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Adult Health Care 7th Edition By Cooper-Test Bank
Sample Questions
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Chapter 2: Care of the Surgical Patient
MULTIPLE CHOICE
- The patient who had a nephrectomy yesterday has not used the patient-controlled analgesia (PCA) delivery system but admits to being in pain but fearful of addiction. What is the nurse’s best response?
| a. | “Modern analgesic drugs do not cause addiction.” |
| b. | “Pain relief is worth a short period of addiction.” |
| c. | “Addiction rarely occurs in the brief time postsurgical analgesia is required.” |
| d. | “Addiction could be a real concern.” |
ANS: C
Addiction rarely occurs in the short time that it is required after surgery. Postsurgical analgesia, because of its brief application, does not usually produce a physical or a psychological dependence.
DIF: Cognitive Level: Application REF: Page 34 OBJ: 13
TOP: Fear of addiction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A 73-year-old patient with diabetes was admitted for below-the-knee amputation of his right leg. Removal of his right leg is an example of which type of surgery?
| a. | Palliative |
| b. | Diagnostic |
| c. | Reconstructive |
| d. | Ablative |
ANS: D
Ablative is a type of surgery where an amputation, excision of any part of the body, or removal of a growth and harmful substance is performed.
DIF: Cognitive Level: Comprehension REF: Page 16, Table 2-1
OBJ: 2 TOP: Types of surgeries
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- In which situation might surgery be delayed?
| a. | The patient has taken Dilantin today. |
| b. | An illegible signature is on the consent form.. |
| c. | The patient is still taking anticoagulants. |
| d. | The admission office is unable to confirm insurance coverage. |
ANS: C
All medications should be cancelled before surgery, except for drugs such as phenytoin (Dilantin). Anticoagulant therapy increases the threat of hemorrhage and may be a cause for delay.
DIF: Cognitive Level: Knowledge REF: Page 34, Page 36 Table 2-6
OBJ: 7 TOP: Anticoagulant therapy
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- Which circumstance could prevent the patient from signing his informed consent for a cholecystectomy?
| a. | The patient complains of pain radiating to the scapula. |
| b. | The patient received an injection of Demerol, 75 mg IM, 1 hour ago. |
| c. | The patient is 85 years of age. |
| d. | The patient is concerned over his lack of insurance coverage. |
ANS: B
Informed consent should not be obtained if the patient is disoriented and under the influence of sedatives. Age, illegibility, and lack of insurance coverage do not prevent signing the consent. Pain into the scapula is a symptom of colitis.
DIF: Cognitive Level: Application REF: Page 23 OBJ: 7
TOP: Informed consent KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- The nurse anticipates that the patient will be given ______________anesthesia because of the extensive tissue manipulation involved in a hysterectomy.
| a. | general |
| b. | regional |
| c. | specific |
| d. | preoperative |
ANS: A
An anesthesiologist gives general anesthetics by IV and inhalation routes through four stages of anesthesia when the procedure requires extensive tissue manipulation.
DIF: Cognitive Level: Knowledge REF: Page 34 OBJ: 9
TOP: Anesthesia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- The nurse caring for a patient who had an epidural block for a vaginal repair should be alert for:
| a. | a flushing of the face and torso. |
| b. | numbness of the perineum. |
| c. | complaint of thirst. |
| d. | a sudden drop in blood pressure. |
ANS: D
Epidural anesthesia may cause a sudden drop in blood pressure or respiratory difficulty as the anesthetic agent moves up in the spinal cord. Elevating the patient’s torso may prevent respiratory paralysis.
DIF: Cognitive Level: Comprehension REF: Page 37 OBJ: 9
TOP: Epidural block KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- Why might the older adult patient not respond to surgical treatment as well as a younger adult patient?
| a. | Poor skin turgor |
| b. | Fear of the unknown |
| c. | Response to physiological changes |
| d. | Decreased peristalsis related to anesthesia |
ANS: C
Of specific concern in older adults is the body’s response to temperature changes, cardiovascular shifts, respiratory needs, and renal function. Fear of the unknown and decreased peristalsis are common to all ages.
DIF: Cognitive Level: Application REF: Page 17 OBJ: 5
TOP: Older adult patients KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
- The postoperative nursing intervention that would be contraindicated for a 45-year-old patient who has had a repair of a cerebral aneurysm and is presenting signs of increased intracranial pressure (ICP) would be:
| a. | coughing every 2 hours. |
| b. | turning every 2 hours. |
| c. | monitoring intravenous therapy at 50 ml/hr. |
| d. | assessing vital signs every 2 hours. |
ANS: A
Coughing increases ICP.
DIF: Cognitive Level: Analysis REF: Page 28, Box 2-6
OBJ: 12 TOP: Postoperative complications
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- The nurse acting as a circulating nurse has a responsibility for:
| a. | observing for breaks in sterile technique. |
| b. | identifying and handling surgical specimens correctly. |
| c. | assisting with surgical draping of the patient. |
| d. | maintaining count of sponges, needles, and instruments during surgery. |
ANS: A
The circulating nurse is responsible for observing breaks in sterile technique. The scrub nurse handles the surgical specimens, drapes the patient, and maintains needle and sponge count during surgery, then does a final sponge and needle check with the circulating nurse before closing.
DIF: Cognitive Level: Analysis REF: Page 43, Box 2-7
OBJ: 11 TOP: Duties of circulating nurse
KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment
- Which statement made by a patient during a preoperative assessment would be significant to report to the charge nurse and surgeon?
| a. | “I have been taking an herbal product of feverfew for my migraines.” |
| b. | “I exercise for 3 hours a day.” |
| c. | “I drink 2 glasses of wine a day.” |
| d. | “I use atropine eyedrops every day.” |
ANS: A
The herbal remedy of feverfew acts as an anticoagulant and increases the possibility of hemorrhage. The drug should be stopped before surgery, and bleeding and clotting times should be evaluated.
DIF: Cognitive Level: Application REF: Page 21, Table 2-3
OBJ: 14 TOP: Preoperative assessment
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- A patient is on postoperative day 2 after a nephrectomy. What is the most effective way to increase her peristalsis?
| a. | Ambulation |
| b. | An enema |
| c. | Encouraging hot liquids |
| d. | Administering a laxative |
ANS: A
Encouraging activity (turning every 2 hours, early ambulation) assists GI activity.
DIF: Cognitive Level: Comprehension REF: Page 50 OBJ: 13
TOP: Postoperative complications KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
- A patient is transferred from the operating room to the recovery room after undergoing an open reduction and internal fixation (ORIF) of his left ankle. Which is the first assessment to make?
| a. | Check ankle dressings for hemorrhage. |
| b. | Check airway for patency. |
| c. | Check intravenous site. |
| d. | Check pedal pulse. |
ANS: B
Evaluation of the patient follows the ABCs of immediate postoperative observation: airway, breathing, consciousness, and circulation.
DIF: Cognitive Level: Application REF: Pages 42-43, Table 2-7
OBJ: 12 TOP: Nursing assessment
KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
- Frequent assessment of a postoperative patient is essential. What is one of the first signs and symptoms of hemorrhage?
| a. | Increasing blood pressure |
| b. | Decreasing pulse |
| c. | Restlessness |
| d. | Weakness, apathy |
ANS: C
A pulse that increases and becomes thready combined with a declining blood pressure, cool and clammy skin, reduced urine output, and restlessness may signal hypovolemic shock.
DIF: Cognitive Level: Comprehension REF: Page 45, Box 2-8
OBJ: 12 TOP: Postoperative complications
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- The nurse instructing a postsurgical patient in the use of thrombolytic deterrent stockings would include which of the following instructions?
| a. | Disregard appearance of edema above the stocking |
| b. | Massage legs to smooth wrinkles out of stockings |
| c. | Wring stockings thoroughly before hanging to dry |
| d. | Wash stockings in warm water and mild soap |
ANS: D
Stockings should be washed gently in warm water and mild soap and laid over a surface to dry. They should not be wrung out or hung. Massaging legs may dislodge a clot and the appearance of edema indicates the stockings are too restrictive.
DIF: Cognitive Level: Comprehension REF: Page 31, Patient Teaching Box
OBJ: 13 TOP: Thrombolytic deterrent stockings
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- The patient is brought into PACU still unconscious. What should the nurse do when the nurse assesses an oral temperature of 94° F?
| a. | Notify the charge nurse immediately |
| b. | Offer warm fluids through a straw |
| c. | Do nothing, this is a normal reaction to anesthesia |
| d. | Cover with a warm blanket |
ANS: D
Hypothermia is a frequent assessment postsurgery. A warm blanket or a ventilated cover would be applied to bring up the temperature. Vital signs are checked every 15 minutes until stable.
DIF: Cognitive Level: Analysis REF: Page 43, Page 45 Table 2-8
OBJ: 13 TOP: Hypothermia
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
- In which location are guidelines for ensuring that all nursing interventions on the day of surgery completed and documented?
| a. | In the nurse’s notes |
| b. | In the anesthesia record |
| c. | In the preoperative checklist |
| d. | In the progress notes |
ANS: C
When the nurse signs the preoperative checklist, that nurse assumes responsibility for all areas of care included on the list.
DIF: Cognitive Level: Knowledge REF: Page 40 OBJ: 6
TOP: Preoperative checklist KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
- While turning a patient who had a bowel resection yesterday, the wound eviscerated. What is the initial nursing intervention?
| a. | Place the patient in the high Fowler’s position. |
| b. | Give the patient fluids to prevent shock. |
| c. | Replace the dressing with sterile fluffy pads. |
| d. | Apply a warm, moist normal saline sterile dressing. |
ANS: D
Cover the wound with a sterile towel moistened with sterile physiological saline (warm).
DIF: Cognitive Level: Application REF: Pages 46-47, Figure 2-13
OBJ: 13 TOP: Evisceration KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- When should the nurse offer prescribed analgesics to a patient who is 24 hours postoperative?
| a. | Only when the patient asks. |
| b. | When the onset of pain is assessed. |
| c. | Sparingly to avoid drug dependence. |
| d. | Only when severe pain is assessed. |
ANS: B
The nurse should assess for pain frequently to medicate at the onset of pain.
DIF: Cognitive Level: Application REF: Page 48 OBJ: 14
TOP: Medication administration KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
- What should the nurse do to minimize the potential for venous stasis?
| a. | Place pillows under the knee in a position of comfort |
| b. | Assist patient to sit with feet flat on the floor |
| c. | Assist with early ambulation |
| d. | Perform gentle leg massage |
ANS: C
Early ambulation has been a significant factor in hastening postoperative recovery and preventing postoperative complications.
DIF: Cognitive Level: Application REF: Page 49 OBJ: 13
TOP: Venous stasis KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
- The nurse clarifies that serum potassium levels are determined before surgery to:
| a. | assess kidney function. |
| b. | determine respiratory insufficiency. |
| c. | prevent arrhythmias related to anesthesia. |
| d. | measure functional liver capability. |
ANS: C
Serum electrolytes are evaluated if extensive surgery is planned or the patient has extenuating problems. One of the essential electrolytes examined is potassium; if potassium is not available in adequate amounts, arrhythmias can occur during anesthesia.
DIF: Cognitive Level: Analysis REF: Page 23 OBJ: 4
TOP: Preoperative assessment KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- In performing the preoperative assessment, the nurse discovers that the patient is allergic to latex. What should the nurse do initially?
| a. | Notify the diet kitchen to omit peaches from diet tray |
| b. | Apply a medical alert band to patient’s wrist |
| c. | Tag chart with allergy alert |
| d. | Place patient in an isolation room |
ANS: B
The initial intervention would be to place a medical alert band on the patient, then tag the chart. The charge nurse and the surgeon should be notified in the event the surgeon wants to order a preoperative prophylactic treatment.
DIF: Cognitive Level: Knowledge REF: Pages 25-26, Box 2-5
OBJ: 13 TOP: Latex allergy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
- Which of the following early postoperative observations should be reported immediately?
| a. | “Coffee ground” emesis |
| b. | Shivering |
| c. | Scanty urine output |
| d. | Evidence of pain |
ANS: A
Any emesis that is red or coffee ground should be reported immediately as it indicates GI bleeding. Shivering, scanty urine output, and evidence of pain are within normal expectation of a postsurgical patient.
DIF: Cognitive Level: Application REF: Page 45 OBJ: 10
TOP: Postoperative assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- When the postoperative patient complains of sudden chest pain combined with dyspnea, cyanosis, and tachycardia, the nurse recognizes the signs of:
| a. | hypovolemic shock. |
| b. | dehiscence. |
| c. | atelectasis. |
| d. | pulmonary embolus. |
ANS: D
Sudden chest pain combined with dyspnea, tachycardia, cyanosis, diaphoresis, and hypotension is a sign of pulmonary embolism.
DIF: Cognitive Level: Analysis REF: Page 47 OBJ: 13
TOP: Assessment and postoperative complications
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- The removal of a nondiseased appendix during a hysterectomy is classified as:
| a. | major, emergency, diagnostic |
| b. | major, urgent, palliative |
| c. | minor, elective, ablative |
| d. | minor, urgent, reconstructive |
ANS: C
Surgery is classified as elective, urgent, or emergency. Surgery is performed for various purposes, which include diagnostic studies, ablation (an amputation or excision of any part of the body or removal of a growth or harmful substance), and palliative (therapy to relieve or reduce intensity of uncomfortable symptoms without cure), reconstructive, transplant, and constructive purposes.
DIF: Cognitive Level: Comprehension REF: Page 16, Table 2-1
OBJ: 2 TOP: Types of surgery
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
- Which medication would cause surgery to be delayed if it had not been discontinued several days before surgery?
| a. | Analgesic agent |
| b. | Antihypertensive agent |
| c. | Anticoagulant agent |
| d. | Antibiotic agent |
ANS: C
Anticoagulants alter normal clotting factors and thus increase risk of hemorrhaging. They should be discontinued for 48 hours before surgery.
DIF: Cognitive Level: Analysis REF: Page 36, Table 2-6
OBJ: 4 TOP: Individual’s ability to tolerate surgery
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
- The most appropriate intervention by the nurse to decrease the pain of an abdominal incision while coughing would be to:
| a. | Support the surgical site with a pillow |
| b. | Position patient in a side-lying position |
| c. | Medicate with prescribed narcotic before coughing |
| d. | Ask the patient to cross arms over the chest to increase force of cough |
ANS: A
To ease the pressure on the incision, the nurse helps the patient support the surgical site with a pillow, rolled bath blanket, or the heel of the hand.
DIF: Cognitive Level: Application REF: Page 47 OBJ: 8
TOP: Postoperative nursing interventions
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
- The nurse would include the nursing diagnosis of deficient knowledge, postoperative, when the patient scheduled for a bowel resection tomorrow remarks:
| a. | “I am going to have adequate pain medication after surgery.” |
| b. | “I know you all are going to make me cough and walk soon after surgery.” |
| c. | ”I am glad I will get to go home tomorrow evening.” |
| d. | “I will have to put up with dressing changes.” |
ANS: C
The patient’s lack of understanding about the length of time in the hospital following such a serious surgery indicates a knowledge deficit that needs to be addressed.
DIF: Cognitive Level: Analysis REF: Page 52, Box 2-11
OBJ: 16 TOP: Nursing process/diagnosis
KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment
- What instruction should a nurse give when teaching the patient to cough effectively after surgery?
| a. | Breathe through the nose, hold breath, and exhale slowly. |
| b. | Take three deep breaths and cough from the chest. |
| c. | Inhale while contracting the abdominal muscles and exhale while contracting the diaphragm. |
| d. | Take short, frequent panting breaths and cough from the throat to clear accumulated mucus. |
ANS: B
Because lung ventilation is vital, the nurse assists the patient to turn, cough, and breathe deeply every 1 to 2 hours until the chest is clear. Having practiced this combination preoperatively, the patient is usually adequately able to remove trapped mucus and surgical gases.
DIF: Cognitive Level: Application REF: Page 29, Skill 2-3
OBJ: 8 TOP: Prevention of postoperative complications
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- What is the responsibility of the nurse as a witness to informed consent?
| a. | Explain the surgical options |
| b. | Explain the operative risks |
| c. | Verify/obtain the patient’s signature |
| d. | Verify the patient’s understanding of the procedure |
ANS: C
A witness is only verifying that this is the person who signed the consent and that it was a voluntary consent. The witness (often a nurse) is not verifying that the patient understands the procedure.
DIF: Cognitive Level: Knowledge REF: Page 23 OBJ: 7
TOP: Informed consent KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
- On the patient’s return to the medical-surgical unit, the nurse performing an abdominal assessment can affirm an absence of bowel sounds after listening in each quadrant for at least:
| a. | 30 seconds. |
| b. | 1 minute. |
| c. | 2 minutes. |
| d. | 3 minutes. |
ANS: D
Normal peristalsis is gauged by hearing 5 to 30 gurgles per minute. Absence of bowel sounds may be recorded if the nurse has listened to each quadrant 3 to 5 minutes.
DIF: Cognitive Level: Knowledge REF: Page 50 OBJ: 12
TOP: Bowel sounds KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- When the patient asks the nurse to make sure no one sees her with her dentures out, the nurse recognizes the common preoperative fear of:
| a. | anesthesia. |
| b. | loss of control. |
| c. | fear of separation from family. |
| d. | mutilation. |
ANS: B
Fear of loss of control may be partially related to concerns about anesthesia, but this patient’s concern is about self-image. Preoperative anxiety from any cause may affect the amount of anesthesia and postoperative analgesia needed.
DIF: Cognitive Level: Assessment REF: Page 20, Box 2-4
OBJ: 4 TOP: Nursing diagnosis
KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
- What is the ideal time for preoperative teaching?
| a. | Immediately before surgery to eliminate fear |
| b. | 2 months in advance so the patient can prepare |
| c. | 1 to 2 days before the surgery when anxiety is not as high |
| d. | In the surgical holding area |
ANS: C
Preoperative teaching is provided 1 to 2 days prior to surgery when anxiety is low.
DIF: Cognitive Level: Implementation REF: Page 22 OBJ: 4
TOP: Preoperative teaching KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
- In preparation for the return of the surgical patient, the patient’s bed and equipment should be in what position?
| a. | Lowest position with side rails elevated with oxygen and suction equipment available |
| b. | Highest position with side rails elevated with IV pole and pump at bedside |
| c. | Lowest position with side rails down on the receiving side |
| d. | Highest position with the side rails down on receiving side and up on opposite side |
ANS: D
In preparation for the return of the surgical patient, the patient’s bed should be in the highest position to be level with the surgical gurney and should have the side rail down on the receiving side, with the opposite side rail up to prevent the patient from falling out of bed during transfer.
DIF: Cognitive Level: Implementation REF: Page 40 OBJ: 12
TOP: Postoperative preparation KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
MULTIPLE RESPONSE
- A postoperative patient who had a left inguinal hernia repair is ready for his discharge instructions. Which information should the nurse provide? (Select all that apply.)
| a. | Care of the wound site and any dressings |
| b. | When he may operate a motor vehicle |
| c. | Signs and symptoms to report to the physician |
| d. | Call the physician’s office once he arrives home |
| e. | Report bowel movements to the physician |
| f. | Actions and side effects of any medications |
ANS: A, B, C, F
As the day of discharge approaches, the nurse should be certain that the patient has vital information.
DIF: Cognitive Level: Analysis REF: Page 53, Box 2-13
OBJ: 15 TOP: Discharge instructions
KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment
- Which of the following are considerations for the older adult surgical patient? (Select all that apply.)
| a. | The need for specific clear preoperative and postoperative teaching |
| b. | Awareness of lower morbidity and mortality rate |
| c. | Presence of coexisting conditions |
| d. | Increased risk of respiratory complications |
| e. | Expectation of normal recovery time |
ANS: A, C, D
Surgery places greater stress on older than on younger patients. Teaching should be given at the older person’s level of understanding. Teaching should be specific and clear. Presence of coexisting conditions may delay recovery time and response to surgery.
DIF: Cognitive Level: Application REF: Page 17, Life Span Considerations
OBJ: 7 TOP: Older adult considerations
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
- Which of the following are preoperative conditions that may affect the patient’s response to surgery? (Select all that apply.)
| a. | Age |
| b. | Religion |
| c. | Mental status |
| d. | Occupation |
| e. | Nutritional status |
ANS: A, C, E
Each system of the body is affected by the patient’s age, health, nutritional status, and mental state. Religion and occupation do not affect the physiological response to the surgery.
DIF: Cognitive Level: Comprehension REF: Page 17 OBJ: 4
TOP: Factors influencing toleration to surgery
KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
- Which interventions in preparing the patient for abdominal surgery may be delegated to unlicensed assistive personnel (UAP)?
| a. | Vital signs |
| b. | Insertion of N/G tube |
| c. | Enema |
| d. | Height and weight |
| e. | Obtaining operative consent |
| f. | Sterile gowning |
ANS: A, C, D
Vital signs, enema, and height and weight can be safely performed by UAP. Insertion of an N/G tube, obtaining an operative consent, and sterile gloving are interventions requiring critical thinking and knowledge unique to a nurse.
DIF: Cognitive Level: Application REF: Page 18, Box 2-2
OBJ: 3 TOP: Delegation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
COMPLETION
- ______________ therapy is performed to alleviate or decrease uncomfortable symptoms without curing the problem.
ANS:
Palliative
Palliative therapy is designed to relieve or reduce intensity of uncomfortable symptoms without cure.
DIF: Cognitive Level: Knowledge REF: Page 16, Table 2-1
OBJ: 1 TOP: Palliative therapy
KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment
- Discharge planning for a surgical procedure begins in the ______________ period and continues through the _____________ period.
ANS:
preoperative, recuperative
When discharge planning is begun in the preoperative period and all through the postoperative period, the patient can assume greater responsibility for self-care and will experience less stress about going home.
DIF: Cognitive Level: Comprehension REF: Page 52 OBJ: 15
TOP: Discharge planning KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
- The type of anesthesia that uses a combination of drugs to reduce the level of consciousness and provides amnesia is _________________ __________.
ANS:
conscious sedation
Conscious sedation uses a combination of drugs to produce a reduced level of consciousness and amnesia, as well as pain control, but allows the patient to control his or her own breathing. The recovery is more rapid than with general anesthesia.
DIF: Cognitive Level: Comprehension REF: Page 48 OBJ: 10
TOP: Conscious sedation KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
- The nurse is aware that there is a loss of _________ during catabolism after severe tissue injury.
ANS:
potassium
The injured cells loose potassium as catabolism (tissue breakdown) occurs.
DIF: Cognitive Level: Knowledge REF: Page 51 OBJ: 13
TOP: Catabolism KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
- The nurse explains that to promote deep breathing and improve lung expansion and oxygenation the patient should use the _____________ ______________ at regular intervals during the day.
ANS:
incentive spirometer
The incentive spirometer is a device to encourage deep breathing and lung expansion. The usual rate of usage is 8 to 10 breaths hourly during waking hours.
DIF: Cognitive Level: Comprehension REF: Page 26 OBJ: 13
TOP: Incentive spirometer KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- The nurse caring for a postsurgical patient is aware that the patient should void ____ to _____ hours postsurgery.
ANS:
6 to 8
6, 8
Urinary output should be obvious 6 to 8 hours postsurgery. If urinary output has not begun, a catheter may be inserted.
DIF: Cognitive Level: Comprehension REF: Page 48 OBJ: 13
TOP: Resumption of urinary flow KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
OTHER
- A patient is transferred from the operating room to the recovery room after undergoing an amputation of his left foot. Place the interventions in the correct order for immediate assessment once the patient enters the PACU. (Separate letters by a comma and space as follows: A, B, C, D)
- System review
- Breathing
- Circulation
- Airway
- Level of consciousness
ANS:
D, B, E, C, A
The assessment of an adequate airway is primary in the postanesthesia assessment, followed by breathing assessment, level of consciousness, circulation, and finally system review.
DIF: Cognitive Level: Application REF: Page 44, Table 2-7
OBJ: 12 TOP: Nursing assessment
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
- Place the instructions for controlled coughing in the correct sequence. (Separate letters by a comma and space as follows: A, B, C, D)
- Inhale deeply and hold breath for a count of three
- Document exercise and patient reaction
- Cough 2 or 3 times without inhaling then relax
- Take several deep breaths
- Inhale through nose
- Exhale through pursed lips
ANS:
D, E, F, A, C, B
The patient should be instructed to take several deep breaths, inhale through the nose, exhale through pursed lips, inhale deeply and hold for a count of three, cough two or three times without exhaling, relax. The procedure may be repeated before documentation.
DIF: Cognitive Level: Application REF: Pages 29-30, Skill 2-3
OBJ: 13 TOP: Controlled coughing
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
Chapter 4: Care of the Patient with a Musculoskeletal Disorder
MULTIPLE CHOICE
- What is the movement of an extremity away from the midline of the body called?
| a. | Abduction |
| b. | Adduction |
| c. | Flexion |
| d. | Extension |
ANS: A
Abduction is movement of an extremity away from the midline of the body.
DIF: Cognitive Level: Knowledge REF: Page 114, Box 4-2
OBJ: 6 TOP: Movements KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- What is the large, fan-shaped muscle that covers the anterior chest from the sternum to the proximal end of the humerus and acts on the joint of the shoulder to flex, adduct, and rotate?
| a. | Serratus anterior |
| b. | Intercostal |
| c. | Transversus abdominis |
| d. | Pectoralis major |
ANS: D
Pectoralis major is the large, fan-shaped muscle that covers the anterior chest and is an adductor muscle, which will cause the shoulder to flex.
DIF: Cognitive Level: Knowledge REF: Page 116, Figure 4-4
OBJ: 4 TOP: Muscle functions
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- What should the nurse instruct the patient before a magnetic resonance imaging (MRI) procedure?
| a. | Void to completely empty the bladder |
| b. | Omit all citrus food for 12 hours before the procedure |
| c. | Remove all metal, such as jewelry, glasses, and hair clips |
| d. | Wear only cotton garments for the procedure |
ANS: C
MRI procedures require that the patient remove all metal because it will become magnetized.
DIF: Cognitive Level: Application REF: Page 116 OBJ: 7
TOP: Diagnostic examinations KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- The nurse instructs the patient who is to have a unicompartmental knee replacement that a major advantage of this partial knee replacement is that:
| a. | the patient will be up and walking 2 to 3 hours after the operation. |
| b. | the kneecap is completely removed. |
| c. | the procedure is especially helpful in the treatment of rheumatoid arthritis. |
| d. | a small titanium disk replaces the worn cartilage. |
ANS: A
Unicompartmental knee arthroplasty is also referred to as partial knee replacement in which the worn cartilage is replaced with a plastic disk. It is not as invasive as a full knee replacement and does not disturb the kneecap so that the patient can be up and walking in 2 to 3 hours after surgery. It is not recommended for RA patients.
DIF: Cognitive Level: Comprehension REF: Page 136 OBJ: 13
TOP: Unicompartmental knee replacement
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A patient who has had a right below the knee amputation continues to complain of unpleasant sensation in the right foot. What can the nurse explain about this “phantom pain”?
| a. | It only exists in the mind. |
| b. | It is a complication following an amputation and can be clarified by the surgeon. |
| c. | It is related to the severed nerves that are still sending messages to the brain. |
| d. | It occurs when the person becomes focused on the loss of the limb. |
ANS: C
Phantom pain (pain felt in the missing extremity as if it were still present) may occur and be frightening to the patient. Phantom pain occurs because the nerve tracts that register pain in the amputated area continue to send a message to the brain (this is normal).
DIF: Cognitive Level: Analysis REF: Page 169 OBJ: 21
TOP: Phantom pain KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- The patient that has a bipolar hip replacement following an intracapsular fracture has an order to be turned every 2 hours. The nurse understands that the correct nursing intervention is to keep the legs:
| a. | together so they do not separate while turning. |
| b. | flexed to stabilize the prosthesis. |
| c. | abducted so the prosthesis does not become dislocated. |
| d. | adducted to prevent additional pain for the patient with turning. |
ANS: C
Nursing interventions also involve postoperative maintenance of leg abduction by using an abduction splint for 7 to 10 days to prevent dislocation of the prosthesis.
DIF: Cognitive Level: Application REF: Page 142, Figure 4-13
OBJ: 14 TOP: Maintaining abduction
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A patient has been casted to stabilize a fracture of the right radius and ulna. The nurse assesses a capillary refill of 5 seconds and cold fingers of the right hand. Which initial intervention should the nurse deploy?
| a. | Notify the charge nurse of a probable compartment syndrome |
| b. | Apply a warm compress to the fingers to relieve swelling |
| c. | Elevate the right hand to heart level to maintain arterial pressure |
| d. | Cut the cast off to release constriction |
ANS: C
The nurse should first elevate the right hand to heart level and notify the charge nurse. Permanent damage can occur in as little time as 6 hours.
DIF: Cognitive Level: Analysis REF: Page 150 OBJ: 19
TOP: Compartment syndrome KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A patient had an open reduction with internal fixation (ORIF) for a compound fracture of the left tibia and has been placed in a long leg cast. The assessments by the nurse are: left foot warm/pink, pedal pulse weaker than right, capillary refill 3 seconds, and small 1 cm area of blood on cast. What should the nurse do?
| a. | Notify charge nurse of impending compartment syndrome |
| b. | Document that all assessments are within normal limits |
| c. | Inform charge nurse about probable hemorrhage |
| d. | Place warm compresses on left foot |
ANS: B
All of the assessments are within normal limits. A small amount of blood on the cast is expected and should be monitored.
DIF: Cognitive Level: Analysis REF: Page 172 OBJ: 19
TOP: Compound fracture KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- When a patient recovering from a fractured tibia asks what callus formation is, the nurse tells her it is:
| a. | when blood vessels of the bone are compressed. |
| b. | a part of the bone healing process after a fracture when new bone is being formed over the fracture site. |
| c. | the formation of a clot over the fracture site. |
| d. | when the hematoma becomes organized and a fibrin meshwork is formed. |
ANS: B
Callus formation occurs when the osteoblasts continue to lay the network for bone buildup and osteoclasts destroy dead bone.
DIF: Cognitive Level: Comprehension REF: Page 146 OBJ: 15
TOP: Bone healing KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- Which patient statement indicates the need for additional teaching for a patient with rheumatoid arthritis who is taking meloxicam (Mobic)?
| a. | “I am keeping a daily record of my blood pressure.” |
| b. | “I take aspirin before I go to bed.” |
| c. | “I know I can take meloxicam with or without regard to meals.” |
| d. | “I weigh every day so I will be aware of any weight gain.” |
ANS: B
Aspirin or products containing aspirin should be avoided while taking meloxicam.
DIF: Cognitive Level: Application REF: Page 121, Table 4-5
OBJ: 9 TOP: Rheumatoid arthritis
KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
- What should the nurse include in the plan of care for a patient following a myelogram?
| a. | Position in a semi-Fowler position for 8 hours to reduce potential of headache |
| b. | Place patient flat on back to compress puncture site |
| c. | Ambulate for brief periods to lessen postmyelogram headache |
| d. | Limit fluids to increase absorption of the dye |
ANS: A
The patient should be positioned in the semi-Fowler position for 8 hours to encourage the dye to stay in the lower spine and to reduce headache.
DIF: Cognitive Level: Application REF: Page 115 OBJ: 7
TOP: Myelogram KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- Which finding would delay a computed tomography (CT) scan?
| a. | Patient’s allergy to shellfish |
| b. | Patient in first trimester of a pregnancy |
| c. | Patient’s allergy to milk products |
| d. | Patient’s gluten intolerance |
ANS: A
Allergy to shellfish predicts an allergy to the contrast media used in the CT scan.
DIF: Cognitive Level: Application REF: Page 117 OBJ: 7
TOP: CT scan KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- Forty-eight hours after a patient sustained a fractured femur in a car accident, the nurse assessed a pulse of 110, respirations at 25, and labored crackles in both lung fields. The nurse immediately reports to the charge nurse the probability of a(n):
| a. | impending pneumonia. |
| b. | atelectasis. |
| c. | fat embolism. |
| d. | anxiety attack. |
ANS: C
A pulmonary fat embolism involves the embolization of fat tissue with platelets and circulation of free fatty acids within the pulmonary circulation. Dyspnea, tachypnea, and chest pain are symptomatic of a fat embolus.
DIF: Cognitive Level: Application REF: Page 151 OBJ: 17
TOP: Fat embolism KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- What is the first priority nursing intervention for an impending fat embolism?
| a. | Administer oxygen in a respiratory emergency |
| b. | Increase intravenous fluids |
| c. | Position in flat position to ease decreased blood pressure |
| d. | Cover with warm blanket |
ANS: A
The airway is always the first priority. If hypoxia is present, the physician will order the administration of oxygen. It is important for the nurse to check the liter flow of oxygen and educate patients and their families as to safety precautions necessary when oxygen is administered.
DIF: Cognitive Level: Analysis REF: Page 152 OBJ: 17
TOP: Fat embolism KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A patient, age 68, has suffered an intertrochanteric fracture of the right hip. Before surgery, to provide support and comfort, an immobilizing device of a ______ is applied.
| a. | Thomas splint |
| b. | Bryant traction |
| c. | Russell traction |
| d. | Buck traction |
ANS: D
Buck traction is a form of traction used as a temporary measure to provide support and comfort to a fractured extremity until a more definite treatment is initiated.
DIF: Cognitive Level: Knowledge REF: Page 158 OBJ: 21
TOP: Fracture KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- Which foods should the home health nurse suggest for the patient with osteoporosis to help slow the disease?
| a. | Leafy green vegetables |
| b. | Foods high in sodium |
| c. | Tea and coffee |
| d. | Vitamin A |
ANS: A
To slow the bone loss, a patient with osteoporosis should eat green leafy vegetables, foods low in sodium, and also avoid caffeine. Vitamin A does not help with the absorption of calcium.
DIF: Cognitive Level: Application REF: Page 32, Patient Teaching
OBJ: 11 TOP: Osteoporosis diet
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- What should the nurse include in the teaching plan for a patient who is taking alendronate (Fosamax)?
| a. | Take drug with any meal |
| b. | Take drug first thing in the morning |
| c. | Drink at least 5 oz of milk before taking drug |
| d. | Take drug with an antacid to avoid heartburn |
ANS: B
Alendronate (Fosamax) should be taken on an empty stomach first thing in the morning with 6 oz of water, accompanied by no other medication.
DIF: Cognitive Level: Application REF: Page 131, Table 4-6
OBJ: 8 TOP: Osteoporosis drug
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
- The patient has been diagnosed as having gouty arthritis. The patient asks the nurse to explain the cause of the inflammation of the great toe. What is the most appropriate nursing response?
| a. | “You have calcium oxalate deposits that are seen in gouty arthritis.” |
| b. | “The inflammation is from small accumulations of uric acid crystals, which are called tophi.” |
| c. | “The small nodules are not related to the arthritis condition.” |
| d. | “You have fat deposits that are common with gouty arthritis.” |
ANS: B
Gout is a metabolic disease resulting from an accumulation of uric acid in the blood. It is an acute inflammatory condition associated with ineffective metabolism of purines.
DIF: Cognitive Level: Application REF: Page 128 OBJ: 8
TOP: Gouty arthritis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- When the patient with rheumatoid arthritis complains about the daily exercise, the nurse encouragingly reminds the patient that exercises:
| a. | keeps the joints from “freezing.” |
| b. | will ensure better sleep. |
| c. | should be vigorous for joint stimulation. |
| d. | need not be done daily. |
ANS: A
Daily gentle exercises keep the joints from “freezing” and keep the muscles from weakening.
DIF: Cognitive Level: Application REF: Page 124 OBJ: 8
TOP: Rheumatoid arthritis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- The nurse clarifies to a patient who is being evaluated for possible rheumatoid arthritis that the elevated erythrocyte sedimentation rate indicates the presence of:
| a. | immunoglobulin M. |
| b. | abnormal serum protein. |
| c. | increased inflammatory reaction in the body. |
| d. | C-reactive protein. |
ANS: C
The ESR indicates an increase in the inflammatory reactions in the body.
DIF: Cognitive Level: Comprehension REF: Page 120 OBJ: 8
TOP: Rheumatoid arthritis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- What should the nurse instruct the patient before the initiation of the antimalarial drug hydroxychloroquine (Plaquenil)?
| a. | Get a complete blood count to assess anemia. |
| b. | Get a chest x-ray. |
| c. | Get an eye examination. |
| d. | Take prophylaxis for malaria. |
ANS: C
An eye examination should be completed before starting the drug and an eye examination should be done every 6 months while on the drug, because the drug can damage the retina and lead to blindness.
DIF: Cognitive Level: Comprehension REF: Page 112, Table 4-5
OBJ: 8 TOP: Gout KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- What should the nurse do when a patient with osteomyelitis is admitted with an open wound that is draining?
| a. | Enforce a low calorie diet |
| b. | Initiate drainage and secretion precautions |
| c. | Frequently do passive ROM on the elbow |
| d. | Ambulate several times daily |
ANS: B
The patient with osteomyelitis should be at least in drainage and secretion precaution. The limb should be positioned for maximum comfort and left at rest. These patients are usually on bed rest and require a high-calorie, high-protein diet.
DIF: Cognitive Level: Application REF: Page 133 OBJ: 19
TOP: Osteomyelitis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A 16-year-old male patient presents in the emergency room with a pathologic fracture of the left femur and complains of pain on weight bearing. These are cardinal indicators of:
| a. | osteogenic sarcoma. |
| b. | osteoporosis. |
| c. | rheumatoid arthritis. |
| d. | osteochondroma. |
ANS: A
Osteogenic sarcoma occurs in young men aged 10 to 25. They are malignant bone tumors that can cause a pathologic fracture and they are accompanied by pain on weight bearing. Osteochondromas are benign and usually do not cause fractures.
DIF: Cognitive Level: Application REF: Page 168 OBJ: 20
TOP: Bone tumor KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- The 14-year-old boy who is scheduled for left leg amputation says to the nurse, “What in the world am I going to do with only one leg?” What is the nurse’s most therapeutic response?
| a. | “What are you thinking about right now?” |
| b. | “With a prosthesis, you will be as good as new.” |
| c. | “It is way too early to be concerned about that now.” |
| d. | “When my brother had his leg removed, he did great!” |
ANS: A
The patient’s concern should be acknowledged and the patient encouraged to express feelings.
DIF: Cognitive Level: Analysis REF: Page 169 OBJ: 20
TOP: Fracture of hip KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
- A patient has undergone a bipolar hip repair (hemiarthroplasty). Which is the most appropriate instruction?
| a. | Sit in whatever position is most comfortable |
| b. | Sit in a firm, straight-backed chair at a 90-degree angle |
| c. | Avoid crossing the legs |
| d. | Begin full weight bearing as soon as tolerated |
ANS: C
Instructing the patient not to cross the legs is important because crossing the legs can adduct the affected extremity and dislocate the hip.
DIF: Cognitive Level: Application REF: Page 142, Figure 4-18
OBJ: 14 TOP: Hip replacement
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- The nurse explains to a patient who has had a knee replacement that warfarin (Coumadin) is ordered to:
| a. | increase the red blood cells. |
| b. | reduce the threat of hemorrhage. |
| c. | prevent formation of emboli. |
| d. | help stabilize the prosthesis. |
ANS: C
Warfarin (Coumadin) is a standard postsurgical drug to prevent the formation of emboli.
DIF: Cognitive Level: Analysis REF: Page 142 OBJ: 13
TOP: Coumadin therapy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- What should the nurse stress to a post–hip replacement patient in quadriceps setting exercises?
| a. | Push knee down to mattress and raise heel off the bed |
| b. | Flex knee and extend foot |
| c. | Adduct leg and flex foot |
| d. | Lift leg and heel off the bed |
ANS: A
Pushing the knee down into the mattress and raising the heel will strengthen the quadriceps muscles.
DIF: Cognitive Level: Application REF: Page 142, Patient Teaching
OBJ: 14 TOP: Quad setting KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- What should the home health nurse include assessment for in the plan of care for an 82-year-old female with severe kyphosis from ankylosis?
| a. | Urinary output |
| b. | Respiratory effort |
| c. | Sleep cycle |
| d. | Nutritional status |
ANS: B
Severe kyphosis may hinder the patient’s ability to expand the ribcage and interfere with easy respiration.
DIF: Cognitive Level: Analysis REF: Page 125 OBJ: 22
TOP: Kyphosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- What should the nurse stress to a patient who has had a hip replacement and is beginning strengthening exercises for the unaffected leg?
| a. | Flex the knee and flex the foot |
| b. | Lift the leg from the mattress and rotate the foot |
| c. | Pull knee to chest and extend the foot |
| d. | Push foot down against the footboard for a count of five |
ANS: D
The unaffected leg should be strengthened by pushing the foot down against the footboard for a count of five and repeating frequently during the day.
DIF: Cognitive Level: Comprehension REF: Page 142, Patient Teaching
OBJ: 13 TOP: Exercise KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- The office nurse has noted the presence of an increase in lumbar curvature in a 20-year-old female patient. What is this condition known as?
| a. | Scoliosis |
| b. | Lordosis |
| c. | Kyphosis |
| d. | Spondylitis |
ANS: B
Common deformities include an increase in the curve at the lumbar space region that throws the shoulder back, making the “lordly or kingly” appearance that is known as lordosis. Scoliosis involves the S curvature of the spine. Kyphosis is the rounding of the thoracic spine.
DIF: Cognitive Level: Knowledge REF: Page 171 OBJ: 22
TOP: Lordosis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- How is rheumatoid arthritis distinguished from osteoarthritis?
| a. | Rheumatoid arthritis is an autoimmune, systemic disease; osteoarthritis is a degenerative disease of the joints. |
| b. | Rheumatoid arthritis is an autoimmune, degenerative disease; osteoarthritis is a systemic inflammatory disease. |
| c. | People with osteoarthritis are considered to be genetically predisposed; there is no known genetic component to rheumatoid arthritis. |
| d. | Osteoarthritis is often caused by a virus; viruses play no part in the pathogenesis of rheumatoid arthritis. |
ANS: A
RA is thought to be an autoimmune disorder. Degenerative joint disease is also known as osteoarthritis.
DIF: Cognitive Level: Analysis REF: Page 119, Table 4-4 | Page 120, Figure 4-5
OBJ: 8 TOP: Rheumatoid arthritis
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- Which patient is most likely to develop osteoporosis?
| a. | 43-year-old African American woman |
| b. | 57-year-old white woman |
| c. | 48-year-old African American man |
| d. | 62-year-old Latino woman |
ANS: B
White and Asian women have a higher incidence of osteoporosis than African American women or Hispanic women because of the greater bone density in the African American.
DIF: Cognitive Level: Knowledge REF: Page 131, Cultural and Ethnic Considerations
OBJ: 11 TOP: Osteoporosis
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- The patient, age 58, is diagnosed with osteoporosis after densitometry testing. She has been menopausal for 5 years and has been concerned about her risk for osteoporosis because her mother has osteoporosis. In teaching her about her osteoporosis, which information does the nurse include?
| a. | Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise. |
| b. | Estrogen replacement therapy must be started to prevent rapid progression of her osteoporosis. |
| c. | With a family history of osteoporosis, there is no way to prevent or slow bone reabsorption. |
| d. | Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. |
ANS: A
To prevent osteoporosis, women are advised to have an adequate daily intake of calcium and vitamin D; exercise regularly; avoid smoking; decrease coffee intake; decrease excess protein in the diet; and engage in regular moderate activity such as walking, bike riding, or swimming at least 3 days a week. A contributing factor may be use of steroids.
DIF: Cognitive Level: Analysis REF: Page 130 OBJ: 11
TOP: Osteoporosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- Certain foods may increase the pain associated with gout. Which foods have the highest concentration of purines?
| a. | Brain, liver, kidney |
| b. | Lettuce, corn, potatoes |
| c. | Beef, pork, chicken |
| d. | Fruits and fruit juices |
ANS: A
Foods high in purines, such as brain, kidney, liver, and heart should be avoided, as well as alcohol.
DIF: Cognitive Level: Analysis REF: Page 129 OBJ: 8
TOP: Gout KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- In order for a patient to flex the lower leg, which muscle must be contracted?
| a. | Quadriceps |
| b. | Gastrocnemius |
| c. | Biceps femoris |
| d. | Rectus femoris |
ANS: C
The contraction of the biceps femoris allows for the contraction of the lower leg.
DIF: Cognitive Level: Comprehension REF: Page 113, Table 4-1
OBJ: 4 TOP: Muscle action
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- Calcium is a mineral found in many foods that can slow bone loss during the aging process. Which food is high in calcium?
| a. | Oranges |
| b. | Bananas |
| c. | Spinach |
| d. | Eggs |
ANS: C
Spinach and green vegetables, as well as yogurt, are considered calcium-rich foods. Fresh oranges, bananas, and eggs are not good calcium choices.
DIF: Cognitive Level: Analysis REF: Page 132, Patient Teaching
OBJ: 11 TOP: Osteoporosis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A 56-year-old female patient is being seen for osteoarthritis of the knee in the clinic. What should the nurse recommend when discussing strengthening exercises?
| a. | Jogging |
| b. | Walking rapidly on a treadmill |
| c. | Bicycling |
| d. | Aerobic exercises |
ANS: C
Bicycling or swimming is recommended for osteoarthritis of the hip or knee. Jogging would put undue stress on knee joints. Climbing stairs should be avoided. Walking should be done on level ground, not up or down elevations.
DIF: Cognitive Level: Analysis REF: Page 126, Box 4-3
OBJ: 10| 11 TOP: Osteoarthritis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- What does prolonged bed rest put the older adult at risk for?
| a. | Ankylosing spondylitis |
| b. | Pathologic fractures |
| c. | Osteomyelitis |
| d. | Gout |
ANS: B
Immobilization results in bone resorption, and the bone tissue becomes less dense. Prolonged bed rest puts the patient at risk for pathologic fracture. This is a serious concern for an older adult in terms of regaining mobility.
DIF: Cognitive Level: Comprehension REF: Page 119 OBJ: 11
TOP: Disorders of musculoskeletal system
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
- Which of the following are the main purposes of traction? (Select all that apply.)
| a. | Align and stabilize a fracture |
| b. | Prevent deformities |
| c. | Relieve muscle spasms |
| d. | Promote bed rest |
| e. | Increase circulation to the rest of the body |
ANS: A, B, C
Skin and skeletal traction provide alignment and stabilize a fracture. This prevents deformities and relieves muscle spasms by putting muscles under tension until they are fatigued.
DIF: Cognitive Level: Application REF: Page 158 OBJ: N/A
TOP: Traction KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- The characteristics of osteoarthritis that should be included in a teaching plan would include that osteoarthritis (select all that apply):
| a. | will cause the formation of Heberden nodes. |
| b. | can involve other organs. |
| c. | results from wear and tear. |
| d. | may affect only one side of the body. |
| e. | may cause constitutional symptoms of fatigue and fever. |
| f. | will cause marked erythema and edema of hands. |
ANS: A, C, D
Osteoarthritis is a disease caused by wear and tear of the joints, causing the appearance of Heberden nodes on the fingers without marked edema or erythema. The disease may only affect one side of the body and does not cause constitutional symptoms.
DIF: Cognitive Level: Application REF: Page 119, Table 4-4
OBJ: 10 TOP: Osteoarthritis
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
- What are the three vital functions muscles perform when they contract? (Select all that apply.)
| a. | Absorb uric acid |
| b. | Maintenance of posture |
| c. | Motion |
| d. | Store minerals |
| e. | Production of heat |
| f. | To assist in return of venous blood to the left side of the heart |
ANS: B, C, E
The three vital functions muscles perform when they contract are maintenance of posture, motion, and production of 85% of body heat.
DIF: Cognitive Level: Comprehension REF: Page 111 OBJ: 6
TOP: Functions of muscular system KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- Which instructions should the nurse include in a teaching plan for a person with gouty arthritis? (Select all that apply.)
| a. | Avoid excessive alcohol. |
| b. | Maintain rest and immobility while disease is symptomatic. |
| c. | Check urine and urine output for possible kidney stones. |
| d. | Include food high in purine in the diet. |
| e. | Use bed cradle to support linens. |
ANS: A, B, C, E
The person with gout should avoid alcohol and food with high purine content, maintain rest and immobility while symptomatic, and check urine and urine output for possible kidney stones.
DIF: Cognitive Level: Application REF: Page 129 OBJ: 8
TOP: Gout KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
COMPLETION
- The division of the skeletal system that comprises the skull, hyoid, vertebral column, and thorax is the _____________ division.
ANS:
axial
The axial division of the skeletal system is comprised of the skull, hyoid, vertebral column, and the throat.
DIF: Cognitive Level: Knowledge REF: Page 111 OBJ: 2
TOP: Skeletal divisions KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A patient’s patellar-femoral cartilage has deteriorated due to arthritis. The medial and lateral cartilage is undamaged. This patient is likely to undergo _________ knee replacement surgery.
ANS:
partial
unicompartmental
Unicompartmental knee arthroplasty is also referred to as partial knee replacement and is performed on patients who have only one of the compartments of the knee affected by arthritis.
DIF: Cognitive Level: Comprehension REF: Page 136 OBJ: 10
TOP: Partial knee replacement KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
- The emergency department nurse assesses the two cardinal signs of a hip fracture in a newly admitted patient, which are the___________ of the injured leg and the ______rotation of that same leg.
ANS:
shortening, external
The two cardinal signs of a fractured hip are the appearance of the shortening of the affected leg and the external rotation of that same leg.
DIF: Cognitive Level: Application REF: Page 141 OBJ: N/A
TOP: Signs of hip fracture KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- The nurse administering the drug colchicine for gout will give 0.5 mg hourly for _____ hours.
ANS:
12
Colchicine is given orally in a dose of 0.5 mg for a period of 12 hours or until relief from pain is achieved or diarrhea occurs.
DIF: Cognitive Level: Comprehension REF: Page 129 OBJ: 8
TOP: Colchicine KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- The nurse explains that the use of the _________brace allows a person with a cervical fracture to be mobile.
ANS:
halo
Halo braces attach to the skull with pins, which stabilize a cervical vertebral fracture, allowing the patient to be mobile.
DIF: Cognitive Level: Knowledge REF: Page 147, Figure 4-21
OBJ: 15 TOP: Halo brace KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
OTHER
- The nurse takes into consideration that a healing fracture progresses through several healing stages. Place the stages in order of healing. (Separate letters by a comma and space as follows: A, B, C, D)
- Development of fibrin meshwork
- Collagen fibers collect calcium
- Osteoblasts home fracture site form
- Callus
- Formation of hematoma
- Clot formation
- Vascularization
ANS:
F, E, A, C, G, B, D
The healing stages of a fracture start with a clot formation, which leads to a hematoma. The development of a fibrin meshwork, which traps osteoblasts to keep the fracture site firm, vascularization, collagen fibers collect calcium to make the callus.
DIF: Cognitive Level: Analysis REF: Page 146 OBJ: 15
TOP: Fracture healing KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
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