Musculoskeletal and derma post test

98問 • 1年前

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On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for:

Early morning stiffness.

A client with rheumatoid arthritis states, "I can't do my household chores without becoming tired. My knees hurt whenever I walk." Which goal for this client should take priority?.

Conserve energy.

A client is in the acute phase of rheumatoid arthritis. In which order of priority should the nurse establish the following goals?

Relieving pain.

The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which of the following client statements indicates that the client still has a knowledge deficit?.

"Heat-producing liniments can be used with other heat devices."

The client with rheumatoid arthritis tells the nurse, "I have a friend who took gold shots and had a wonderful response. Why didn't my physician let me try that?" Which of the following responses by the nurse would be most appropriate?.

“Every person is different. What works for one client may not always be effective for another."

The teaching plan for the client with rheumatoid arthritis includes rest promotion. Which of the following would the nurse expect to instruct the client to avoid during rest periods?.

Positions of flexion.

After teaching the client with rheumatoid arthritis about measures to conserve energy in activities of daily living involving the small joints, which of the following, if stated by the client, would indicate the need for additional teaching?.

Carrying a laundry basket with clinched fingers and fists.

After teaching the client with severe rheumatoid arthritis about prescribed methotrexate, which of the following statements indicates the need for further teaching?.

"I will take my vitamins while I'm on this drug."

A 25-year-old client taking hydroxychloroquine (Plaquenil) for rheumatoid arthritis reports difficulty seeing out of the left eye. Correct interpretation of this assessment finding indicates which of the following?.

Possible retinal degeneration.

A client with rheumatoid arthritis tells the nurse, "I know it is important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which of the following responses by the nurse would be most appropriate?.

"Take a warm tub bath or shower before exercising. This may help with your discomfort."

A physician prescribes a lengthy x-ray examination for a client with osteoarthritis. Which of the following actions by the nurse would demonstrate client advocacy?.

Contact the x-ray department and ask the technician if the lengthy session can be divided into shorter sessions.

Which of the following should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis?.

Local joint pain.

Which of the following statements indicates that the client with osteoarthritis understands the effects of capsaicin (Zostrix) cream?.

"I always wash my hands right after I apply the cream."

At which of the following times should the nurse instruct the client to take Ibuprofen (Motrin), prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation?.

Immediately after a meal.

The client diagnosed with osteoarthritis states, *My friend takes steroid pills for her rheumatoid arthritis. Why don't I take steroids for my osteoarthritis?" Which of the following is the best explanation?.

intra-articular corticosterold injections are used to treat osteoarthritis.

A client has a leg immobilized in traction. Which of the following activities demonstrated by the client indicate that the client understands actions to take to prevent muscle atrophy?.

The client performs isometric exercises to the affected extremity three times per day.

The client with a fractured tibia has been taking methocarbamol (Robaxin). Which of the following indicate that the drug is having the intended effect?.

Relief of muscle spasms.

A client who has been taking hydrocodone with acetaminophen at home for 6 weeks following a fractured tibia is admitted with a blood pressure of 80/50 mm Hg, a pulse rate of 115 bpm, and respirations of 8 breaths per minute and shallow. The nurse Interprets these findings as indicating which of the following?.

Possible habituating effect of the long-term drug use.

When admitting a client with a fractured extremity, the nurse should first focus the assessment on which of the following?

The area distal to the fracture.

Which of the following client statements identifies a knowledge deficit about cast care?.

"I can pull out cast padding to scratch inside the cast."

Which of the following interventions would be least appropriate for a client who is in a double hip spica cast?.

Advising the client to eat large amounts of cheese.

The nurse prepares a teaching plan for a client about crutch walking using a two-point gait pattern. Which of the following should the nurse include?.

Advance a crutch on one side and simultaneously advance and bear weight on the opposite foot; repeat on the opposite side.

A client returned from surgery with a debrided open tibial fracture and has a three-way drainage system. The nurse should first

Review the results of culture and sensitivity testing of the wound.

Client has a tibial fracture that required casting. Approximately 5 hours later, the client has increasing pain distal to the left tibial fracture despite the morphine injection administered 30 minutes previously. Which of the following should be the nurse's next assessment?.

Presence of a distal pulse.

A client with a fracture develops compartment syndrome. Which of the following signs should alert the nurse to impending organ failure?.

Dark, scanty urine.

After teaching the client with a femoral fracture about the purpose of treatment with skeletal traction, which of the following, if stated by the client, would indicate the need for additional teaching?.

To pull weight with a boot.

The nurse is planning care for the client with a femoral fracture who is in balanced suspension traction. Which of the following would the nurse be least likely to include in the plan of care?.

Personal hygiene with a complete bed bath.

Which of the following indicates that a client with a fracture of the right femur may be developing a fat embolus?

Numbness in the right leg.

Which of the following is the priority for a client with a fractured femur who is in traction at this time?.

Prevent effects of immobility while in traction.

The client asks the nurse what the activity limitations are while in Buck's traction. The nurse should tell the client:.

"You can sit up whenever you want."

A nurse is caring for a patient who has had a plaster arm cast applied. Immediately post application, the nurse should provide what teaching to the patient?

The cast will only have full strength when dry.

A patient broke his arm in a sports accident and required the application of a cast. Shortly following application, the patient complained of an inability to straighten his fingers and was subsequently diagnosed with Volkmann contracture. What pathophysiologic process caused this complication?

Obstructed arterial blood flow to the forearm and hand

A patient is admitted to the unit in traction for a fractured proximal femur and requires traction prior to surgery. What is the most appropriate type of traction to apply to a fractured proximal femur?

Buck's extension traction

A nurse is caring for a patient who is in skeletal traction. To prevent the complication of skin breakdown in a patient with skeletal traction, what action should be included in the plan of care?

Assess the pin insertion site every 8 hours.

A nurse is caring for a patient who is postoperative day 1 right hip replacement. How should the nurse position the patient?

Keep the patients hips in abduction at all times.

Had knee replacement surgery, the nurse notes that the pattern has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this patient?

Risk for Peripheral Neurovascular Dysfunction

A patient was brought to the emergency department after a fall. The patient is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize?

Make sure you don't bring your knees close together.

A patient with a fractured femur is in balanced suspension traction. The patient needs to be repositioned toward the head of the bed. During repositioning, what should the nurse do?

Maintain consistent traction tension while repositioning

A patient with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of a new onset of pain at the surgical site. What is the nurse's best action?

Assess the surgical site and the affected extremity.

A nurse is caring for a patient who has a leg cast. The nurse observes that the patient uses a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation?

Encourage the patient to avoid scratching, and obtain an order for an antihistamine if severe itching persists.

Teplacement gerter day. attent ould une reuven da total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis?

Protect the affected leg from internal rotation.

A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. The nurse should identify the warning signs of what complication?

Compartment syndrome

The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote?

Knots in the rope should not be resting against pulleys.

The orthopedic surgeon has prescribed balanced skeletal traction for a patient. What advantage is conferred by balanced traction?

Balanced traction allows for greater patient movement and independence than other forms oftraction.

The nursing care plan for a patient in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a patient's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?

Increased warmth of the calf

A nurse is providing discharge education to a patient who is going home with a cast on his leg. What teaching point should the nurse emphasize in the teaching session?

Reporting signs of impaired circulation

A patient with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the patients cast care?

Keep your right leg elevated above heart level.

An elderly patient's hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse's priority assessment?

Signs of neurovascular compromise

A nurse is caring for a patient who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the patient's statements would indicate to the nurse that the patient requires further Teaching?

I will need my husband to assist me in getting off the low toilet seat at home.

A nurse is admitting a patient to the unit who presented with a lower extremity fracture. What signs and symptoms would suggest to the nurse that the patient may have a Peroneal nerve palsy

Numbness and burning of the foot

The nurse is assessing an 80-year-old client who has scald burns on the hands and both forearms (first- and second-degree burns on 10% of the body surface area). What Should the nurse do first?

Refer the client to a burn center.

During the emergent (resuscitative) phase of burn injury, which of the following indicates that the client is requiring additional volume with fluid resuscitation?

Serum creatinine level of 2.5 mg/dL (221 umol/L).

A client is admitted to the hospital after sustaining burns to the chest, abdomen, right.arm, and right leg. Using the “rule of nine" estimate what percentage of the client's body surface has been burned.

45%.

The nurse is caring for a client with severe burns who is receiving fluid resuscitation. Which of the following indicates that the client is responding to the fluid resuscitation?

Urine output of 30 mL/h.

Which of the following activities should the nurse include in the plan of care for a client with burn injuries to be carned out about one-half hour before the daily whirlpool bath and dressing change?

Administer an analgesic.

The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to:

Ensure adequate caloric and protein intake.

An advantage of using biologic burn grafts such as porcine (pigskin) grafts is that they:

Promote the growth of epithelial tissue.

Which of the following factors would have the least influence on the survival and effectiveness of a burn victim's porcine grafts?

Use of analgesics as necessary for pain relief.

The nurse should plan to begin rehabilitation efforts for the burn client:

After the client's circulatory status has been stabilized.

During the early phase of burn care, the nurse should assess the client for?

Hyperkalemia.

Which of the following clients with burns will most likely require an endotracheal or tracheostomy tube? A client who has:

Thermal burns to the head, face, and airway resulting in hypoxia.

After the initial phase of the burn injury, the client's plan of care will focus primarily on

Preventing infection.

The rate at which IV fluids are infused is based on the burn client's:

Total body weight and BSA burned.

The nurse is conducting a focused assessment of the gastrointestinal system of a client with a burn injury. The nurse should assess the client for:

Curling's ulcer.

In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain?

Intravenous opioids.

The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. The critical component in the nurse's assessment is noting the:

Changes from the normal expected findings.

Which of the following changes are associated with normal aging?

Subcutaneous fat and extracellular water decrease.

The nurse will anticipate which of the following problems that can result for the older adult undergoing abdominal surgery?

Decreased healing.

Health maintenance and promotion activities are especially important for the older adult. Which of the following activities reflects a health maintenance activity for an otherwise healthy older adult?

Drinks 1,500 mL of fluids per day.

Which of the following characteristics would put a client at the greatest risk for impaired wound healing after Abdominal surgery?

Age 30 years, with poorly controlled diabetes.

An older adult has several ecchymotic areas on the left arm. The nurse should further assess the client for:

Increased capillary fragility and permeability.

An older adult reports being cold in the room even though the thermostat is set at 75°F (24°C). The client may feel cold because older adults have:

Decreased ability to thermoregulate.

Palpation of the skin provides the nurse useful information regarding:

Turgor of the skin.

A priority for nursing care for an adult who has pruritus, is continuously scratching the affected areas, and demonstrates agitation and anxiety regarding the itching would be:

Preventing infection.

The nurse is applying a hand mitt restraint for a client with pruritus. The nurse should first:

Verify the physician prescription to use the restraint.

The nurse is assessing a client with dark skin for the presence of a Stage I pressure ulcer. The nurse should:

Look for skin color that is darker than the surrounding tissue.

The nurse is assessing a client who is immobile and notes an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. The most appropriate nursing action at this time Is to:

Reposition the client off of the reddened skin and reassess in a few hours.

The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1° x 1" area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the chart?

Stage Il pressure ulcer.

A Stage Il pressure ulcer is characterized by:

Pain in the involved area.

Which of the following factors places a client at greatest risk for skin cancer?

Fair skin and history of chronic sun exposure.

A client with malignant melanoma asks the nurse about the prognosis. The nurse should base a response that informs the client that the prognosis depends on:

The thickness of the lesion.

The nurse is to administer an antiblotic to a client with burns now, but there is no medication in the client's medication box. What should the nurse do first?

Call the pharmacy department.

When planning the skin care of a patient with decreased mobility, the nurse is aware of the varying thickness of the epidermis. At what location is the epidermal layer thickest?

The palms of the hands

A young student is brought to the school nurse after falling off a swing. The nurse is documenting that the child has bruising on the lateral aspect of the right arm. What term will the nurse use to describe bruising on the skin in documentation?

Ecchymoses

The nurse in an ambulatory care center is admitting an older adult patient who has bright red moles on the skin. Benign changes in elderly skin that appear as bright red moles are termed what?

Cherry angiomas

While assessing a dark-skinned patient at the clinic, the nurse notes the presence of patchy, milky white spots. The nurse knows that this finding is characteristic of what diagnosis?

Vitiligo

While waiting to see the physician, a patient shows the nurse skin areas that are flat, nonpalpable, and have had a change of color. The nurse recognizes that the patient is demonstrating what?

Macules

An African American Is admitted to the medical unit with liver disease. To correctly assess this patient for jaundice, on what body area should the nurse look for yellow discoloration?

Sclerae

A nurse is doing a shift assessment on a group of patients after first taking report. An elderiy patient is having her second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new rash on the patient's chest. The nurse should ask what priority question regarding the presence of a reddened rash?

Are you allergic to any foods or medication?

A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best Integrate these changes into care planning?

By protecting older adults against shearing injuries

A patient is diagnosed with atrial fibrillation and the physician orders Coumadin (warfarin). For what skin lesion should the nurse monitor this patient?

Ecchymosis

A new patient has come to the dermatology clinic to be assessed for a reddened rash on his abdomen. What diagnostic test would most likely be ordered to identify the causative allergen?

Patch testing

A nurse practitioner is seeing a 16-year-old male patient who has come to the dermatology clinic for treatment of acne. The nurse practitioner would know that the treatment may consist of which of the following medications?

Benzoyl peroxide and erythromycin (Benzamycin)

A nurse is caring for a patient who has been diagnosed with psoriasis. The nurse is creating an education plan for the patient. What information should be included in this plan?

Use caution when taking nonprescription indications.

A patient with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention?

Surgical excision

When writing a plan of care for a patient with psoriasis, the nurse would know that an appropriate nursing diagnosis for this patient would be what?

Impaired Skin Integrity Related to Scaly Lesions

A patient who has sustained third-degree facial burns and a facial fracture is undergoing reconstructive surgery and Implantation of a prosthesis. The nurse has identified a nursing diagnosis of Disturbed Body Image Related to Disfigurement. What would be an appropriate nursing intervention related to this diagnosis?

Teaching the patient how to use and care for the prosthesis

While performing an initial assessment of a patient admitted with appendicitis, the nurse observes an elevated blue-black lesion on the patients ear. The nurse knows that this lesion is consistent with what type of skin cancer?

Malignant melanoma

Astignars random QS

Kyla Angelique Son · 19問 · 1年前

Astignars random QS