Description
Adult Health Nursing 6th Edition By kockrow – Test Bank
Sample Questions
Instant Download With Answers
Christensen: Adult Health Nursing, 6th Edition
Chapter 02: Care of the Surgical Patient
Test Bank
MULTIPLE CHOICE
- The patient is 38 years old and is in her second postoperative day after placement of an intramedullary rod in her left femur. She is receiving analgesia via a patient-controlled analgesia (PCA) device. The inappropriate intervention related to caring for a patient with a PCA is:
| a. | Maintaining the system. |
| b. | Recording activations of the system. |
| c. | Administering the analgesia to the patient. |
| d. | Monitoring the patient’s pain. |
ANS: C
With the PCA system of medication administration, the patient can self-administer an analgesic by pressing a control button. The nurse should not give medication doses by pushing the control button.
DIF: Cognitive Level: Application REF: Page 50 OBJ: 13
TOP: Medication administration 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 18, Table 2-1
OBJ: 2 TOP: Types of surgery
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- The Patient’s Bill of Rights states that a patient must give his or her permission for any specific test or procedure to be performed. What is the legal term for this permission?
| a. | Verbal consent |
| b. | Medical documentation |
| c. | Informed consent |
| d. | Informed decision |
ANS: C
The Patient’s Bill of Rights affirms that the patients must give informed consent (permission obtained from the patient to perform a specific test or procedure) before the beginning of any procedure.
DIF: Cognitive Level: Knowledge REF: Page 24 OBJ: 6
TOP: Informed consent KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment
- An informed consent was to be obtained from the patient for his scheduled open cholecystectomy. Which circumstance could prevent the patient from signing his informed consent?
| a. | Pain radiating to the scapula |
| b. | An injection of Demerol, 75 mg IM, 1 hour ago |
| c. | The presence of jaundice and scleral icterus |
| d. | His concern over his insurance company not covering the procedure |
ANS: B
Informed consent should not be obtained if the patient is disoriented and under the influence of sedatives.
DIF: Cognitive Level: Application REF: Page 25 OBJ: 6
TOP: Informed consent KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
- The anesthesiologist provides ____ anesthesia by inhalation and IV administration routes.
| 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.
DIF: Cognitive Level: Knowledge REF: Page 37 OBJ: 11
TOP: Anesthesia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- A type of anesthesia that requires a depressed level of consciousness is
| a. | regional anesthesia. |
| b. | specific anesthesia. |
| c. | optional sedation. |
| d. | conscious sedation. |
ANS: D
Conscious sedation is routinely used for procedures that do not require complete anesthesia but rather a depressed level of consciousness.
DIF: Cognitive Level: Knowledge REF: Page 40 OBJ: 12
TOP: Conscious sedation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- The older adult patient may not respond to surgical treatment as well as a younger adult because of
| a. | poor skin turgor resulting in dehydration. |
| b. | disturbed body image related to surgical incision. |
| c. | his or her body’s response to physiological changes. |
| d. | decreased peristalsis related to general anesthesia. |
ANS: C
Of specific concern in older adults is the body’s response to temperature changes, cardiovascular shifts, respiratory needs, and renal function.
DIF: Cognitive Level: Analysis REF: Page 20 OBJ: 7
TOP: Older adult patient KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- A 45-year-old patient has had a repair of a cerebral aneurysm and is presenting signs of increased intracranial pressure (ICP). Which postoperative nursing interventions would be contraindicated?
| a. | Coughing every 2 hours |
| b. | Leg exercises 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 32, Box 2-6
OBJ: 5 TOP: Postoperative complications
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A male patient, age 80, has had a total hip replacement. Anxiety, hypotension, and jarring during transfer from the recovery room to his room can cause a postoperative increase in which of his vital signs?
| a. | Pulse rate |
| b. | Temperature |
| c. | Blood pressure |
| d. | Pain |
ANS: A
An increase in pulse rate is an objective, detectable sign that the body is responding to “pain.” Other objective changes include a decrease in blood pressure in the immediate postoperative period, restlessness, diaphoresis, and pallor.
DIF: Cognitive Level: Analysis REF: Page 48, Box 2-8
OBJ: 10 TOP: Postoperative complications
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- A patient, age 65, underwent a right hemicolectomy. On postoperative day 4, her surgical wound dehisced. This means that
| a. | there is partial or complete wound separation. |
| b. | there has been inadequate wound closure. |
| c. | abdominal viscera protrude through the walls. |
| d. | the wound will not heal well when it is resutured. |
ANS: A
A surgical incision may separate; this action of dehiscence (the separation of a surgical incision or rupture of a wound closure) may occur within 3 days to over 2 weeks postoperatively.
DIF: Cognitive Level: Knowledge REF: Page 48, Figure 2-15
OBJ: 1 TOP: Postoperative complications
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- A patient is on postoperative day 2 after a nephrectomy. The nurse is aware that the most effective way to increase her peristalsis is
| 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: Application REF: Page 52, Box 2-10
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. |
| b. | Check airway for patency. |
| c. | Check intravenous site. |
| d. | Check vital signs. |
ANS: B
Evaluation of the patient follows the ABCs of immediate postoperative observation: airway, breathing, consciousness, and circulation.
DIF: Cognitive Level: Application REF: Page 45, Table 2-6
OBJ: 12 TOP: Nursing assessment
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
- Frequent assessment of a postoperative patient is essential. One of the first signs and symptoms of hemorrhage may be
| 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 48 OBJ: 10
TOP: Postoperative complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- Frequent monitoring of the postoperative patient’s vital signs assesses which body system?
| a. | Gastrointestinal |
| b. | Endocrine |
| c. | Neurological |
| d. | Cardiovascular |
ANS: D
Hypotension and cardiac dysrhythmias are the most common cardiovascular complications of the surgical patient, and early recognition and management of these complications before they become serious enough to diminish cardiac output depend on frequent assessment of the patient’s vital signs.
DIF: Cognitive Level: Comprehension REF: Pages 35, 51, Table 2-4
OBJ: 14 TOP: Postoperative patient
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
- Decreased activity in an obese surgical patient predisposes the patient to which complication?
| a. | Cardiac arrest |
| b. | Pneumonia |
| c. | Incisional hernias |
| d. | Hypoventilation |
ANS: D
Immediate postoperative hypoventilation can result from drugs (anesthetics, narcotics, tranquilizers, sedatives) incisional pain, obesity, chronic lung disease, or pressure on the diaphragm.
DIF: Cognitive Level: Analysis REF: Page 48 OBJ: 13
TOP: Postoperative complications KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
- The nurse acknowledges that all preoperative nursing interventions have been performed by signing which document?
| a. | Nurse’s notes |
| b. | Anesthesia record |
| c. | Preoperative checklist |
| d. | Physician’s order sheet |
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 41, Figure 2-10
OBJ: 9 TOP: Preoperative checklist
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
- Which nursing interventions would be appropriate after a wound evisceration?
| a. | Place the patient in 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: Page 48, Figure 2-15
OBJ: 13 TOP: Postoperative interventions
KEY: Nursing Process Step: Planning 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. | Regularly every three to four hours before pain gets severe. |
| c. | Only when the physician orders. |
| d. | Only when the patient is in severe pain. |
ANS: B
The nurse should ask the patient every 3-4 hours if something is needed for pain because some patients will not ask for an analgesic.
DIF: Cognitive Level: Application REF: Page 49 OBJ: 10
TOP: Medication administration KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
- What nursing interventions will minimize the effects of venous stasis?
| a. | Pillows under the knee in a position of comfort |
| b. | Sitting with the feet flat on the floor |
| c. | Early ambulation |
| d. | 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 52, Box 2-10
OBJ: 13 TOP: Interventions
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
- Serum potassium levels are usually determined before surgery to
| a. | assess kidney function. |
| b. | determine respiratory insufficiency. |
| c. | prevent dysrhythmias 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, dysrhythmias can occur during anesthesia.
DIF: Cognitive Level: Analysis REF: Page 24 OBJ: 9
TOP: Preoperative assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- The nurse is assisting with the sponge and instrument count in the operating room. The operative phase in which the nurse is assisting is called the
| a. | perioperative phase. |
| b. | preoperative phase. |
| c. | intraoperative phase. |
| d. | postoperative phase. |
ANS: C
Counting of sponges, needles, and instruments with the scrub nurse before surgery and before closing the wound is done during the intraoperative phase of the surgery.
DIF: Cognitive Level: Knowledge REF: Page 24, Box 2-7
OBJ: 8 TOP: Intraoperative responsibilities
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
- Which early postoperative observation is abnormal and should be reported immediately?
| a. | Emesis that is red |
| b. | Complaint of feeling cold |
| c. | Nausea |
| d. | Complaint of pain |
ANS: A
Any emesis that is red should be reported immediately.
DIF: Cognitive Level: Analysis REF: Page 46, Box 2-7
OBJ: 10 TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- Sudden chest pain combined with dyspnea, cyanosis, and tachycardia is an indication 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 49 OBJ: 13
TOP: Assessment and postoperative complications
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- An appendectomy during a hysterectomy would be 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 18, Table 2-1
OBJ: 2 TOP: Types of surgery
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
- Which patients would be at greatest risk during surgery?
| a. | 78-year-old taking an analgesic agent |
| b. | 43-year-old taking an antihypertensive agent |
| c. | 27-year-old taking an anticoagulant agent |
| d. | 10-year-old taking an 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 21, Box 2-3, Table 2-5
OBJ: 4 TOP: Individual’s ability to tolerate surgery
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
- A patient will have an incision in the lower left abdomen. Which intervention by the nurse will help decrease discomfort in the incisional area when she coughs postoperatively?
| a. | Apply a splint directly over the lower abdomen. |
| b. | Keep the patient flat with feet flexed. |
| c. | Turn her on her right side. |
| d. | Apply a splint above and below the incision. |
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: Pages 31-32, Skill 2-4 Step 10, NCP 2-1
OBJ: 14 TOP: Postoperative nursing interventions
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
- Although informed about the proposed surgical procedure, the patient has only vague responses about the postoperative period. A nursing diagnosis at this time would be
| a. | Impaired verbal communication. |
| b. | Impaired gas exchange. |
| c. | Deficient knowledge, postoperative. |
| d. | Acute pain. |
ANS: C
Knowledge, deficient regarding implications of surgery related to information misinterpretation is a correct nursing diagnosis.
DIF: Cognitive Level: Analysis REF: Page 20, Box 2-11
OBJ: 14 TOP: Nursing process/diagnosis
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment
- A patient and a nurse develop a preoperative teaching plan. In teaching the patient to cough effectively after surgery, the nurse should tell her to practice
| a. | breathing through her nose, holding her breath, and exhaling slowly. |
| b. | taking three deep breaths and coughing from the chest. |
| c. | inhaling while contracting the abdominal muscles and exhaling while contracting the diaphragm. |
| d. | taking short, frequent panting breaths and coughing 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 able to adequately remove trapped mucus and surgical gases.
DIF: Cognitive Level: Application REF: Pages 29-30, Skills 2-2, 2-3
OBJ: 13 TOP: Prevention of postoperative complications
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- What is the responsibility of the nurse regarding informed consent?
| a. | Explain the surgical options. |
| b. | Explain the operative risks. |
| c. | Obtain the patient’s signature. |
| d. | Check form for appropriate signatures. |
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 25 OBJ: 6
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 performs an abdominal assessment. To assess bowel sounds, the nurse auscultates the lower abdomen for
| a. | 1 minute. |
| b. | 5 to 20 seconds. |
| c. | as long as it takes to hear a bowel sound. |
| d. | one full inspiration and expiration. |
ANS: A
Normal peristalsis is gauged by hearing 5 to 30 gurgles per minute.
DIF: Cognitive Level: Knowledge REF: Page 52, Box 2-10
OBJ: 10 TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- Which preoperative fear is linked to postoperative behavior?
| a. | Fear of anesthesia and death |
| b. | Fear of death and malnutrition |
| c. | Fear of unknown and lack of respect |
| d. | Fear of malnutrition and addiction to new medications |
ANS: A
The preoperative anxiety level influences the amount of anesthesia required, the amount of postoperative pain medication needed, and the speed of recovery from surgery.
DIF: Cognitive Level: Assessment REF: Pages 20, 24, Box 2-4
OBJ: 4 TOP: Nursing diagnosis
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
- Ideally, preop teaching should be done
| 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
Preop teaching is provided 1 to 2 days prior to surgery when anxiety is low.
DIF: Cognitive Level: Implementation REF: Page 24 OBJ: 8
TOP: Nursing diagnosis KEY: Nursing Process Step: Assessment
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 43 OBJ: 13
TOP: Nursing diagnosis KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
- Southeast Asian and Native American patients often do not make eye contact when preoperative teaching is being performed because
| a. | they aren’t educated. |
| b. | they aren’t paying attention. |
| c. | they believe eye contact is disrespectful. |
| d. | they believe they are superior to the nurse. |
ANS: C
Southeast Asians and Native Americans may believe eye contact is disrespectful.
DIF: Cognitive Level: Application REF: Page 22, Cultural Considerations box
OBJ: N/A TOP: Nursing diagnosis
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
- What are the high-risk conditions that may affect perioperative procedures? (Select all that apply):
| a. | Age, health, occupation, mental status |
| b. | Financial income, health, nutritional status |
| c. | Age, mental state, nutritional status, health |
| d. | Occupation, age, nutritional status, health |
| e. | Financial Income, occupation, age, health |
ANS: C
Each system of the body is affected by the patient’s age, health, nutritional status, and mental state.
DIF: Cognitive Level: Assessment REF: Page 24 OBJ: 4
TOP: Nursing diagnosis KEY: Nursing Process Step: Assessment
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 56, Box 2-13
OBJ: 13 TOP: Discharge instructions
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment
- Two considerations for the older adult surgical patient include (Select the two that apply.)
| a. | pre- and postoperative teaching. |
| b. | lower morbidity and mortality. |
| c. | quick assessment skills. |
| d. | surgery causes much physiological stress. |
ANS: A, D
Surgery places greater stress on older than on younger patients. Teaching should be given at the older person’s level of understanding.
DIF: Cognitive Level: Application REF: Page 20, Life Span Considerations box
OBJ: 7 TOP: Older adult considerations
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
- In preparing the patient for abdominal surgery, the Assistive Personnel (AP) can perform which interventions? (Select all that apply.)
| a. | Vital signs |
| b. | Insertion of N/G tube |
| c. | Enema |
| d. | Height and weight |
| e. | Obtain operative consent |
| f. | Sterile gowning |
ANS: A, C, D
The AP can perform vital signs, enema, and height and weight.
DIF: Cognitive Level: Application REF: Page 38 OBJ: 16
TOP: Nursing diagnosis 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 18, Table 2-1
OBJ: 1 TOP: Palliative therapy
KEY: Nursing Process Step: Assessment MSC: NCLEX: Comprehension
- Discharge planning for a surgical procedure begins in the ______________ period and continues through the _____________ period.
ANS:
preoperative, recuperative
Discharge planning for a surgical procedure begins in the preoperative and continues through the recuperative period.
DIF: Cognitive Level: Knowledge REF: Page 55 OBJ: 15
TOP: Nursing diagnosis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
- 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. Place a comma between each answer choice (a, b, c, d, etc.).
| a. | System review |
| b. | Breathing |
| c. | Circulation |
| d. | Airway |
| e. | Level of consciousness |
ANS: D, B, E, C, A
DIF: Cognitive Level: Application REF: Page 45, Table 2-6
OBJ: 12 TOP: Nursing assessment
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
Christensen: Adult Health Nursing, 6th Edition
Chapter 04: Care of the Patient with a Musculoskeletal Disorder
Test Bank
MULTIPLE CHOICE
- The movement of an extremity away from the midline of the body is 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 113, Box 4-2
OBJ: 6 TOP: Movements KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- 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 is
| 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 112, Table 4-1, Figure 4-5
OBJ: 5 TOP: Muscle functions
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- Which diagnostic exam is used to find pathological abnormalities of the brain?
| a. | CT scan |
| b. | Nuclear medicine scan |
| c. | MRI |
| d. | Radiograph |
ANS: C
Magnetic resonance imaging (MRI) is used to detect pathological conditions of the cerebrum and spinal cord.
DIF: Cognitive Level: Knowledge REF: Page 115 OBJ: 9
TOP: Diagnostic examinations KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- The term unicompartmental knee arthroplasty is also referred to as
| a. | partial knee replacement. |
| b. | removal of the kneecap. |
| c. | total knee replacement. |
| d. | total knee replacement bilaterally. |
ANS: A
Unicompartmental knee arthroplasty is also referred to as partial knee replacement.
DIF: Cognitive Level: Knowledge REF: Pages 133, 172
OBJ: 15 TOP: Knee replacement
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- A patient, age 89, has had a right below-the-knee amputation. He is progressing well but continues to complain of pain in the toes on his right foot. The physician told him that he is suffering from “phantom pain” in his amputated extremity. He asks the nurse to explain phantom pain. The most appropriate response would be
| a. | “Phantom pain does not exist except in your mind.” |
| b. | “I can’t answer that. You’ll have to ask the physician.” |
| c. | “Phantom pain occurs because the nerve tracts that register pain in the amputated limb continue to send a message to the brain.” |
| d. | “Phantom pain occurs when you start thinking about your loss. It’s best to keep your mind occupied with other things.” |
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: Pages 168-169
OBJ: 21 TOP: Amputation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A patient, age 79, fell at home and suffered an intracapsular fracture of his left hip. The orthopedic surgeon inserted a prosthetic implant for a bipolar hip replacement. The physician has instructed the nurse to turn him every 2 hours. The nurse understands that the correct nursing intervention is to keep the legs
| a. | together so they don’t separate while turning. |
| b. | from rubbing together. |
| c. | abducted so the prosthesis does not become dislocated. |
| d. | abducted 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: Pages 139, 142 Patient Teaching box, Figure 4-15 OBJ: 16
TOP: Fractured hip KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A patient, age 24, has a compartment syndrome after a fracture of his radius and ulna. Nursing assessment will include careful observation for signs and symptoms of
| a. | buccal petechiae. |
| b. | thromboembolism. |
| c. | Volkmann’s contracture. |
| d. | fat embolism. |
ANS: C
Volkmann’s contracture is a permanent contracture that can occur as a result of circulatory obstruction secondary to compartment syndrome.
DIF: Cognitive Level: Analysis REF: Page 149, Figure 4-27
OBJ: 19 TOP: Compartment syndrome
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- A patient fell 2 days ago; he has a compound fracture of his left tibia. The physician performed an open reduction with internal fixation (ORIF) to treat the fracture. An important nursing assessment for him would include
| a. | hyperactive bowel sounds. |
| b. | elevated temperature and presence of erythema at incision site. |
| c. | ecchymosis and edema at incision site. |
| d. | complaints of activity intolerance. |
ANS: B
Collection of objective data includes careful inspection of any wounds. The drainage is assessed for color, amount, and presence of odor. Vital signs are assessed for signs of infection (temperature elevation, tachycardia, and tachypnea).
DIF: Cognitive Level: Analysis REF: Page 131 OBJ: 10
TOP: Compound fracture KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- A patient, age 24, is recovering from a fractured tibia. She has been wearing a leg cast for the past month to immobilize the fracture and promote proper alignment. She is being seen at the clinic for follow-up radiographic evaluation of the fracture. The physician tells her that he is hoping for good callus formation to have occurred. When she 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 build-up and osteoclasts destroy dead bone.
DIF: Cognitive Level: Analysis REF: Page 144 OBJ: 18
TOP: Bone healing KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A patient, age 45, has worked as a basket weaver for the past 10 years. She is being seen at the clinic for symptoms of carpal tunnel syndrome. Collection of subjective data might include
| a. | complaints of burning pain or tingling in the hands. |
| b. | edema of the fingers. |
| c. | radicular pain. |
| d. | complaints of weight loss and fatigue. |
ANS: A
Collection of subjective data includes the patient’s description of discomfort, such as burning pain or tingling in the hands and numbness of thumb, index, and ring fingers.
DIF: Cognitive Level: Comprehension REF: Page 163, Figure 4-38
OBJ: 10 TOP: Carpal tunnel syndrome
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- A patient, age 24, had a traumatic amputation of his left foot in a motorcycle accident. He is receiving morphine by a patient-controlled analgesia (PCA) device. He complains of a burning sensation in his left foot. The nurse should explain that
| a. | this is a phantom pain and that its cause is not clearly understood. |
| b. | this is not possible because his foot was amputated. |
| c. | his regular pain medication will relieve the pain. |
| d. | this phantom pain will disappear in about 1 week. |
ANS: A
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 continued to send a message to the brain (this is normal).
DIF: Cognitive Level: Analysis REF: Page 168 OBJ: 23
TOP: Phantom pain KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A patient, age 28, has a fractured tibia and fibula. The nurse is performing an assessment of her extremities. The purpose of assessing capillary filling or performing a blanching test is to assess for adequate
| a. | arterial peripheral circulation. |
| b. | cardiac output. |
| c. | venous peripheral circulation. |
| d. | nutritional deficiency. |
ANS: A
The blanching test measures the rate of capillary refill, which signals circulation status.
DIF: Cognitive Level: Application REF: Pages 153, 170
OBJ: 10 TOP: Fractures KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- A patient has sustained a fractured femur in a car accident. The physician has stated concern about the possibility of a fat embolism. The patient’s wife asks the nurse about the cause of a fat embolism. The nurse’s most appropriate response would be
| a. | “Arterial blood flow is interrupted at the site of injury.” |
| b. | “Floating fat sometimes causes problems.” |
| c. | “The break in the bone forces molecules of fat into the bloodstream.” |
| d. | “We don’t know the cause. We just know that it sometimes happens.” |
ANS: C
Pulmonary fat embolism involves the embolization of fat tissue with platelets and circulation of free fatty acids within the pulmonary circulation.
DIF: Cognitive Level: Application REF: Page 150 OBJ: 20
TOP: Fat embolism KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- The first priority nursing intervention for an impending fat embolism is to administer
| a. | oxygen in a respiratory emergency. |
| b. | intravenous fluids in hypovolemic emergency. |
| c. | Lasix IV for fluid overload. |
| d. | blood therapy in a cardiac emergency. |
ANS: A
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 150 OBJ: 20
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 is applied. This is called a
| a. | Thomas splint. |
| b. | Bryant’s traction. |
| c. | Russell’s traction |
| d. | Buck’s traction. |
ANS: D
Buck’s 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 139, Figure 4-32
OBJ: 21 TOP: Fracture KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A patient, age 18, has multiple soft tissue injuries from a bicycle accident. Primary medical management for soft tissue injuries includes
| a. | rest and heat to control edema. |
| b. | elevation and ice to control edema. |
| c. | immediate immobilization to halt pain. |
| d. | aspiration of excessive fluid. |
ANS: B
Contusions are the most common soft tissue injury. Most contusions are treated by applying ice bags or cold compresses.
DIF: Cognitive Level: Application REF: Page 160 OBJ: 10
TOP: Soft tissue injury KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
- The patient who undergoes total hip replacement may be prescribed prophylactic drugs such as heparin or warfarin (Coumadin). The rationale for this is that it
| a. | decreases the risk of thrombus formation. |
| b. | decreases the risk of hemorrhage. |
| c. | facilitates the wound-healing process. |
| d. | decreases the risk of systemic infection. |
ANS: A
Treatment will include administration of anticoagulants, such as heparin or warfarin (Coumadin), which decreases the risk of deep vein thrombus.
DIF: Cognitive Level: Analysis REF: Page 151 OBJ: 16
TOP: Medication KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- The patient has been diagnosed as having gouty arthritis. He asks the nurse to explain the cause of the inflammation of his great toe. The most appropriate nursing response is
| 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 127 OBJ: 11
TOP: Gouty arthritis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- Which nursing intervention would be appropriate for a patient with rheumatoid arthritis?
| a. | Sleeping at least 8 hours at night and a nap during the day |
| b. | Sleeping at 4-hour intervals at night |
| c. | No exercise regimen and apply ice to joints as needed |
| d. | Jogging at least 20 minutes three days a week |
ANS: A
Rest is important because fatigue is a major problem. Sleeping 8 to 10 hours a night and taking a 2-hour nap during the day are recommended.
DIF: Cognitive Level: Application REF: Page 123 OBJ: 12
TOP: Rheumatoid arthritis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- When caring for a patient who is 34 years old and has rheumatoid arthritis, the nurse should remember that
| a. | exercise should be avoided to decrease pain. |
| b. | the patient should be discouraged from performing activities of daily living. |
| c. | rest and exercise are both important parts of therapy. |
| d. | pain is best controlled by use of narcotic analgesics. |
ANS: C
Rest is important because fatigue is a major problem. Exercise helps prevent the joints from “freezing” and the muscles from weakening.
DIF: Cognitive Level: Comprehension REF: Page 123 OBJ: 11
TOP: Rheumatoid arthritis KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
- A 71-year-old patient is manifesting signs and symptoms of gout. When assessing him for signs and symptoms of gout, the nurse should pay particular attention to
| a. | dietary intake of foods high in cholesterol. |
| b. | mobility in the hip and knee joints. |
| c. | edema or discoloration of the great toe. |
| d. | a history of trauma or occupational injury. |
ANS: C
Tophi (calculi containing sodium urate deposits that develop in periarticular fibrous tissue, typically in patients with gout) result in inflammation of the joint; it is unclear why this occurs. Typically the big toes are involved, but other joints can also be affected. Particular attention should be paid to foods high in purines.
DIF: Cognitive Level: Analysis REF: Page 127 OBJ: 11
TOP: Gout KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- A patient, age 44, has chronic osteomyelitis. He should be taught to
| a. | take antibiotics prophylactically. |
| b. | avoid trauma to the affected bone. |
| c. | decrease activity levels. |
| d. | increase dietary intake of calcium and vitamin D. |
ANS: B
The patient must avoid trauma to the affected bone because pathological fracture is common.
DIF: Cognitive Level: Application REF: Page 131 OBJ: 14
TOP: Osteomyelitis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- The patient is a 20-year-old who has suffered a compound fracture of the femur. The nurse would expect the physician to order ____ intramuscularly.
| a. | tetanus toxoid |
| b. | morphine gluconate |
| c. | low-molecular–weight heparin |
| d. | calcium gluconate |
ANS: A
Administration of tetanus toxoid is an additional medical measure for compound fracture of the femur.
DIF: Cognitive Level: Application REF: Page 145 OBJ: 18
TOP: Fracture KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- A patient, age 72, has a left intertrochanteric fracture as a result of a fall. In planning ways to increase her safety, the nurse realizes it is most important to determine
| a. | preexisting health conditions. |
| b. | nutritional status. |
| c. | psychosocial history. |
| d. | pain level. |
ANS: A
The patient’s medical and surgical history is significant, as well as any family history of bone disease. Although pain level, nutritional status, and psychosocial history are important, they are not the most important.
DIF: Cognitive Level: Analysis REF: Page 138 OBJ: 17
TOP: Fracture of the hip KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- A patient has undergone a bipolar hip repair (hemiarthroplasty). She should be instructed to
| a. | sit in whatever position is most comfortable. |
| b. | sit in a firm, straight-backed chair at a 90-degree angle. |
| c. | avoid crossing her 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 139 OBJ: 17
TOP: Fracture of the hip KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A patient, age 64, has osteoarthritis of the left hip. He has had a left total hip replacement. The nurse should
| a. | encourage use of the high Fowler’s position. |
| b. | administer oxygen through a nasal cannula. |
| c. | encourage use of an incentive spirometer. |
| d. | turn the patient frequently from side to side. |
ANS: C
The use of incentive spirometers is valuable in assisting the patient to perform adequate respiratory ventilation to prevent pneumonia.
DIF: Cognitive Level: Analysis REF: Page 134 OBJ: 17
TOP: Total hip replacement KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A 28-year-old male patient has a fractured left humerus. He has a cast on his arm. The nurse observes pallor, coolness, and a decrease in capillary refill time to his left hand and fingers. These observations are likely to indicate
| a. | compartment syndrome. |
| b. | early infection. |
| c. | hemorrhage. |
| d. | shock. |
ANS: A
Collection of objective data involves assessment of the patient’s ability to flex the fingers or toes, coolness of the extremity, and absence of pulse in the affected extremity all of which indicate the impaired circulation symptomatic of compartment syndrome. Assessment of skin color for signs of pallor or cyanosis is made.
DIF: Cognitive Level: Analysis REF: Page 148, Figure 4-26
OBJ: 19 TOP: Fracture KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- A patient, age 45, has had a left intramedullary rod placed into his left femur. He is presenting with signs and symptoms of postoperative shock. The recommended position for a person going into shock is
| a. | semi-Fowler’s. |
| b. | supine. |
| c. | Fowler’s |
| d. | Trendelenburg. |
ANS: B
The patient should remain flat in bed. Avoid the Trendelenburg position because it pushes the abdominal organs against the diaphragm, affecting the lung and heart.
DIF: Cognitive Level: Analysis REF: Page 149, Figure 4-27
OBJ: 17 TOP: Fracture of the femur
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- When caring for the patient who is in shock, the nurse should provide
| a. | adequate oral fluids to replace blood loss. |
| b. | external heat to combat shivering. |
| c. | sedatives to decrease anxiety and apprehension. |
| d. | oxygen to support respiratory function. |
ANS: D
Respiratory assistance may be given by administering oxygen. IV fluids are required for rapid access to blood volume. Shock causes altered level of consciousness and does not require medication to decrease anxiety or apprehension.
DIF: Cognitive Level: Application REF: Page 149 OBJ: 17
TOP: Shock 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. This condition is 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 thoracic spine.
DIF: Cognitive Level: Knowledge REF: Page 149 OBJ: 8
TOP: Lordosis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- Rheumatoid arthritis is distinguished from osteoarthritis in that:
| 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: Pages 117-119, Table 4-4, Figure 4-7
OBJ: 11 TOP: Rheumatoid arthritis
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- Which ethnic group is at a highest risk of developing osteoporosis?
| a. | African American women |
| b. | Caucasian and Asian women |
| c. | African American men |
| d. | Latino women |
ANS: B
Caucasian and Asian women have a higher incidence of osteoporosis than African American women or Hispanic women.
DIF: Cognitive Level: Knowledge REF: Page 128, Cultural Considerations box
OBJ: 14 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: Pages 129-130, Patient Teaching box
OBJ: 14 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 127 OBJ: 8
TOP: Gout KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- The immediate medical management of any fracture is:
| a. | Observe patient for signs of shock. |
| b. | Administer analgesics for pain. |
| c. | Splint and elevate the involved part. |
| d. | Apply heat to control pain. |
ANS: C
Immediate management includes splinting and elevation of the involved part to prevent edema. After the immediate management, analgesic for pain, application of cold to prevent edema, and observing for signs of shock must be part of the plan of care.
DIF: Cognitive Level: Comprehension REF: Page 145 OBJ: 15
TOP: Contact dermatitis 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. The following are high in calcium:
| a. | Oranges, yogurt |
| b. | Oranges, bananas |
| c. | Broccoli, yogurt |
| d. | Skim milk, eggs |
ANS: C
Fresh oranges, bananas, and eggs are not good calcium choices. Broccoli and green vegetables, as well as yogurt, are considered calcium-rich foods.
DIF: Cognitive Level: Analysis REF: Page 160 OBJ: 11
TOP: Osteoporosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A 76-year-old female patient is being seen for osteoarthritis of the knee in the clinic. In discussing strengthening exercises, which exercises would you recommend?
| a. | Jogging |
| b. | Climbing stairs 2 to 3 times daily |
| c. | Bicycling for short distances |
| d. | Walking up and down small elevations |
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 125, Box 4-3
OBJ: 11 TOP: Osteoarthritis
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- Prolonged bed rest puts the older adult at risk for
| a. | ankylosing spondylitis. |
| b. | pathological 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 pathological fracture. This is a serious concern for an older adult in terms of regaining mobility.
DIF: Cognitive Level: Analysis REF: Pages 117-119, Table 4-4, Figure 4-7
OBJ: 15 TOP: Disorders of the musculoskeletal system
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
COMPLETION
- In gangrene, there is an acute infection to the skeletal muscle. If untreated, _________ will destroy the tissue.
ANS:
exotoxins
These injuries can produce exotoxins that destroy tissue. The onset is usually sudden and may occur 1 to 14 days after injury. These organisms are anaerobic (grow and function without oxygen) and are spore-formers.
DIF: Cognitive Level: Knowledge REF: Page 150 OBJ: N/A
TOP: Gangrene KEY: Nursing Process Step: Assessment
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: Knowledge REF: Pages 133, 172
OBJ: 15 TOP: Partial knee replacement
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- A female patient has been diagnosed with a pelvic fracture that she sustained during a fall. The physician has ordered strict bed rest for this patient. The patient is crying and states, “I’m not used to lying in bed all day. I have many things I need to do at home.” An appropriate nursing diagnosis for this patient would be ____________ related to decreased mobility.
ANS:
powerlessness
Strict bed rest can cause a normally active person to feel powerless because she is unable to carry out her daily activities.
DIF: Cognitive Level: Application REF: Page 146 OBJ: N/A
TOP: Nursing diagnosis KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity
- __________ traction is utilized to provide support for the patient with a hip fracture.
ANS:
Buck’s
This traction is frequently used to maintain the reduction of a hip fracture before surgery.
DIF: Cognitive Level: Knowledge REF: Pages 139, 156-157, Figure 4-32
OBJ: 21 TOP: Buck’s traction
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- Among the most common fractures in older women are _______fractures.
ANS:
hip
Hip fractures or compression fractures of the spine. Changes in bone mass place older women at risk for hip fractures.
DIF: Cognitive Level: Knowledge REF: Page 137 OBJ: 15
TOP: Fractures KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
- The main purpose of traction is to (Select all that are correct)
| 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: Analysis REF: Page 156 OBJ: N/A
TOP: Traction KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- Which of the significant neurovascular impairment symptoms, following a musculoskeletal trauma, should be reported to the physician? (Select all that apply.)
| a. | Extremity feels warm to touch |
| b. | Slow capillary refill |
| c. | Diminished or absent pulses, |
| d. | Extremity pink in color |
| e. | +1 edema of extremity |
| f. | Unrelieved pain after administration of pain medication |
ANS: B, C, F
Assessments of slow capillary refill, diminished or absent pulses, and unrelieved pain after administration of pain medication are complications needing immediate attention. The physician should be notified. The extremity should be warm to touch, pink in color, and may have a slight edema.
DIF: Cognitive Level: Analysis REF: Page 135, 139
OBJ: 11 TOP: Fractures KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- The three vital functions muscles perform when they contract are: (Select all that apply.)
| a. | To allow for accumulation of uric acid in blood |
| b. | Maintenance of posture |
| c. | Motion |
| d. | To serve as a storage area for various 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 110 OBJ: 6
TOP: Functions of muscular system KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
Reviews
There are no reviews yet.