Ch. 49 Flashcards
A client is having a myelography. What action by the nurse is most important?
a.
Assess serum aspartate aminotransferase (AST) levels.
b.
Ensure that informed consent is on the chart.
c.
Position the client flat after the procedure.
d.
Reinforce the dressing if it becomes saturated.
ANS: B
This diagnostic procedure is invasive and requires informed consent. The AST does not need to be assessed prior to the procedure. The client is positioned with the head of the bed elevated after the test to keep the contrast material out of the brain. The dressing should not become saturated; if it does, the nurse calls the provider.
DIF: Applying/Application REF: 1025
A client is undergoing computed tomography (CT) of a joint. What action by the nurse is most important before the test?
a.
Administer sedation as prescribed.
b.
Assess for seafood or iodine allergy.
c.
Ensure that the client has no metal on the body.
d.
Provide preprocedure pain medication.
ANS: B
Because CT uses iodine-based contrast material, the nurse assesses the client for allergies to iodine or seafood (which often contains iodine). The other actions are not needed.
DIF: Applying/Application REF: 1028
A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to be pale and cool, with 1+/4+ pedal pulses. What action by the nurse is best?
a.
Assess the neurovascular status of the right leg.
b.
Document the findings in the client’s chart.
c.
Elevate the left leg on at least two pillows.
d.
Notify the provider of the findings immediately.
ANS: A
The nurse should compare findings of the two legs as these findings may be normal for the client. If a difference is observed, the nurse notifies the provider. Documentation should occur after the nurse has all the data. Elevating the left leg will not improve perfusion if there is a problem.
DIF: Applying/Application REF: 1027
A hospitalized client’s strength of the upper extremities is rated at 3. What does the nurse understand about this client’s ability to perform activities of daily living (ADLs)?
a.
The client is able to perform ADLs but not lift some items.
b.
No difficulties are expected with ADLs.
c.
The client is unable to perform ADLs alone.
d.
The client would need near-total assistance with ADLs.
ANS: A
This rating indicates fair muscle strength with full range of motion against gravity but not resistance. The client could complete ADLs independently unless they required lifting objects.
DIF: Understanding/Comprehension REF: 1024
A client is distressed at body changes related to kyphosis. What response by the nurse is best?
a.
Ask the client to explain more about these feelings.
b.
Explain that these changes are irreversible.
c.
Offer to help select clothes to hide the deformity.
d.
Tell the client safety is more important than looks.
ANS: A
Assessment is the first step of the nursing process, and the nurse should begin by getting as much information about the client’s feelings as possible. Explaining that the changes are irreversible discounts the client’s feelings. Depending on the extent of the deformity, clothing will not hide it. While safety is more objectively important than looks, the client is worried about looks and the nurse needs to address this issue.
DIF: Applying/Application REF: 1021
The nurse knows that hematopoiesis occurs in what part of the musculoskeletal system?
a.
Cancellous tissue
b.
Collagen matrix
c.
Red marrow
d.
Yellow marrow
ANS: C
Hematopoiesis occurs in the red marrow, which is part of the cancellous tissues containing both types of bone marrow.
DIF: Remembering/Knowledge REF: 1018
A nurse is providing community education about preventing traumatic musculoskeletal injuries related to car crashes. Which group does the nurse target as the priority for this education?
a.
High school football team
b.
High school homeroom class
c.
Middle-aged men
d.
Older adult women
ANS: A
Young men are at highest risk for musculoskeletal injury due to trauma, especially due to motor vehicle crashes. The high school football team, with its roster of young males, is the priority group.
DIF: Applying/Application REF: 1020
A school nurse is conducting scoliosis screening. In screening the client, what technique is most appropriate?
a.
Bending forward from the hips
b.
Sitting upright with arms outstretched
c.
Walking across the room and back
d.
Walking with both eyes closed
ANS: A
To assess for scoliosis, a spinal deformity, the student should bend forward at the hips. Standing behind the student, the nurse looks for a lateral curve in the spine. The other actions are not correct.
DIF: Applying/Application REF: 1023
The client’s chart indicates genu varum. What does the nurse understand this to mean?
a.
Bow-legged
b.
Fluid accumulation
c.
Knock-kneed
d.
Spinal curvature
ANS: A
Genu varum is a bow-legged deformity. A fluid accumulation is an effusion. Genu valgum is knock-kneed. A spinal curvature could be kyphosis or lordosis.
DIF: Remembering/Knowledge REF: 1023
The nurse is assessing four clients with musculoskeletal disorders. The nurse should assess the client with which laboratory result first?
a.
Serum alkaline phosphatase (ALP): 108 units/L
b.
Serum aspartate aminotransferase (AST): 26 units/L
c.
Serum calcium: 10.2 mg/dL
d.
Serum phosphorus: 2 mg/dL
ANS: D
A normal serum phosphorus level is 3 to 4.5 mg/dL; a level of 2 mg/dL is low, and this client should be assessed first. The values for serum ALP, AST, and calcium are all within normal ranges.
DIF: Understanding/Comprehension REF: 1024
A nursing student studying the musculoskeletal system learns about important related hormones. What information does the student learn? (Select all that apply.)
a.
A lack of vitamin D can lead to rickets.
b.
Calcitonin increases serum calcium levels.
c.
Estrogens stimulate osteoblastic activity.
d.
Parathyroid hormone stimulates osteoclastic activity.
e.
Thyroxine stimulates estrogen release.
ANS: A, C, D
Vitamin D is needed to absorb calcium and phosphorus. A deficiency of vitamin D can lead to rickets. Estrogen stimulates osteoblastic activity. Parathyroid hormone stimulates osteoclastic activity. Calcitonin decreases serum calcium levels when they get too high. Thyroxine increases the rate of protein synthesis in all tissue types.
DIF: Remembering/Knowledge REF: 1019
A student nurse learns about changes that occur to the musculoskeletal system due to aging. Which changes does this include? (Select all that apply.)
a.
Bone changes lead to potential safety risks.
b.
Increased bone density leads to stiffness.
c.
Osteoarthritis occurs due to cartilage degeneration.
d.
Osteoporosis is a universal occurrence.
e.
Some muscle tissue atrophy occurs with aging.
ANS: A, C, E
Many age-related changes occur in the musculoskeletal system, including decreased bone density, degeneration of cartilage, and some degree of muscle tissue atrophy. Osteoporosis, while common, is not universal. Bone density decreases with age, not increases.
DIF: Remembering/Knowledge REF: 1020
An older client’s serum calcium level is 8.7 mg/dL. What possible etiologies does the nurse consider for this result? (Select all that apply.)
a.
Good dietary intake of calcium and vitamin D
b.
Normal age-related decrease in serum calcium
c.
Possible occurrence of osteoporosis or osteomalacia
d.
Potential for metastatic cancer or Paget’s disease
e.
Recent bone fracture in a healing stage
ANS: B, C
This slightly low calcium level could be an age-related decrease in serum calcium or could indicate a metabolic bone disease such as osteoporosis or osteomalacia. A good dietary intake would be expected to produce normal values. Metastatic cancer, Paget’s disease, or healing bone fractures will elevate calcium.
DIF: Remembering/Knowledge REF: 1024
When assessing gait, what features does the nurse inspect? (Select all that apply.)
a.
Balance
b.
Ease of stride
c.
Goniometer readings
d.
Length of stride
e.
Steadiness
ANS: A, B, D, E
To assess gait, look at balance, ease and length of stride, and steadiness. Goniometer readings assess flexion and extension or joint range of motion.
DIF: Remembering/Knowledge REF: 1021
