<P>

<Q>The
<TYPE>single</TYPE>
nurse prepares a client for a bone scan. What priority assessment should
the nurse perform
<MC1>History
<MC2>Presence
<MC3>Current
<MC4>Presence
<F>Rationale:
<CORRECT>2</CORRECT>
ofAofbone
vitalclaustrophobia</MC1>
intravenous
metallic
for
signs</MC3>
scan
thisinvolves
implants
client?</Q>
(IV) access</MC2>
such as a pacemaker
administering a radioisotope
or aneurysm
to visualize
clips</MC4>the
bone for diagnostic purposes. It is critical that the nurse ensure that the cli
ent has IV access for injection of the radioisotope prior to the procedure (opti
on 2). Claustrophobia (option 1) and metallic implants (option 4) are relevant f
or an MRI.
Cognitive
Client
Integrated
Content
Strategy:Need:
Area:
Level:
To
Vital
Process:
Physiological
answer
Adult
signs
Application
Nursing
Health:
thisarequestion
unrelated
Integrity:
Process:
Musculoskeletal
correctly,
toReduction
Implementation
the diagnostic
youofneed
Risktotests
Potential
know(option
that the3).bone scan
requires the administration of a radioisotope and how to prepare the client for
Reference:
this procedure.
LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p.retired
<Q>A
<TYPE>single</TYPE>
<P>
</P> 1387.</F> 66-year-old female client is being evaluated for osteoporosis as pa
rt of a yearly physical. The client states that she is a smoker, watches televis
ion for most of the day, and has been hospitalized with three different fracture
s within the last year. Based on this information, the nurse suspects which of t
he following?</Q>
<MC1>Low
<MC2>Degeneration
<MC3>Recurrent
<MC4>Personality
<F>Rationale:
<CORRECT>1</CORRECT>
bone Low mass
attacks
changes
ofleading
bonethemass,
ofcaused
articular
acute
tostructural
increased
arthritis</MC3>
by cartilage</MC2>
chronic bonenature
deterioration
fragility</MC1>
of illness</MC4>
of bone tissue leading to
bone fragility, and increased susceptibility to fractures is seen with osteoporo
sis. The client also has risk factors associated with osteoporosis: smoking, sed
entary lifestyle, and being female and postmenopausal (option 1). Degenerative c
hanges (option 2) are associated with frequent exacerbations (option 3) of arthr
itis. There
Cognitive
Client
Integrated
Content
Strategy:Need:
Area:
Level:
The
Process:
isPhysiological
Adult
stem
noApplication
indication
provides
NursingIntegrity:
Health: Process:
Musculoskeletal
the
of risk
a personality
Analysis
factors
Physiological
and
change
consequences
Adaptation
in this client
of osteoporosis.
(option 4).I
dentify theLeMone,
Reference: distracter P., &thatBurke,
reflects
K. (2008).
the pathophysiology
<i>Medical-surgical
of thenursing:
disease.Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. 1433-1434.</F>
<Q>Following
<TYPE>single</TYPE>
<P>
</P> laminectomy surgery, the nurse should turn and reposition the clien
t by doing which
<MC1>Having
<MC2>Elevating thethe client
ofhead
theusefollowing?</Q>
of the bed
side45railsdegrees,
of thethenbed.</MC1>
turning the legs together to
ward the floor, the
<MC3>Logrolling bending
clientat astheawaist.</MC2>
unit, keeping the body in proper alignment.</MC3
><MC4>Turning the
<F>Rationale:
<CORRECT>3</CORRECT>After
client's
laminectomy,
head anditshoulders
is critical thenthat
hips.</MC4>
proper body alignment is ma
intained to prevent postoperative complications such as neurological damage. Log
rolling technique ensures that the client turns as a unit (option 3). Using the
side rail (option 1), asking the client to bend at the waist (option 2), and tur
ning theNeed:
Cognitive
Client
Integrated
Content
Strategy: Area:
client
Level:
This
Process:
Physiological
Adult
item
inApplication
stages
Nursing
Health:
is testing
(option
Integrity:
Process:
Musculoskeletal
your4)knowledge
disrupt
Implementation
Reductionthe
ofofthe
alignment.
Risk
principles
Potentialof care followin
g spinal surgery. Select the distracter that allows the client to maintain stric
t body alignment.
Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 1609-1610.</F>
receives a client with a hip spica cast that is not completely dry.
When turning the client, the nurse uses the palms and not the fingertips. The n
urse chooses
<MC1>To
<MC2>To
<MC3>To
<MC4>To
<F>Rationale:
<CORRECT>3</CORRECT>
speed-dry
decrease
preventthis
Handling
damage
swelling</MC4>
pain
technique
the cast</MC1>
from
atocast
the
moving</MC2>
forthat
cast</MC3>
which
is not
of the
completely
followingdrypurposes?</Q>
with the fingertips cre
ates indentations in the cast that can create pressure points within the cast th
at predispose to breakdown beneath the cast (option 3). A wet cast should be exp
osed to air and allowed to dry slowly (option 1). How the cast is handled is unr
elated Need:
Cognitive
Client
Integrated
Content
Strategy:
toArea:
swelling
Level:
Recall
Process:
Physiological
Adult
Application
that
(option
Nursing
Health:
a fundamental
4)Musculoskeletal
Integrity:
Process:
or painprinciple
Implementation
associated
Reduction ofofcast
with
Riskcare
moving
Potential
is(option
to prevent
2). impairm
ent to the skin beneath the cast. Select the distracter that best adheres to thi
s principle.LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
Reference:
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>multi</TYPE>
<P>
</P> 1409-1410.</F>
is caring for a client with Buck's traction following a hip fractur
e. Identify the appropriate nursing interventions for this client. Select all th
at apply.</Q>weights
<MC1>Remove
<MC2>Maintain
<MC3>Administer
<MC4>Monitor
<MC5>Increase
<F>Rationale:
<CORRECT>[2,4,5]</CORRECT>
neurovascular
countertraction
fluid
Buck's
antispasmodics
prior
intake</MC5>
tractiontointegrity
lifting
(weight)
is
asaordered</MC3>
skin
theattraction
of the
client
allaffect
times</MC2>
upcommonly
in bed</MC1>
leg</MC4>used for hip fractures
to stabilize the fracture, reduce muscle spasm, and reduce pain until surgery i
s performed. It is essential that the weight not be removed (options 1 and 2) to
maintain bone alignment. Since it is commonly associated with a fracture, neuro
vascular integrity (option 3) must be evaluated regularly to assure no damage to
the vessels or nerves on the affected side. Antispasmodics (option 4) are not c
ommonly ordered because traction is applied short-term prior to taking the clien
t to surgery. Fluids should be increased (option 5) to prevent constipation and
renal calculi.
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
Focus
Process:
Physiological
Adult
onApplication
the
Nursing
Health:
current
Integrity:
Process:
Musculoskeletal
situationImplementation
Physiological
of the client.Adaptation
Select distracters that
maintain the traction and prevent complications of this type of therapy and the
immobility LeMone,
Reference: that accompanies
P., & Burke, the K.fracture
(2008).and<i>Medical-surgical
treatment. nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp.client
<Q>A
<TYPE>single</TYPE>
<P>
</P> 1408-1409.</F>
fractured his femur yesterday. Monitoring for which potential compli
cation must
<MC1>Crush
<MC2>Chronic
<MC3>Disturbed
<MC4>Fat
<F>Rationale:
<CORRECT>4</CORRECT>
emboli
injury</MC1>
bepain</MC2>
Fat
included
body
syndrome</MC4>
emboli
image</MC3>
bysyndrome
the nurse is ainpotential
the client'scomplication
plan of care?</Q>
of long bone fract
ures and occurs when fat globule leave the shaft of the long bone and enter the
circulation (option 4). There is no evidence that the client experienced soft in
jury at the time of the fracture (option 1). Once the bone is realigned, spasms
are relieved and bone is significantly relieved. Once the bone is healed, there
is no long-term pain (option 2). The fracture is temporary and unlikely to chang
e body Need:
Cognitive
Client
Integrated
Content
Strategy:
image
Area:
Level:
Identify
Process:
(option
Physiological
AdultAnalysis
the
Nursing
Health:
3),potential
andIntegrity:
Process:
Musculoskeletal
if itcomplications
does,
Analysis
Physiological
it is of
temporary
a long
Adaptation
and not
bone fracture.
the priority.
Select t
he distracter
Reference: LeMone,
that P.,is specifically
& Burke, K. (2008).
related <i>Medical-surgical
to this type of fracture.nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 1406.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse observes that an 18-year-old female client has asymmetry of the sho
ulders and hips, and the hem of her dress is uneven. The nurse suspects that the
<MC1>Congenital
<MC3>Fractured
<MC2>Scoliosis</MC2>
<MC4>Degenerative
<F>Rationale:
<CORRECT>2</CORRECT>
client may beAtibia</MC3>
presenting
hipdisc
classic
dislocation</MC1>
disease</MC4>
sign
withofwhich
scoliosis
of theisfollowing
asymmetrical
disorders?</Q>
dress or skirt hem cau
sed by unevenness of the affected shoulder and hip (option 2). The lateral curva
ture resulting from the spinal deformity causes the asymmetry. Congenital hip di
slocation is diagnosed during infancy (option 1). A fractured pelvis would cause
pain making ambulation difficult (option 3). Degenerative disc disease is typic
ally experienced by older adults and causes a uniform decline in height (option
Cognitive
4).
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
Identify
Process:
Health
AdultApplication
the
Promotion
Nursing
Health:
disorders
Process:
Musculoskeletal
andthat
Maintenance
Assessment
commonly present in adolescence. The quest
ion provides the presentation as one that reflects uneven hips and shoulders. Se
lect the distracter
Reference: LeMone, P., that& Burke,
meets these
K. (2008).
criteria.
<i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 1488.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse is caring for a client with skeletal traction. It is most important
<MC1>The
that thepinnurse
sitemonitor
for unusual
which redness,
of the following?</Q>
swelling, purulent drainage, and foul odo
<MC2>The the
r.</MC1>
<MC3>The
<MC4>How
<F>Rationale:
<CORRECT>1</CORRECT>
distance
numberclient
Theofpin
between
times
isincoping
the
skeletal
theclient
client's
with traction
immobilization.</MC4>
exercises
hip goes
andthe
the
directly
affected
traction.</MC2>
through
limb.</MC3>
the bone, makin
g infection and osteomyelitis a major complication of skeletal traction (option
1). The nurse must provide pin site care using aseptic technique to prevent infe
ction. Although the assessment items in options 2, 3, and 4 are appropriate, the
y are not
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
the
Level:
Review
Process:
Physiological
priority
AdultApplication
the Nursing
Health:
principles
in relation
Integrity:
Process:
Musculoskeletal
andtorisks
Planning
the of
Reduction
riskskeletal
ofofosteomyelitis.
Risktraction.
PotentialApply this infor
mation to each
Reference: LeMone,
of the P.,distracters
& Burke, K.to(2008).
select<i>Medical-surgical
the best response. nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 1408-1409.</F>
is discussing carpal tunnel syndrome with a client who is experienc
ing pain at night. Which of the following interventions might the nurse suggest?
<MC1>Take narcotic
</Q>
<MC2>Apply
<MC3>Exercise
<MC4>Surgery
<F>Rationale:
<CORRECT>2</CORRECT>
splint
must
the be
Carpalatanalgesic
handbedtime</MC2>
done
tunnel
andimmediately</MC4>
wrist
syndrome
before
regularly</MC3>
bed</MC1>
is a repetitive stress injury. The pain ass
ociated with carpal tunnel syndrome is caused by pressure on the radial nerve. S
plinting the joint relieves the pressure and the related pain (option 2). Nonste
roidal medications relieve the pain (option 1). Injection of steroids is tried b
efore surgery
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
This
Process:
Physiological
(option
Adult
itemApplication
Nursing
Health:
identifies
4). Exercise
Integrity:
Process:
Musculoskeletal
the symptom
mayAnalysis
Physiological
worsen
as occurring
the painAdaptation
(option
only at3).
night. Select th
e distracter that can be used locally at bedtime and would have no systemic effe
Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
cts.
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp.client
<Q>A
<TYPE>single</TYPE>
<P>
</P> 1427-1428.</F>
is admitted following a motor vehicle accident where his left thigh
was crushed beneath the vehicle. The nurse must assess for which of the followin
g complications?</Q>
<MC1>Acute
<MC4>Fat
<MC3>Hypotension</MC3>
<MC2>Hypokalemia</MC2>
<F>Rationale:
<CORRECT>1</CORRECT>
emboli
renal
A client
syndrome</MC4>
failure</MC1>
with a crush injury is at risk for muscle breakdown and r
elease of myoglobin into the circulation. This can result in acute tubular necro
sis and renal failure (option 1). This client is more likely to develop hyperkal
emia from cell destruction than hypokalemia (option 2). Hypotension is a risk if
the client begins to hemorrhage (option 3). Since there is no evidence of a fra
cture, Need:
Cognitive
Client
Integrated
Content
Strategy:
the
Area:
Level:
Identify
risk
Process:
Physiological
Adult
ofAnalysis
fat
the
Nursing
Health:
emboli
structures
Integrity:
Process:
Musculoskeletal
syndrome
thatAssessment
Physiological
is low
are damaged
(option
inAdaptation
a4).crush injury. Then selec
t the distracter
Reference: LeMone,that P.,reflects
& Burke,theK. (2008).
extent of<i>Medical-surgical
this injury. nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 902.</F>
</P>