable and easily displaced.Although wrapping and supporting the extremitiesis important, it does not take priority over immobilizingthe head and neck. Pain usually is not asignifi cant consideration with this type of injury.Cushioning is contraindicated. The neck should bekept in a neutral position and immobilized. Flexionof the neck is : Safety and infection control;CL: Synthesize108. 3. This client has a spinal cord injury of thesacral region of the spinal cord and will have bladderand bowel dysfunction, as well as loss of sensationand muscle control below the injury. The otheroptions are true of a client who has : Physiological adaptation;CL: Analyze109. 2. Although assessment of renal status,gastrointestinal function, and biliary function isimportant, with the spinal cord transection at T4the client’s vascular status is the primary focus ofthe nursing assessment because the sympatheticfeedback system is lost and the client is at risk forhypotension and : Physiological adaptation;CL: Analyze110. 1. The client with a spinal cord transectionabove T5 is least likely to develop diarrhea. Rather,constipation due to atonia would be possible. Theclient with a spinal cord transection above T5 is atrisk for development of a paralytic ileus because thesympathetic nerve innervation to the vagus nerve,which dominates all the vessels and organs belowT5 (e.g., the intestinal tract), has been disrupted andtherefore so has movement or peristalsis. The clientis at risk for development of stress ulcers becausethe sympathetic nerve innervation to the stomachhas been disrupted, which results in an excessiverelease of hydrochloric acid in the stomach, allowingcontact of hydrochloric acid with the stomachmucosa. The client does not feel subjective signs ofstress ulcers (e.g., pain, guarding, tenderness) andtherefore is at increased risk for bleeding becausecomplications of an ulcer can develop before : Reduction of risk potential;CL: Synthesize111. 1. The client should eat enough calories tomaintain her desired weight, a positive nitrogenbalance, and enough protein to help decrease therate of muscle atrophy and prevent skin breakdownand infection. The client with a spinal cord injurydoes not have poikilothermy, the ability to adjustbody temperature to the environmental temperature.The client should add additional clothes orcoverage below the level of transection in coolenvironments. The client does not sweat belowthe level of transection and should be sensitiveto the possibility of overheating in extremely hotclimates and the need for sprinkling or movinginto an air-conditioned environment. The clientwith intermittent nasogastric suctioning is at riskfor development of metabolic alkalosis and anelectrolyte imbalance that leads to decreased tissueperfusion; therefore, the client needs to increasethe sodium and potassium in her diet, not decreasethe : Reduction of risk potential;CL: Synthesize112. 4. Measuring the leg girth is the most appropriatemethod because the usual signs, such as apositive Homans’ sign, pain, and tenderness, arenot present. Other means of assessing for deep veinthrombosis in a client with a spinal cord injury arethrough a Doppler examination and : Reduction of risk potential;CL: Analyze113. 3. During the period of spinal shock, thebladder is completely atonic and will continue tofi ll passively unless the client is catheterized. The bladder will not go into spasms or cause uncontrolledurination. Bladder function will not be normalduring the period of spinal : Reduction of risk potential;CL: Analyze114. 4. The movements occur from muscle refl exesand cannot be initiated or controlled by the brain.After the period of spinal shock, the muscles graduallybecome spastic owing to an increased sensitivityof the lower motor neurons. It is an expectedoccurrence and does not indicate that healing istaking place or that the client will walk again. Themovement is not voluntary and cannot be broughtunder voluntary : Physiological adaptation;CL: Synthesize115. 3. Long-bone demineralization is a seriousconsequence of the loss of weight bearing. Anexcessive calcium load is brought to the kidneys,and precipitation may occur, predisposing to stoneformation. Excessive intake of dairy products maypromote constipation. However, this is not themost accurate reason for decreasing calcium intake.Immobility does not increase calcium absorptionfrom the intestine. Dairy products do not necessarilycontribute to weight : Basic care and comfort;CL: Synthesize116. 2. The woman with spinal cord injury canparticipate in sexual activity but might not experienceorgasm. Cessation in the nerve pathway mayoccur in spinal cord injury, but this does not negatethe client’s mental and emotional needs to creativelyparticipate with her partner in a sexual relationshipand to reach orgasm. An indwelling urinary cathetermay be left in place during intercourse and need notbe removed because the indwelling urinary catheteris placed in the urethra, which is not the channelused for sexual intercourse. There are no contraindications,such as hypertension, to sexual activity in awoman with spinal cord injury. Sexual intercourseis allowed, and hypertension should be manageable.Because a spinal cord injury does not affect fertility,the client should have access to family planninginformation so that an unplanned pregnancy can : Basic care and comfort; CL: Evaluate117. 3. Spinal cord injury represents a physicalloss; grief is the normal response to this loss. Workingthrough grief entails reviewing memories andeventually letting go of them. The process may takeas long as 2 years. Telling the client to be patientand that adjustment takes time is a clichéd type ofresponse, one that is not empathetic or responsive to the client’s needs. Telling the client to focus ontoday does not allow time for the grief process,which is necessary for the client to work throughand adjust to the loss. The client is not escaping butis reminiscing on what is lost, to work through thegrieving : Psychosocial adaptation;CL: SynthesizeManaging Care Qualityand Safety118. 1, 2, 3, 5. A restraint is a method of involuntaryphysical restriction of a client’s freedom ofmovement, physical activity, or normal access tohis/her body. The nurse must monitor and providecare to optimize the physical and psychologicalwell-being of the client including, but not limitedto, respiratory and circulatory status, skin integrity,and vital signs. With each assessment, the nurseneeds to ascertain that restraints are still requiredfor client safety. The least restrictive interventionbased on an individualized assessment of the client’smedical or behavioral status or condition : Safety and infection control;CL: Analyze119. 1, 2, 3, 4, 5, 6. Client safety is a priority forthe client, the client’s family, and all of the personnelworking on this unit. All of these personsmust be engaged in using strategies to : Safety and infection control;CL: Create120. 3. The client is identifi ed as being at risk forfalling and a staff member or family member shouldaccompany the client when walking. The nursecan delegate the task of ambulating the client to theunlicensed assistive personnel (UAP), but shouldremain with the client until the UAP arrives. Walkingonly in the room will not provide an opportunityfor the client to gain strength and improveambulation. The client should not walk beyond thepoint of being fatigued; the UAP should observe forfatigue and the nurse should set appropriate goalsfor distance to be : Reduction of risk potential;CL: Synthesize121. 1, 2, 3. To assure client safety when usinganticoagulants, the nurse should coordinate care atthis time with the pharmacist, dietician and laboratory.The pharmacist will collaborate in teaching the client about using the drug; dietary serviceswill plan a diet that limits foods which have highamounts of vitamin K (spinach, cabbage, blueberries)that will interfere with anticoagulation, andthe laboratory will draw daily INR levels to assureaccurate dosing. Although the nurse coordinatesdischarge planning at the time of admission to thehospital, at this point it is too soon for dischargeplanning services to be involved because it is notknown if the client will continue to take the coumadinwhen discharged. There is no indication achaplain is needed at this : Management of care; CL: Synthesize 122. 3. Hand-off communication is an interactivecommunication allowing the opportunity forquestioning between the giver and receiver of clientinformation including up-to-date information regardingthe client’s care, treatment, and services; currentcondition; and any recent or anticipated changes.“Hand off” communication does occur when a nurseis leaving the nursing unit, but the purpose is not tolet the charge nurse know that the nurse is going tolunch or to have someone else assigned to care forthe client. “Hand-off” communication focuses oncurrent information, not the client’s : Management of care; CL: Synthesize ................
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