Chapter 31

Question 1

The nurse is discussing actions that can be taken to best prevent osteoporosis with a patient.

Which information should the nurse include?

a. Take an extra calcium supplement.
b. Eat a balanced diet.
c. Exercise throughout life.
d. Increase daily intake of milk products.

Answer 1

ANS: C

A lifetime of even mild daily exercise will delay or prevent osteoporosis.

Question 2

What does goniometry measure?

a. Bone strength
b. Muscle density
c. Muscle strength
d. Range-of-motion (ROM)

Answer 2

ANS: D

Goniometry measures joint mobility, described as the number of degrees that the joint can move from the 0-degree mark

Question 3

Positioning and range-of-motion (ROM) exercises most help the immobilized patient to prevent which complication?

a. Increased pain
b. Contractures
c. Pressure ulcers
d. Compromised circulation

Answer 3

ANS: B

Although positioning may help decrease pain and increase circulation, anatomical alignment and ROM exercises are most helpful in preventing contractures in the immobilized patient. Pressure ulcers are prevented by frequent position changes.

Question 4

The nurse adds interventions for range-of-motion (ROM) and isometric exercises for the new patient with a stroke. The nurse’s reasoning stems from her awareness that contracture formation may begin with how many days of immobilization?

a. 1 day
b. 2 days
c. 3 days
d. 10 days

Answer 4

ANS: C

Contracture-related muscle changes occur as early as 3 days of immobilization.

Question 5

If muscles are not regularly stretched and contracted, how will the muscles be effected?

a. Muscles will become longer and flexed.
b. Muscles will become fibrosed and spastic.
c. Muscles will become shorter and less elastic.
d. Muscles will become shorter and painful

Answer 5

ANS: C

The formation of contractures (shortening of skeletal muscle tissue causing deformity), loss of muscle tone, and fixation of joints can be prevented in most cases by consistent nursing intervention. The major components of the intervention are gradual mobilization, an exercise program, proper positioning, and instruction of the patient and family. Within a matter of a few days, the structures of immobilized muscles and joints begin to undergo changes. If no effort is made to prevent these changes, the patient will become permanently disabled.

Question 6

If muscles are not regularly stretched and contracted, how will the muscles be effected?

a. Muscles will become longer and flexed.
b. Muscles will become fibrosed and spastic.
c. Muscles will become shorter and less elastic.
d. Muscles will become shorter and painful

Answer 6

ANS: C

The formation of contractures (shortening of skeletal muscle tissue causing deformity), loss of muscle tone, and fixation of joints can be prevented in most cases by consistent nursing intervention. The major components of the intervention are gradual mobilization, an exercise program, proper positioning, and instruction of the patient and family. Within a matter of a few days, the structures of immobilized muscles and joints begin to undergo changes. If no NURSINGTB.COM effort is made to prevent these changes, the patient will become permanently disabled.

Question 7

The nurse uses a visual aid to show the pathologic muscle tone changes that result in footdrop.

Which changes should the nurse include?

a. The stretching of calf muscles
b. The stretching of flexor muscles
c. The toes curl downward
d. The thigh muscles contract

Answer 7

ANS: B

The most frequent contractures occurring in patients immobilized for long periods are “footdrop,” knee and hip flexion contractures, “wrist drop,” and contractures of the fingers and arms. Calf muscles contract and flexor muscles are stretched, allowing the unbraced foot to drop toward the surface of the bed.

Question 8

How often should range-of-motion (ROM) exercises be performed?

a. Once a day
b. Once in the morning and once in the afternoon
c. Three to four times a day
d. Four to six times a day

Answer 8

ANS: C

ROM exercises, both passive and active, are planned and carried out as soon as feasible after immobilization occurs as a result of disease, injury, or surgery. The exercises are done to maintain functional connective tissue within the joint and thereby ensure that every joint retains its function and mobility. ROM exercises should be done three to four times a day.

Question 9

The physician has prescribed isometric exercises for a patient. For which patient should the nurse question this order?

a. A patient experiencing an acute exacerbation of congestive heart failure
b. A patient with uncontrolled diabetes
c. A patient with a urinary tract infection (UTI)
d. A patient with resolving epistaxis

Answer 9

ANS: A

Isometric exercises are based on the energy of opposing muscles working against each other. Isometric exercise may be contraindicated in patients with hypertension, increased intracranial pressure, or congestive heart failure, as there is a significant increase in blood pressure and NURSINGTB.COM heart rate during isometric exercise

Question 10

When the patient returns to the unit from having had an arthrogram, which intervention should the nurse perform first?

a. Ambulate the patient in the room.
b. Apply ice packs to the knee.
c. Perform passive range-of-motion (ROM) exercises.
d. Wrap the knee in an elastic bandage.

Answer 10

ANS: B

Ice packs applied to the knee will reduce swelling. The patient will ambulate at some point but not before the application of ice. There is not going to be a significant loss of mobility for the patient, so ROM exercises will not likely be included in the plan of care. There is no indication that an elastic bandage is needed.

Question 11

The nurse encourages the patient to use the four-point crutch gait technique. Which statement indicates that the patient accurately understands the nurse’s teaching?

a. “This way of walking takes weight off of one leg.”
b. “This way of walking is the most stable gait.”
c. “This way of walking mimics normal walking pattern.”
d. “This way of walking allows the most rapid pace.”

Answer 11

ANS: B

The four-point crutch gait is the most stable, requires that there may be partial weight bearing on both legs, and does not mimic normal walking pattern.

Question 12

The nurse is assessing the patient’s cane for appropriate length. Which observation affirms that an appropriate cane has been selected?

a. The handgrip is at hip level.
b. The elbow flexes at 45 degrees when weight is placed on the cane.
c. The cane tip is placed touching outside the good foot.
d. The rubber tip has been removed when measuring cane length.

Answer 12

ANS: A

The handgrip should be at hip level to allow for proper flexion of the arm to bear weight. The cane tip should be placed 6 inches from the good foot. The elbow angle should be 30 degrees.

Question 13

The nurse is instructing the patient on quadriceps and gluteal muscle exercises. Which instructions should the nurse include?

a. In a supine position, straighten the leg and tense leg muscles while raising heel.
b. Flex the leg and hold it with the hands while pulling the leg back toward the hip.
c. Straighten the legs while raising the head.
d. Flex both legs and perform an abdominal crunch up toward the knees.

Answer 13

ANS: A

The quad setting exercise is to straighten the leg and tense the leg muscles while raising the heel.

Question 14

What is the name for the anatomical structure that joins the bones of a joint together?

a. A ligament
b. A tendon
c. A muscle
d. Cartilage

Answer 14

ANS: A

Ligaments hold the bones of a joint together. Tendons are connective tissues that provide joint movement. Cartilage is a type of connective tissue in which fibers and cells are embedded in a semisolid gel material.

Question 15

Which bodily component constantly renews bone?

a. Osteoblasts
b. Stem cells
c. Free circulating calcium ions
d. Combination of phosphorus and vitamin D

Answer 15

ANS: A

Osteoblasts build bone as the old bone is reabsorbed into the body.

Question 16

The patient’s plan of care includes using the continuous passive motion (CPM) machine.

Which statement indicates the patient needs for further teaching?

a. “I marched in the Marines for 20 NURSINGTB.COM years, and now I’m marching flat on my back!”
b. “My new knee will be glad to rest at night.”
c. “I can make my new knee stronger if I reset this thing to go faster and flex my

knee more.”

d. “I almost wish this CPM ran at night. The motor noise is soothing.”

Answer 16

ANS: C

The continuous passive motion (CPM) machine is used to provide movement to a joint in recovery. The apparatus is driven by a motor and requires no effort on the part of the patient or nurse to move the limb. It is usually left on all day and is discontinued at night while the patient sleeps. CPM is preset as to speed and the degree of flexion that is determined by the physician and should not be adjusted by the patient.

Question 17

When preparing a patient for electromyography (EMG), which instructions should the nurse include?

a. Cease smoking for 12 hours before the test.
b. Refrain from caffeine drinks for 3 hours before the test.
c. Take muscle relaxants before the test.
d. Prepare for a lengthy testing time (usually about 2 hours).

Answer 17

ANS: B

Electromyography (EMG) is used to detect abnormal nerve transmission to the muscle and abnormal muscle function, and to assess the rehabilitation progress. Before the test, smoking and use of caffeine should be ceased for 3 hours. The test usually takes 1 hour.

Question 18

The nurse is caring for an older adult patient. Which age-related factor increases this patient’s risk for falls?

a. Multiple lines and tubes
b. Increased postural sway
c. Room clutter
d. Pain medication

Answer 18

ANS: B

Approximately 30% to 40% of inpatient safety incidents are related to falls, and older adults are particularly vulnerable because of changes related to aging such as decreased strength, unsteady balance, loss of endurance, slow reflexes, gait disturbances, and increased postural sway, and chronic diseases such as arthritis. Lines and tubes, room clutter, and pain medications are risk factors for falls regardless of age.

Question 19

The nurse is changing the position of a person with flaccid paralysis. Which action is most important?

a. Change the patient’s joint position frequently.
b. Refrain from footboard usage.
c. Only move the patient from side to side, not supine.
d. Refrain from using pillows to keep the patient in place.

Answer 19

ANS: A

Frequent changes in joint position reduce the incidence of ankylosis.

Question 20

The nurse is caring for a patient who has had an arthrocentesis. The nurse has completed discharge instructions. Which statement indicates the patient needs further instruction?

a. “I should avoid moving my knee for at least 2 weeks.”
b. “The steroids prescribed by my physician will reduce the inflammation in my
knee. ”
c. “Some pain is anticipated.”
d. “My elastic bandage will be worn for 2 to 3 days.”

Answer 20

ANS: A

The patient with the arthrocentesis will be instructed to avoid overuse of the joint; however, it may be moved in moderation. Steroids will be prescribed to limit inflammation. Pain is anticipated and analgesics will likely be prescribed. Elastic bandages are frequently worn for 2 to 3 days.

Question 21

A patient is learning to use crutches on the stairs. Which action indicates that the patient needs further instruction?

a. The patient places the good leg on the step to be climbed first.
b. The patient places the affected leg on the step to be climbed first.
c. The patient places the crutches on the floor and uses a swing-through method to

get to the next step.

d. The patient places the crutch on the affected side on the next step first.

Answer 21

ANS: A

When climbing stairs with crutches, the patient should first stand at the foot of the stairs with weight on the good leg and crutches, put weight on the crutch handles, and then lift the good leg up onto the first step of the stairs. Weight should be placed on the good leg to lift the injured leg and crutches up to that step.

Question 22

The nurse is assessing the patient’s crutches. Which observation confirms that the crutches are sized correctly?

a. The crutches are the same height as the patient’s shoulders.
b. The crutches are approximately 12 inches shorter than the patient’s shoulders.
c. The crutches are approximately 16 inches shorter than the patient’s height.

d. The crutches are tall enough to allow the patient’s arms to be fully extended when
walking.

Answer 22

ANS: C

Crutches should be about 16 inches (40 cm) shorter than the patient’s height. When in the standing position with axillary crutches, the axillary bar should be two finger breadths below the axilla. The elbow should be flexed at a 30-degree angle when the palms of the hands rest on the handgrip. It is important that the patient not rest the body at the axilla on the top of the crutch; body weight should be borne by the arms on the hand rests of the crutches. If crutches are too long, pressure on the axilla will occur and can cause nerve and circulatory impairment.

Question 23

A patient at risk for the development of osteoporosis has reported plans to increase calcium intake. Which meal choice is most appropriate for this patient?

a. Grilled salmon, green beans, and milk
b. Hamburger patty on a wheat bun, baked chips, and milk
c. Grilled chicken breast, tossed salad, and fruit punch
d. Bacon, lettuce, and tomato sandwich on whole-grain bread, orange slices, and milk

Answer 23

ANS: A

In addition to dairy products, sources of calcium include canned sardines or salmon, tofu, figs, and green vegetables.

Question 24

Which component(s) is/are functions of the musculoskeletal system? (select all that apply.)

a. Motion
b. Fighting of infections
c. Support
d. Protection of organs
e. Body shape

Answer 24

ANS: A, C, D, E

Musculoskeletal system functions include motion, support, organ protection, and retention of body shape. The musculoskeletal system does not fight infections.

Question 25

Which age-related change(s) occur(s) in the musculoskeletal system? (select all that apply.)

a. Increased bone density
b. Increased brittleness and fragility of bones
c. Decreased healing times
d. Decreased muscle mass
e. Tendon sclerosis

Answer 25

ANS: B, C, D, E

Age-related musculoskeletal changes include increased fragility, decreased healing times and muscle mass, and tendon sclerosis. Bone density usually decreases with aging.

Question 26

When the nurse plans for the progressive mobilization of a hemiplegic, the nurse will consider the patient’s ability to perform which function(s)? (select all that apply.)

a. Move limbs
b. Change position in bed independently
c. Transfer self from bed to chair
d. Perform all activities of daily living (ADLs) independently
e. Walk

Answer 26

ANS: A, B, C, E

Progressive mobilization is assessing the patient’s ability to move their limbs, turn themselves in bed, transfer themselves from bed to chair and back again, and stand and walk. These measurable signs of independent movement represent various stages to which the patient can gradually progress. According to the Joint Commission’s National Patient Safety Goals, it is a nursing responsibility to recognize that these patients are at risk for falls while they are learning to regain mobility. Progressive mobilization does not require that the patient perform all ADLs independently.

Question 27

When a joint is obliterated by bony overgrowth, the joint is said to be _________.

Answer 27

ANS:

ankylosed

Ankylosis occurs when the joint is overgrown with bony overgrowth.

Question 28

The canal system that runs through the bone and contains the blood and lymph vessels is called the ____________.

Answer 28

ANS:

haversian system

The haversian system is the canal system that runs through the bone to carry blood and lymph vessels.

Question 29

Arrange the instructions for a person on crutches to sit down.

a. Transfer both crutches to the side of injury.
b. With weight on good leg, reach back, and grasp chair arm.
c. Sit back in chair.
d. Turn slowly and touch backs of legs to seat of chair.
e. Using crutch and chair arm for support, slowly sit on chair.

Answer 29

28. Step 1 d. Turn slowly and touch backs of legs to seat of chair.
29. Step 2 a. Transfer both crutches to the side of injury.
30. Step 3 b. With weight on good leg, reach back, and grasp chair arm.
31. Step 4 e. Using crutch and chair arm for support, slowly sit on chair.
32. Step 5 c. Sit back in chair.