LA#6 (Musculoskeletal) chapters 64, 65, 66, 67 in Med Surg

Question 1

Based on the nurse’s understanding of the physiology of bone and cartilage, what is the injury that the nurse would expect to heal most rapidly?

a. Fractured nose
b. Severely sprained ankle
c. Fracture of the midhumerus
d. Torn cruciate ligament in the knee

Answer 1

ANS: C

Bone is dynamic tissue that is continually growing; therefore, the fracture of the midhumerus would heal most rapidly.

Question 2

While assessing a patient’s musculoskeletal function, the nurse asks the patient to demonstrate active range of motion of the shoulder. What is the motion(s) at the shoulder that the patient should be able to perform but cannot do at the elbow?

a. Circumduction
b. Opposition
c. Eversion
d. Adduction

Answer 2

ANS: A
Circumduction is a combination of flexion, extension, abduction, and adduction resulting in circular motion of a body part, and the elbow is not able to do this.

Question 3

When the doctor tells a patient that the pain in his knee is caused by bursitis, the patient asks the nurse to explain what bursitis is. What is the best response that would explain bursitis to the patient?

a. An inflammation of the fibrocartilage that acts as a shock absorber in the knee
b. An inflammation of any connective tissue that is found supporting the joints of the body
c. An inflammation of the synovial membrane that lines the capsule between two bones of a joint
d. An inflammation of a small, fluid-filled bursa sac of protective connective tissue commonly found at joints

Answer 3

ANS: D

Bursae are fluid-filled sacs that cushion joints and bony prominences.

Question 4

During assessment of the musculoskeletal system of a 74-year-old woman, what is a finding that reflects the normal age-related vertebral disc compression?

a. Kyphosis
b. Back pain
c. Loss of height
d. Crepitation on movement

Answer 4

ANS: C

An age-related change is loss of height from disc compression and posture change.

Question 5

Skeletal muscle accounts for approximately what percentage of a person’s body weight?

a. 25%
b. 33%
c. 50%
d. 66%

Answer 5

ANS: C
Skeletal muscle, which requires neuronal stimulation for contraction, accounts for about half of a human being’s body weight.

Question 6

The wrist joint is an example of which one of the following joint types?

a. Hinge joint
b. Pivot joint
c. Condyloid joint
d. Gliding joint

Answer 6

ANS: C

The wrist joint is a condyloid joint.

Question 7

During assessment of the musculoskeletal system, the nurse notes that the patient’s gait is disturbed. To further assess this problem, what should the nurse do?

a. Measure the length of both legs.
b. Perform muscle strength testing of the legs.
c. Ask the patient to demonstrate active range of motion of the legs.
d. Perform deep palpation on the hip joints to identify the presence of pain.

Answer 7

ANS: A

Measuring the length of both legs will give the nurse more information related to the disturbed gait.

Question 8

While testing the patient’s muscle strength, the nurse finds that although the patient can move his limbs, he cannot apply muscle resistance to force. How should the nurse grade the muscle strength?

a. 1
b. 2
c. 3
d. 4

Answer 8

ANS: C

A level 3 grade indicates that the patient is unable to move against resistance but can move against gravity.

Question 9

When assessing the musculoskeletal system, what is the nurse’s initial action?

a. Have the patient move the extremities against resistance.
b. Feel for the presence of crepitus during joint movement.
c. Observe the patient’s body build and muscle configuration.
d. Check active and passive range of motion for the extremities.

Answer 9

ANS: C

The usual technique in the physical assessment is to begin with inspection.

Question 10

A patient is seen at the urgent care centre following a blunt injury to his left knee. The knee is grossly swollen and very painful, but the skin is intact. During an arthrocentesis on the patient’s knee, how would the nurse expect the aspirated fluid to appear?

a. Sanguineous
b. Purulent and thick
c. Light yellow in colour
d. White, thick, and ropelike

Answer 10

ANS: A
The patient’s clinical manifestations suggest hemarthrosis, and the appearance of blood in the synovial fluid is expected.

Question 11

A patient suffers an injury to the shoulder while playing football. To identify abnormalities of cartilage and soft tissue surrounding the joint, what would the nurse expect the patient to be evaluated with?

a. A bone scan
b. An arthrogram
c. Standard X-ray films
d. Magnetic resonance imaging (MRI)

Answer 11

ANS: D

MRI is most useful in assessing for soft tissue injuries.

Question 12

Which of the following is an age-related change in the musculoskeletal system?

a. Increased diameter of muscle cells
b. Increased storage of glycogen
c. Loss of water from discs between vertebrae
d. Widening of intervertebral spaces

Answer 12

ANS: C
A normal age-related change is a loss of water from discs between the vertebrae. Muscle cells decrease in diameter with aging. Glycogen storage decreases with aging. The intervertebral spaces narrow rather than widen as a normal age-related change.

Question 13

Which type of bone cell plays a role in bone remodelling?

a. Osteoblast
b. Osteoclast
c. Osteocyte
d. Osteon

Answer 13

ANS: B

Osteoclasts participate in bone remodeling by assisting in the breakdown of bone tissue.

Question 14

The sacrum is classified as which type of bone?

a. Long bone
b. Short bone
c. Flat bone
d. Irregular bone

Answer 14

ANS: D

Irregular bones appear in a variety of shapes and sizes, for example, the vertebrae, sacrum, and mandible.

Question 15

A 73-year-old woman tells the nurse that she is “slowing down” and does not try to push herself to do much these days because of her age. She spends most of the day and evening watching television and has hired someone to do most of her home maintenance chores. Recognizing that the woman is at risk for musculoskeletal problems, what is the best response to her comment?

a. “To improve your condition, you should join an exercise program, perhaps one at your local senior centre.”
b. “Mild, regular exercise will increase your strength and coordination and help increase your sense of well-being.”
c. “Many older people benefit from occasional exercise, which helps prevent muscle wasting and fatigue common in old age.”
d. “Many musculoskeletal changes occur with age that may limit physical activities. This is normal and to be expected.”

Answer 15

ANS: B

Prevention of musculoskeletal problems in the older adult includes regular and daily exercise.

Question 16

A woman is seen at the urgent care centre after falling on her right arm and shoulder. What is an assessment finding noted by the nurse that would indicate the patient has a dislocated shoulder?

a. Bruising at the shoulder area
b. The right arm being shorter than the left arm
c. Decreased range of motion of the right shoulder
d. Increased pain caused by flexing and extending the elbow

Answer 16

ANS: B

A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency.

Question 17

A cashier in a grocery store has muscle and tendon tears that have become inflamed, causing pain and weakness in her left hand and elbow. What should the nurse identify these symptoms as being related to?

a. Bursitis
b. Meniscus injury
c. Repetitive strain injury (RSI)
d. Carpal tunnel syndrome

Answer 17

ANS: C

The patient’s occupation and the inflammation, pain, and weakness in the elbow and hand suggest a RSI.

Question 18

While working in an urgent care centre, the nurse sees many patients with sports-related injuries. In teaching these patients about health promotion during physical activity, what should the nurse emphasize?

a. Stretching and warm-up exercises are an important part of the exercise routine.
b. All joints at risk for injury should be wrapped with adhesive tape before exercising.
c. Low-impact activities should be substituted for strenuous, physically stressful exercise.
d. All strenuous exercise should be followed with a period of complete physical relaxation.

Answer 18

ANS: A

Stretching and warm-up exercises before vigorous activity significantly reduce sprains and strains.

Question 19

A patient arrives in the emergency department with ankle swelling and severe pain after twisting the ankle playing soccer. All of the following orders are written by the physician. Which one will the nurse act on first?

a. Administer naproxen (Naprosyn) 500 mg orally.
b. Wrap the ankle, and apply an ice pack.
c. Give acetaminophen with codeine (Tylenol No. 3).
d. Take the patient to the radiology department for X-ray films.

Answer 19

ANS: B
Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling.

Question 20

Following X-ray films of an injured wrist, the patient is informed that it is just badly sprained. In teaching the patient to care for the injury, what should the nurse teach the patient to do?

a. Apply a heating pad to reduce muscle spasms.
b. Wear an elastic compression bandage continuously.
c. Gently exercise the joint to prevent muscle shortening.
d. Keep the arm elevated above the heart, even during sleep.

Answer 20

ANS: D
Elevation of the arm will reduce the amount of swelling and pain; therefore, it is important to keep the arm elevated, even during sleep.

Question 21

A 24-year-old man recently started an exercise regimen that includes running 5 to 7 km a day. He tells the nurse he has developed shin splints so severe that they limit his ability to run. What is an appropriate response?

a. “You may be increasing your running time too quickly and need to cut back a little bit.”
b. “You need to have X-ray films made of your lower legs to be sure you do not have stress fractures.”
c. “You should expect some leg pain while running.”
d. “You should try speed-walking rather than running.”

Answer 21

ANS: A
The patient’s information about running 5 to 7 km daily after starting an exercise program only 2 months previously suggests that the shin splints are caused by overuse.

Question 22

A 20-year-old baseball pitcher has an arthroscopic repair of a rotator cuff injury performed as same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included?

a. “You have an appointment with a physiotherapist for tomorrow.”
b. “Leave the shoulder immobilizer on for the first few days to minimize pain.”
c. “The doctor will use the drop-arm test to determine the success of the procedure.”
d. “You should try to find a different position to play on the baseball team.”

Answer 22

ANS: A

Physiotherapy after a rotator cuff repair begins on the first postoperative day to prevent “frozen shoulder.”

Question 23

A patient with a fractured radius asks when the cast can be removed. The nurse will instruct the patient that the cast can be removed only after the bone completes which process?

a. Ossification
b. Remodelling
c. Consolidation
d. Callus formation

Answer 23

ANS: A

The cast may be removed when callus ossification has occurred.

Question 24

A patient with a comminuted fracture of the right femur has Buck’s traction in place while waiting for surgery. What should the nurse do to assess for pressure areas on the patient’s back and sacral area and to provide skin care?

a. Have the patient lift the buttocks by bending and pushing with the left leg.
b. Turn the patient partially to each side with the assistance of another nurse.
c. Place a pillow between the patient’s legs, and turn gently to each side.
d. Loosen the traction, and have the patient turn onto the unaffected side.

Answer 24

ANS: A
The patient can lift the buttocks off the bed by using the left leg, or the patient could also be encouraged to use the overhead trapeze bar and the opposite siderail to assist in changing positions, without changing the right-leg alignment.

Question 25

A patient in the emergency department is diagnosed with a patellar dislocation. What will the nurse’s initial patient teaching focus on?

a. Conscious sedation
b. A knee immobilizer
c. Gentle knee flexion
d. Cast application

Answer 25

ANS: A
The first goal of collaborative management is realignment of the knee to its original anatomical position, which will require anaesthesia or conscious sedation.

Question 26

Following a motor vehicle accident, a patient arrives in the emergency department with massive right lower leg swelling. Which action will the nurse take first?

a. Elevate the leg on pillows.
b. Apply a compression bandage.
c. Place ice packs on the lower leg.
d. Check leg pulses and sensation.

Answer 26

ANS: D
The nurse’s initial action will be to assess the circulation to the leg and to observe for any evidence of injury such as fractures or dislocations.

Question 27

Following the application of a hip spica cast for a patient with a fracture of the proximal third of the left femur, what is an appropriate nursing intervention?

a. Reposition the patient, using the support bar at the thighs.
b. Assess the patient for abdominal pain, and nausea and vomiting.
c. Psychologically prepare the patient for a long period of bed rest without ambulation.
d. Turn the patient to the prone position every 4 hours to promote drying of the posterior part of the cast.

Answer 27

ANS: B
Assessment of bowel tones, abdominal pain, and nausea and vomiting will detect the development of cast syndrome. To avoid breakage, the support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physiotherapy personnel. The patient should not be placed in the prone position until the cast has dried to avoid breaking the cast.

Question 28

A patient is admitted to the emergency department with possible fractures of the bones of the left lower extremity. Before initiating treatment for the patient, what is it most important for the nurse to do?

a. Splint the lower leg.
b. Elevate the injured limb.
c. Check neurovascular status distal to the injury.
d. Assess the patient’s tetanus immunization status.

Answer 28

ANS: C
Musculoskeletal injuries have the potential to cause changes in the neurovascular status of an injured extremity. With musculoskeletal trauma, application of a cast or constrictive dressing, poor positioning, and the physiological response to the traumatic injury can cause nerve or vascular damage, usually distal to the injury. A thorough neurovascular assessment consists of a peripheral vascular assessment (colour, temperature, capillary refill, peripheral pulses, and edema) and a peripheral neurological assessment (sensation, motor function, and pain).

Question 29

In developing a care plan for a patient with an open reduction and internal fixation (ORIF) of an open, displaced fracture of the tibia, what is a priority nursing diagnosis?

a. Risk for constipation related to immobilization
b. Activity intolerance related to prolonged immobility
c. Risk for impaired skin integrity related to immobility
d. Risk for infection related to disruption of skin integrity

Answer 29

ANS: D

A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis.

Question 30

A patient hospitalized with multiple fractures has a long arm plaster cast applied for immobilization of a fractured radius. Until the cast has completely dried, what should the nurse do?

a. Keep the extremity in a dependent position.
b. Handle the cast with the palms of the hands.
c. Position the cast on a pillow to prevent abnormal shaping.
d. Cover the cast with a small blanket to absorb the dampness.

Answer 30

ANS: B
Until a plaster cast has dried, placing pressure on the cast should be avoided to prevent creating areas inside the cast that could place pressure on the arm.

Question 31

A patient has a short arm plaster cast applied at the outpatient centre for a stable wrist fracture. An understanding of discharge teaching is apparent when the patient gives which of the following responses?

a. “I can get the cast wet if I dry it right away with a hair dryer.”
b. “I should avoid moving my fingers and elbow until the cast is removed.”
c. “I will apply an ice pack to the cast over the fracture site for the next 24 hours.”
d. “If I have itching under the cast, I can apply lotion to the area with a cotton-tipped applicator.”

Answer 31

ANS: C
Ice packs may be applied for the first 24 hours after a fracture to help reduce swelling and can be placed over the cast.

Question 32

A patient with a fractured right tibia has a long leg cast applied and has been taught crutch walking with no weight bearing on his affected leg. The nurse determines that the patient is prepared to ambulate independently with the crutches on observing the patient do which of the following actions?

a. Advancing the crutches together and swinging the body past the crutches
b. Advancing the right leg and both crutches together and then advancing the left leg
c. Advancing the left crutch with the right leg and then the right crutch with the left leg
d. Advancing the left crutch, then the left leg, and then the right crutch followed by the right leg

Answer 32

ANS: B
When using crutches, patients are usually taught to move the assistive device and the injured leg forward at the same time and then to move the unaffected leg.

Question 33

A patient with open, comminuted fractures of the tibia and fibula is treated with open reduction and application of an external fixator. The day following surgery, the patient complains of severe pain in her affected leg, which is unrelieved by ordered analgesics. The patient’s toes are pink, but she says they are numb and tingling. What is the most appropriate nursing action?

a. Notify the patient’s physician.
b. Check the patient’s temperature.
c. Loosen the screws on the pins of the external fixator.
d. Elevate the extremity, and apply ice at the wound site.

Answer 33

ANS: A
The patient’s clinical manifestations point to compartment syndrome and delay in diagnosis, and treatment may lead to severe functional impairment; therefore, the physician should be notified.

Question 34

A patient with a fractured pelvis is initially treated with bed rest, with no turning from side to side permitted. The second day after admission, the patient develops chest pain, tachypnea, and tachycardia. Which of the following nursing assessments helps determine that the patient’s symptoms are most likely related to fat embolism?

a. A blood pressure of 100/65 mm Hg
b. Anxiety, restlessness, and confusion
c. Warm, reddened areas in the calf
d. Pinpoint red areas on the upper chest

Answer 34

ANS: D

The presence of petechiae helps distinguish fat embolism from other problems.

Question 35

The physician initially orders bed rest for a patient with a fractured pelvis. During assessment of the patient, which of the following findings would alert the nurse to a complication of the fracture?

a. Absence of bowel sounds
b. Unusual pelvic movement
c. Lower abdominal tenderness
d. Ecchymosis of the lower abdomen

Answer 35

ANS: A
Absent bowel tones may be due to complications of pelvic fractures such as paralytic ileus, hemorrhage, or trauma to the bladder, urethra, or colon.

Question 36

After falling at home, an 81-year-old man was admitted to the emergency department, where X-ray films confirmed the presence of an extracapsular fracture of the femur. When assessing the patient, what would the nurse expect to find?

a. Bruising of the left hip and thigh
b. Numbness in the left leg and hip
c. Outward-pointing toes on the left leg
d. Weak or nonpalpable left leg pulses

Answer 36

ANS: C

External rotation of the leg is a classic sign associated with a hip fracture.

Question 37

A patient with an intracapsular fracture of the left femur is placed in Buck’s traction before surgery for a hip replacement. The patient asks why traction is necessary when surgery is planned. The nurse’s response to the patient is based on what knowledge about traction?

a. Will help prevent flexion contractures of the affected hip
b. Is necessary to prevent displacement of the fracture
c. Will decrease the incidence of painful muscle spasms
d. Is used to maintain the leg in the external rotation position

Answer 37

ANS: C

Buck’s traction keeps the leg immobilized and reduces muscle spasm.

Question 38

When performing preoperative teaching for a patient who is scheduled for an ORIF of a left intertrochanteric hip fracture, what should the nurse inform the patient about regarding the expected outcome of this surgery?

a. Restriction of activity to bed rest and sitting in a chair
b. Confinement in bed with skeletal traction applied to the distal part of her femur
c. Early ambulation with the use of an assistive device, such as a walker or crutches
d. The ability to ambulate several days after surgery with full weight bearing on the affected limb

Answer 38

ANS: C

Early ambulation with an assistive device is an important part of rehabilitation after hip surgery.

Question 39

For which one of the following injuries would the nurse anticipate treatment with rest, ice, and nonsteroidal anti-inflammatory drugs (NSAIDs)?

a. Ligament injury
b. Impingement syndrome
c. Rotator cuff tear
d. Tendinoligamentous injury

Answer 39

ANS: A
Treatment for a ligament injury includes rest, ice, NSAIDs, and gradual return to activity. A protective brace may be required.

Question 40

A patient is admitted with facial injuries after a bicycle accident and has a repair of a fractured mandible. When doing postoperative teaching, the nurse will include information about which of the following?

a. The use of sterile technique for dressing changes
b. The importance of including high-fibre foods in the diet
c. When the patient may have to cut the immobilizing wires
d. Self-administration of nasogastric tube feedings

Answer 40

ANS: C
The jaw will be wired for stabilization, and the patient should know what emergency situations require that the wires be cut to protect the airway.

Question 41

A patient who has severe peripheral arterial disease and ischemic foot ulcers is very upset with the physician’s recommendation that she have an above-the-knee amputation. She tells the nurse, “If they want to cut off my leg, they should just shoot me instead.” What is the most appropriate response to the patient’s statement?

a. “Let’s talk about how you feel this surgery will affect you.”
b. “I will stay with you because I know this is a difficult decision for you to make.”
c. “I’m so sorry, but there really is no choice because your leg is so badly diseased.”
d. “Many people are able to function normally with a prosthesis after amputation, and you can too.”

Answer 41

ANS: A
The initial nursing action should be to assess how the patient feels about the amputation and what the patient knows about the procedure and rehabilitation process.

Question 42

On the first postoperative day, a patient with a below-the-knee amputation complains of pain in the amputated limb. What is an appropriate nursing action?

a. Administer prescribed opioids to relieve the pain.
b. Ask the patient to ignore the pain because it is not real.
c. Loosen the compression bandage to prevent pressure on the surgical incision.
d. Tell the patient that this phantom pain will diminish over time with increasing awareness of the absence of the limb.

Answer 42

ANS: A
Phantom limb pain is treated as any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient.

Question 43

Which of the following describes a complication of fracture healing known as malunion?

a. Fracture healing progresses more slowly than expected.
b. Fracture fails to heal properly despite treatment.
c. Fracture heals in the expected time but in an unsatisfactory position.
d. Fracture heals in an abnormal position in relation to midline of structure.

Answer 43

ANS: C
A complication of fracture healing called malunion is when a fracture heals in expected time, but in unsatisfactory position.

Question 44

The nurse provides discharge instructions to a patient with an above-the-knee amputation who will be fitted with a prosthesis when healing is complete and the residual limb is well moulded. The nurse determines that teaching has been effective when the patient gives which of the following responses?

a. “I should lie on my abdomen for 30 minutes three or four times a day.”
b. “I should change the limb sock when it becomes soiled or stretched out.”
c. “I should use lotion on the stump to prevent drying and cracking of the skin.”
d. “I should elevate the residual limb on a pillow several times a day to decrease edema.”

Answer 44

ANS: A

The patient lies in the prone position several times daily to prevent flexion contractures of the hip.

Question 45

The nurse identifies a nursing diagnosis of impaired physical mobility related to decreased muscle strength for a 75-year-old patient recovering from a right total hip arthroplasty. What is an appropriate nursing intervention for the patient?

a. Promote vitamin D and calcium intake in the diet.
b. Encourage quadriceps-setting exercises at least four times daily.
c. Provide passive range of motion to all of the joints four times daily.
d. Keep the right leg in extension and abduction to prevent contractures.

Answer 45

ANS: B
Straight-leg raises and quadriceps-setting exercises strengthen the quadriceps and should be performed several times per day.

Question 46

Which diagnosis does the nurse anticipate when a patient has a positive McMurray’s test?

a. Torn knee meniscus
b. Tear in the rotator cuff
c. Carpal tunnel syndrome
d. RSI

Answer 46

ANS: A
When pain is elicited by flexion, internal rotation, and then extension of the knee (McMurray’s test), the patient has torn the meniscus in the knee.

Question 47

A patient with severe osteoarthritis of the left knee has undergone left knee arthroplasty with replacement of the total knee joint with a plastic prosthesis. Postoperatively, what should the nurse expect care of the leg to include?

a. Progressive leg exercises to obtain 90-degree flexion
b. Early ambulation with full weight bearing on the left leg
c. Bed rest for 3 days with the left leg immobilized in extension
d. Immobilization of the left knee in 30-degree flexion for 6 weeks to prevent dislocation

Answer 47

ANS: A

After knee arthroplasty, active or passive flexion exercises are used to obtain a 90-degree flexion of the knee.

Question 48

A patient with severe ulnar drift caused by rheumatoid arthritis is scheduled for an arthroplasty of the right hand and fingers. The nurse determines that the patient has realistic expectations of the outcome of surgery when the patient gives which of the following responses?

a. “I will be able to use my fingers to grasp objects better.”
b. “My fingers will appear normal in size and shape after this surgery.”
c. “This procedure will prevent further deformity in my hands and fingers.”
d. “I will not have to perform exercises of my hands as frequently as I did before the surgery.”

Answer 48

ANS: A
The goal of hand surgery in rheumatoid arthritis is to restore function, not to correct for cosmetic deformity or treat the underlying process.

Question 49

Which one of the following workers would be most at risk for an RSI?

a. Butcher
b. Car sales person
c. Long-haul truck driver
d. Nurse

Answer 49

ANS: A
Persons most often affected by RSI include musicians, dancers, butchers, grocery clerks, vibratory tool workers, and those frequently using a computer mouse and keyboard. Competitive athletes and poorly trained athletes may also develop RSI.

Question 50

A patient who has a proximal humerus fracture that is immobilized with a left-sided long arm cast and a sling is admitted to the medical–surgical unit. Which nursing intervention will be included in the plan of care?

a. Use surgical net dressing to hang the arm from an intravenous pole.
b. Immobilize the fingers on the left hand with gauze dressings.
c. Assess the left axilla, and change absorbent dressings as needed.
d. Assist the patient in passive range of motion for the right arm.

Answer 50

ANS: C
The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this.

Question 51

A patient has been diagnosed with a Greenstick fracture. Which of the following describes what type of fracture this is?

a. The line of the fracture extends across the bone shaft at a right angle to the longitudinal axis.
b. The line of the fracture extends in a spiral direction along the shaft of the bone.
c. An incomplete fracture with more than two fragments.
d. The line of the fracture extends in an oblique direction.

Answer 51

ANS: C
A Greenstick fracture is one where there is an incomplete fracture with more than two fragments; the smaller fragments appear to be floating.

Question 52

The nurse observes a patient doing all of these activities after having hip replacement surgery. Which patient action requires that the nurse intervene immediately?

a. The patient sits straight up on the edge of the bed.
b. The patient leans over to pull shoes and socks on.
c. The patient bends over the sink while brushing the teeth.
d. The patient uses crutches with a swing-to gait.

Answer 52

ANS: B

Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation.

Question 53

A patient with an open fracture of the left tibia with major soft tissue damage underwent surgical reduction and fixation of the tibia with debridement of nonviable tissue and drain placement in the damaged soft tissue. During the postoperative period, the nurse suspects the development of osteomyelitis on finding which of the following data?

a. Fever with chills and night sweats
b. Light-yellow drainage from the wound
c. Pain on movement of the affected limb
d. Muscle spasms around the affected bone

Answer 53

ANS: A

Fever, chills, and night sweats are suggestive of osteomyelitis.

Question 54

A patient is hospitalized for initiation of regional antibiotic perfusion for chronic osteomyelitis of the right femur. Which intervention will be included in the plan of care?

a. Frequent weight-bearing exercise
b. Immobilization of the right leg
c. Avoiding administration of nonsteroidal anti-inflammatory drugs
d. Supporting the right leg in a flexed position

Answer 54

ANS: B

Immobilization of the affected leg helps decrease pain and reduce the risk for pathological fractures.

Question 55

A patient is being discharged after 2 weeks of intravenous (IV) antibiotic therapy for acute osteomyelitis in the left leg. Which information will be included in the discharge teaching?

a. The reason for taking oral antibiotics for 7 to 10 days after discharge
b. The need for daily aerobic exercise to help maintain muscle strength
c. How to monitor and care for the long-term IV catheter site
d. How to apply warm packs safely to the leg to reduce pain

Answer 55

ANS: C
The patient will be on IV antibiotics for several months and will need to recognize signs of infection at the IV site and how to care for the catheter during daily activities such as bathing.

Question 56

A patient has chronic osteomyelitis of his femur, which he is managing at home with self-administration of IV antibiotics. On a home visit, the nurse identifies the nursing diagnosis of ineffective therapeutic regimen management when the nurse makes which of the following observations?

a. The patient is unable to plantar-flex the foot on the affected side.
b. The patient uses crutches to avoid weight bearing on the affected leg.
c. The patient takes and records the oral temperature twice a day.
d. The patient is irritable and frustrated with the length of treatment required.

Answer 56

ANS: A

Footdrop is an indication that the foot is not being supported in a neutral position by a splint.

Question 57

Which statement by a patient who is scheduled for an above-the-knee amputation for treatment of osteosarcoma of the right tibia indicates that patient teaching is needed?

a. “I wish that I did not have to have chemotherapy after this surgery.”
b. “I do not mind the surgery because it will finally cure the cancer.”
c. “I know that I will need a lot of physiotherapy after surgery.”
d. “I will use the patient-controlled analgesia to help control my pain level after surgery.”

Answer 57

ANS: B

Osteosarcoma is an aggressive cancer with early metastasis and is not considered cured by surgery alone.

Question 58

The nurse identifies a nursing diagnosis of pain related to muscle spasms for a patient with acute low back pain associated with acute lumbosacral strain. What is an appropriate nursing intervention for this problem to teach to the patient?

a. Gently perform range-of-motion exercises of the lower extremities.
b. Place a small pillow under the upper back to gently flex the lumbar spine.
c. Rest in bed with the head of the bed elevated 20 degrees, and flex the knees.
d. Elevate the head of the bed on blocks, and lie with the feet firmly against the foot of the bed.

Answer 58

ANS: C

Resting with the head elevated and knees flexed will reduce the strain on the back and decrease muscle spasms.

Question 59

A 43-year-old truck driver who is responsible for loading and unloading the business machines he transports has a history of chronic back pain. Following teaching regarding care of his back, the nurse determines that the patient understands management of his condition when he makes which of the following responses?

a. “I plan to start doing sit-ups and leg lifts to strengthen the muscles of my back.”
b. “I will try to sleep with my hips and knees extended to prevent back strain.”
c. “I can tell my boss that I need to change to a job where I can work at a desk.”
d. “I will keep my back straight when I need to lift anything higher than my waist.”

Answer 59

ANS: A

Sit-ups and leg lifts will help strengthen the muscles that support the back.

Question 60

A patient with a herniated intravertebral disc undergoes a laminectomy and discectomy. Following the surgery, how should the nurse position the patient on his side?

a. By placing a pillow between the patient’s legs and turning his body as a unit
b. By turning the patient’s head and shoulders and then his hips, keeping him centred in the bed
c. By having the patient turn himself to the side by grasping the siderails and pulling himself over
d. By elevating the head of the bed 30 degrees and having the patient extend his legs while turning to the side

Answer 60

ANS: A
Logrolling, by placing a pillow between the patient’s legs and turning his body as a unit, is used to maintain correct body alignment after laminectomy.

Question 61

Following a laminectomy with a spinal fusion, a patient reports numbness and tingling of the right lower leg. What is the first nursing action?

a. Report the patient’s complaint to the surgeon.
b. Check the vital signs for indications of hemorrhage.
c. Turn the patient to the side to relieve pressure on the operative area.
d. Compare these findings with preoperative assessments of neuromuscular symptoms.

Answer 61

ANS: D
The postoperative movement and sensation of the extremities should be unchanged (or improved) from the preoperative assessment.

Question 62

After teaching a patient with a bunion about how to prevent further problems, the nurse will determine that more teaching is needed if the patient says which of the following?

a. “I will wear soft slippers whenever possible.”
b. “I will throw away my high-heeled shoes.”
c. “I will use the bunion pad to relieve the pain.”
d. “I will take ibuprofen when I need it.”

Answer 62

ANS: A

The shank of the shoe should be rigid enough to support the foot.

Question 63

While working in a gerontology clinic, the nurse sees older adult women on a long-term basis. What is an assessment finding that alerts the nurse to the presence of osteoporosis in a patient?

a. The presence of bowed legs
b. Measurable loss of height
c. Poor appetite and aversion to dairy products
d. The development of unstable, wide-gait ambulation

Answer 63

ANS: B

Osteoporosis occurring in the vertebrae produces a gradual loss of height.

Question 64

A 58-year-old woman who has been menopausal for 5 years is diagnosed with osteoporosis following densitometry testing. The woman has been concerned about her risk for osteoporosis because her mother has the condition. In teaching the woman about her osteoporosis, what should the nurse explain?

a. With a family history of osteoporosis, bone resorption cannot be prevented or slowed.
b. Estrogen replacement therapy must be started to prevent rapid progression of her osteoporosis.
c. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis.
d. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.

Answer 64

ANS: D

Progression of osteoporosis can be slowed by increasing calcium intake and weight-bearing exercise.

Question 65

Which reflex is affected in a patient with a disc herniation at the level of L3?

a. None
b. Patellar
c. Achilles
d. Deep-tendon reflex

Answer 65

ANS: B

The patellar reflex is affected in a patient with a herniated disk at the level of L3.

Question 66

Which foot disorder does the patient have when there is an elevation of the longitudinal arch of the foot, resulting from contracture of the plantar fascia?

a. Hallux valgus
b. Morton’s neuroma
c. Pes cavus
d. Pes planus

Answer 66

ANS: C

Pes cavus is an elevation of the longitudinal arch of the foot resulting from contracture of the plantar fascia.

Question 67

Which of the following is a major risk factor for osteoporosis?

a. Age under 65 years
b. Fragility fracture experienced in adulthood
c. Hypergonadism
d. Hyperparathyroidism

Answer 67

ANS: D

Hyperparathyroidism is a major risk factor for the development of osteoporosis.

Question 68

Which of the following foods would the nurse recommend to the patient as having the highest amount of calcium per serving, to increase the patient’s nutritional intake of calcium?

a. Yogourt
b. Whole milk
c. Shrimp
d. Salmon

Answer 68

ANS: A
Although all of the foods listed contain calcium, the highest is yogourt, which is followed by whole milk, salmon, and shrimp.

Question 69

A patient complains that he has a sore foot. Upon assessment, the nurse notes a localized thickening area of skin where the patient indicates that the pain is located. Based upon this assessment, which of the following is the most likely cause of the patient’s pain?

a. Corn
b. Soft corn
c. Callus
d. Plantar wart

Answer 69

ANS: A
A corn is a localized thickening area of skin caused by continual pressure over bony prominences, especially the metatarsal head, and frequently causes localized pain.

Question 70

A 60-year-old woman has primary osteoarthritis (OA) of the left knee. What is a finding that the nurse would expect to be present on examination of the patient’s knee?

a. Heberden’s nodules
b. A reddened, swollen joint
c. Pain on joint movement
d. Stiffness that increases with movement

Answer 70

ANS: C

Initial symptoms of OA include pain with joint movement. Heberden’s nodules occur on the fingers.

Question 71

During assessment of patients, the nurse recognizes that which of the following patients is at the greatest risk for OA?

a. A 56-year-old man who is a member of a construction crew
b. A 42-year-old woman who works on an automotive assembly line
c. A 24-year-old man who participates in his employer’s softball team
d. A 36-year-old woman who is newly diagnosed with diabetes mellitus

Answer 71

ANS: B
OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals whose work involves repetitive movements and lifting.

Question 72

The physician has prescribed naproxen (Naprosyn) twice daily for a patient with OA of the hands. The patient tells the nurse after 3 weeks of use that the medication does not seem to be effective in controlling the pain. The nurse’s response to the patient is based on what knowledge?

a. It can take up to 4 to 6 weeks for nonsteroidal anti-inflammatory drugs (NSAIDs) to reach therapeutic levels in the blood.
b. If NSAIDs are not effective in controlling her symptoms, corticosteroids are the next medication of choice.
c. The patient is probably not compliant with the drug therapy because of the need for frequent dosing.
d. Another type of NSAID may be indicated because of variations in individual response to the drugs.

Answer 72

ANS: D

Individual responses to NSAIDs can vary, so the physician may prescribe a different NSAID.

Question 73

When teaching a patient with OA of the left hip and lower lumbar vertebrae about management of the condition, the nurse determines that additional instruction is needed when the patient gives which of the following responses?

a. “I can use a cane if I find it helpful in relieving the pressure on my back and hip.”
b. “A warm shower in the morning will help relieve the stiffness I have when I get up.”
c. “I should try to stay active throughout the day to keep my joints from becoming stiff.”
d. “I should take no more than 1 g of acetaminophen four times a day to help control the pain.”

Answer 73

ANS: C
Protection and avoidance of joint stressors are recommended for patients with OA, so this patient should alternate periods of rest with necessary activity.

Question 74

A 58-year-old woman has been diagnosed with primary OA of her hands and feet. She is very upset about the diagnosis and tells the nurse she is too young to have arthritis and at this rate she will be hopelessly crippled by the time she is 70. What is the best response to the patient?

a. Osteoarthritis can be well controlled with a regimen of exercise, diet, and medications.
b. Osteoarthritis is an inflammatory disease of the joints, which may occur at any age.
c. Joint degeneration with pain and deformity occurs in the majority of people by the age of 60.
d. Osteoarthritis is more common with aging but usually is localized and does not cause deformity.

Answer 74

ANS: D
OA is localized to joints that have been injured or have high use. Although exercise, diet, and medications can help decrease symptoms and slow disease progression, they will not prevent progression of the disease.

Question 75

A patient with hip pain is diagnosed with OA. The nurse may need to teach the patient about the use of which of the following?

a. Prednisone (Deltasone)
b. Capsaicin cream (Zostrix)
c. Sulphasalazine (Salazopyrin)
d. Doxycycline (Vibramycin)

Answer 75

ANS: B

Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA.

Question 76

A 71-year-old obese man has bilateral OA of the hips. The nurse teaches the patient that the most beneficial measure to protect his joints is to do which of the following activities?

a. Use a wheelchair to avoid walking as much as possible.
b. Use a weight-reduction diet to obtain a healthy body weight.
c. Use a walker for ambulation to relieve the pressure on his hips.
d. Sit in chairs that do not cause his hips to be lower than his knees.

Answer 76

ANS: B
Because the patient’s major risk factor is obesity, the nurse should teach the patient that weight loss is the best way to reduce stress on the hips.

Question 77

The physician prescribes methotrexate (Rheumatrex) for a 28-year-old woman with stage II, moderate rheumatoid arthritis (RA). When obtaining a health history from the patient, the nurse consults with the physician on finding which of the following information?

a. The patient has a history of infectious mononucleosis as a teenager.
b. The patient has a family history of macular degeneration of the retina.
c. The patient had been trying to have a baby before her disease became more severe.
d. The patient has been using large doses of vitamins and health foods in an effort to control her disease.

Answer 77

ANS: C

Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy.

Question 78

A patient with an acute exacerbation of RA has localized pain and inflammation of the fingers, wrists, and feet, with swelling, redness, and limited movement of the joints. In developing a plan with the patient to promote the management of the disease, what does the nurse recognize is an appropriate outcome for the patient at this time?

a. Maintain a positive self-image.
b. Perform activities of daily living independently.
c. Achieve satisfactory control of pain and fatigue.
d. Make a successful adjustment to the disease progression.

Answer 78

ANS: C
The focus during an acute exacerbation of RA is to manage pain effectively. The other outcomes are appropriate long-term outcomes.

Question 79

A home care patient with RA complains to the nurse about having chronically dry eyes and a dry mouth. Which nursing action is most appropriate?

a. Have the patient withhold the daily methotrexate until talking with the physician.
b. Reassure the patient that dry eyes and mouth are very common with RA.
c. Teach the patient to use an antiseptic mouthwash three times daily.
d. Suggest that the patient start using over-the-counter (OTC) artificial tears.

Answer 79

ANS: D
The patient’s dry eyes and oral mucous membranes are consistent with Sjögren’s syndrome, a common extra-articular manifestation of RA. Symptomatic therapy, such as OTC eyedrops, is recommended.

Question 80

The nurse emphasizes the need for range-of-motion exercises for a patient who is having an acute exacerbation of RA with joint pain and swelling in both hands. What should the nurse teach the patient?

a. The joints should not be exercised when pain is present.
b. Cold applications to the joints before exercise will decrease the pain.
c. The exercises should be performed passively by someone other than the patient.
d. Joint motion required for activities of daily living is sufficient exercise for the joints.

Answer 80

ANS: B
Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful.

Question 81

Prednisone is prescribed for a patient with an acute exacerbation of RA. When the patient has a follow-up visit 1 month later, the nurse recognizes that the patient’s response to the treatment may be best evaluated by which of the following?

a. Blood glucose testing
b. Liver function tests
c. Serum electrolyte levels
d. C-reactive protein level

Answer 81

ANS: D
C-reactive protein is a marker for inflammation, and a decrease would indicate that the corticosteroid therapy was effective.

Question 82

When teaching a patient to protect the small joints affected by RA, what should the nurse instruct the patient to do?

a. Stand rather than sit when performing household chores.
b. Avoid activities that require continuous use of the same muscles.
c. Strengthen small hand muscles by wringing sponges or washcloths.
d. Protect the knee joints by sleeping with a small pillow under the knees.

Answer 82

ANS: B

Patients are advised to avoid repetitious movements.

Question 83

When reviewing laboratory data for a patient who is taking methotrexate, which information is most important to communicate to the physician?

a. The platelet count is 130,000 cells/microlitre.
b. The white blood cell (WBC) count is 1500 cells/microlitre.
c. The blood glucose is 7.2 mmol/L (130 mg/dL).
d. The potassium concentration is 5.2 mmol/L.

Answer 83

ANS: B
Bone marrow suppression is a possible side effect of methotrexate, and the patient’s low WBC count places the patient at high risk for infection.

Question 84

When helping a patient with RA plan a daily routine, the nurse informs the patient that it is most helpful to start the day with which of the following activities?

a. A warm bath followed by a short rest
b. A 10-minute routine of isometric exercises
c. Stretching exercises to relieve joint stiffness
d. Range-of-motion exercises followed by application of capsaicin cream

Answer 84

ANS: A

Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning.

Question 85

The biological agent anakinra (Kineret) is prescribed for a patient who has moderately severe RA. When teaching the patient about this medication, what information will the nurse include?

a. Symptoms of gastrointestinal irritation or bleeding
b. Self-administration of subcutaneous injections
c. Taking the medication with at least 235 mL of fluid
d. Avoiding concurrently taking aspirin or NSAIDs

Answer 85

ANS: B
Anakinra is administered by subcutaneous injection; therefore, self-administration will be included in the teaching of this patient.

Question 86

Which one of the following medications would the nurse teach the patient to take with food or milk?

a. Ibuprofen (Advil)
b. Capsaicin
c. Diclofenac diethylamine (Voltaren)
d. Triamcinolone (Aristospan)

Answer 86

ANS: A

Ibuprofen should be administered with food, milk, or an antacid.

Question 87

In teaching a patient with ankylosing spondylitis about management of the condition, what should the nurse instruct the patient to do?

a. Sleep on his side with his hips flexed.
b. Take slow, long walks as a form of exercise.
c. Perform daily chest expansion and deep-breathing exercises.
d. Maintain 10 to 12 hours of bed rest daily to prevent pressure on weight-bearing joints.

Answer 87

ANS: C
Deep-breathing exercises are used to decrease the risk for pulmonary complications that may occur with the reduced chest expansion that can occur with ankylosing spondylitis.

Question 88

Which anatomical stage of RA is the patient in when the patient has bony ankylosis?

a. Stage I
b. Stage II
c. Stage III
d. Stage IV

Answer 88

ANS: D

Stage IV indicates that the patient has all of the stage III criteria, plus fibrous or bony ankylosis.

Question 89

A young man hospitalized with severe pain in the knees and hips, a fever, and shaking chills is suspected of having septic arthritis. Which of the following information obtained from the patient during the nursing history indicates a risk factor for septic arthritis?

a. His father has Reiter syndrome.
b. He recently returned from a trip to South America.
c. He has a history of intermittently treated gonorrhea.
d. He had a number of sports-related knee and hip injuries as a teenager.

Answer 89

ANS: C

Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults.

Question 90

The mother of a family who lives in an area endemic for Lyme disease asks the nurse what precautions should be taken for the disease. The nurse’s response to the woman is based on what knowledge?

a. Transmission of the disease can be prevented by covering ticks attached to the skin with oil to suffocate them.
b. An early sign of Lyme disease is a lesion at the bite site that increases in size and has a red border and clear centre.
c. Early treatment of the infection with antiviral agents can prevent the development of cardiac and neurological manifestations.
d. If Lyme disease is transmitted by a tick, symptoms of nausea, vomiting, and diarrhea occur before the onset of joint pain.

Answer 90

ANS: B

Erythema migrans is the typical early lesion associated with a tick bite causing Lyme disease.

Question 91

A patient is hospitalized with an acute attack of primary gout, which is affecting his left great toe and ankle. What is the patient outcome that the nurse determines as most important for the patient?

a. Maintains a purine-free diet
b. Experiences no evidence of tophi
c. Experiences satisfactory pain relief
d. Has minimal loss of function of the affected joint

Answer 91

ANS: C

The priority patient outcome for an acute attack of gout is to control pain.

Question 92

A patient with an acute attack of gout is treated with colchicine. The nurse determines that the drug is effective on observing which of the following findings?

a. Relief of pain
b. Increased urine purine levels
c. Increased urine uric acid levels
d. Decreased serum uric acid levels

Answer 92

ANS: A

Colchicine produces pain relief in 24 to 48 hours by decreasing inflammation.

Question 93

A patient with gout tells the nurse that he takes losartan (Cozaar) for control of his condition. What history should the nurse ask the patient about?

a. Hypertension
b. Diabetes mellitus
c. Renal insufficiency
d. Immunosuppressant therapy

Answer 93

ANS: A
Losartan, an angiotensin II receptor antagonist, will lower blood pressure, so the nurse needs to reveal whether the patient has a history of hypertension.

Question 94

A patient has been diagnosed with early systemic lupus erythematosus (SLE) involving her joints. In teaching the patient about the disease, the nurse includes which of the following information?

a. SLE is a hereditary disorder of women but usually does not show clinical symptoms unless a woman becomes pregnant.
b. SLE is an autoimmune disease of women in which antibodies are formed that destroy all nucleated cells in the body.
c. SLE is a disorder of immune function, but it is extremely variable in its course, and its progression cannot be predicted.
d. During an acute exacerbation of SLE, the body produces antibodies that bind with cells with estrogen receptors, causing an inflammatory response.

Answer 94

ANS: C

SLE has an unpredictable course, even with appropriate treatment.

Question 95

A patient with an acute exacerbation of SLE is hospitalized with incapacitating fatigue, fever, and acute pain in her hands and wrists. A urinalysis reveals proteinuria and hematuria, and the physician prescribes corticosteroids. During the acute phase of the patient’s illness, what is it most important for the nurse to do?

a. Institute seizure precautions.
b. Orient her frequently to time and place.
c. Monitor intake, output, and daily weight.
d. Protect her from injury that may cause bleeding.

Answer 95

ANS: C
Lupus nephritis is a common complication of SLE, and when the patient is taking corticosteroids, it is especially important to monitor renal function.

Question 96

A young woman is upset about the unsightly rash on her face and the hair loss she is experiencing as a result of her SLE. She refuses to see friends and will not go out of her home except to visit the health clinic. What nursing diagnosis should the nurse document for the patient?

a. Ineffective coping related to inadequate support system
b. Impaired skin integrity related to itching and skin sloughing
c. Social isolation related to embarrassment about the effects of SLE
d. Impaired social interaction related to lack of social skills

Answer 96

ANS: C
The patient’s statement about not going anyplace because of hating the way he or she looks supports the diagnosis of social isolation because of embarrassment about the effects of the SLE.

Question 97

A patient with polyarthralgia with joint swelling and pain is being evaluated for SLE. The nurse knows that which of the following serum test results is the most specific for SLE?

a. The presence of rheumatoid factor
b. The presence of antinuclear antibody
c. The presence of anti-Smith antibody
d. The presence of lupus erythematosus cells

Answer 97

ANS: C
Anti-Smith (Sm) antibodies are found almost exclusively in SLE. The other blood tests are also used in screening but are not as specific to SLE.

Question 98

Following instruction for a patient with newly diagnosed SLE, the nurse determines that teaching about the disease has been effective when the patient gives which of the following responses?

a. “I should expect to have a fever all the time with this disease.”
b. “I need to restrict my exposure to sunlight to prevent an acute onset of symptoms.”
c. “I should try to ignore my symptoms as much as possible and have a positive outlook.”
d. “If I become pregnant, a therapeutic abortion can prevent an exacerbation of symptoms.”

Answer 98

ANS: B
Sun exposure is associated with SLE exacerbation, so patients should use sunscreen with a sun protection factor of at least 15 and stay out of the sun between 1100 hours and 1500 hours.

Question 99

A 19-year-old patient who is taking azathioprine (Imuran) for SLE has a checkup before leaving home for college. The physician writes all of these orders. Which one should the nurse question?

a. Administer naproxen (Aleve) 200 mg twice daily.
b. Give measles–mumps–rubella immunization.
c. Draw anti-DNA titre.
d. Administer famotidine (Pepcid) 20 mg daily.

Answer 99

ANS: B

Live virus vaccines, such as rubella, are contraindicated in a patient taking immunosuppressive drugs.

Question 100

A patient has systemic sclerosis manifested by the CREST syndrome. During assessment of the patient, what would the nurse expect to find?

a. Bony ankylosis of the small joints
b. The presence of intention tremors of the hands
c. Burning, itching, and photosensitivity of the eyes
d. A history of numbness and tingling with colour changes in the fingers and toes

Answer 100

ANS: D
Raynaud’s phenomenon is one aspect of the CREST syndrome (calcinosis, Raynaud’s phenomenon, esophageal dysfunction, sclerodactyly, telangiectasia) revealing a history of numbness and tingling in the fingers and toes.

Question 101

The nurse teaches a patient diagnosed with progressive systemic sclerosis about health maintenance activities. The nurse determines that additional instruction is needed when the patient gives which of the following responses?

a. “I should lie down for an hour after meals.”
b. “Lotions will help if I rub them in for a long time.”
c. “I should perform range-of-motion exercises to all joints daily.”
d. “I can try biofeedback training to raise the temperature in my fingers and toes.”

Answer 101

ANS: A

Because of the esophageal scarring, patients should sit up for 2 hours after eating.

Question 102

A patient with polymyositis is hospitalized during an onset of active inflammation. What is a nursing diagnosis that is appropriate for the patient at this time?

a. Risk for aspiration related to dysphagia
b. Acute pain related to muscle inflammation
c. Risk for impaired skin integrity related to pruritus
d. Ineffective breathing pattern related to immobility

Answer 102

ANS: A

The patient’s vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a high risk for aspiration.

Question 103

A 62-year-old patient is hospitalized for onset of diffuse erythema of his upper body with periorbital edema. The physician suspects dermatomyositis. In planning care for the patient, what should the nurse anticipate that the collaborative care of the patient will involve?

a. Instillation of artificial tears
b. Local steroid injections of skin lesions
c. Administration of high-dose corticosteroids
d. Electroencephalogram evaluation for central nervous system inflammation

Answer 103

ANS: C

Dermatomyositis is initially treated with high-dose steroids.

Question 104

When caring for a patient with fibromyalgia syndrome, the nurse knows that although multiple drugs are used for symptom control, which of the following medications has had the best results in the treatment of the overall symptoms of the disorder?

a. Diazepam (Valium)
b. Amitriptyline (Elavil)
c. Ibuprofen
d. Cyclobenzaprine (Flexeril)

Answer 104

ANS: B
Amitriptyline is ordered to improve sleep, to decrease stress and fatigue, and as an adjuvant medication for pain control. It would not be ordered to prevent depression, although it might be ordered to treat depression in a patient with fibromyalgia syndrome.

Question 105

A patient is being assessed for a diagnosis of RA. Which of the following total scores on the American College of Rheumatology/European League Against Rheumatism Classification Criteria for Rheumatoid Arthritis would be interpreted as a definite diagnosis of RA?

a. 0
b. 2
c. 4
d. 6

Answer 105

ANS: D

A total score greater than or equal to 6 to 10 indicates a definite diagnosis of RA.

Question 106

The physician plans to prescribe methotrexate to a patient with newly diagnosed RA. The patient tells the nurse, “That medication has too many side effects. I would rather wait until my joint problems are worse before beginning any medications.” Which is the most appropriate response?

a. “You should tell the doctor how you feel so the two of you can make a decision together.”
b. “It is important to start methotrexate early in order to decrease the joint damage.”
c. “Methotrexate is not expensive and will be cheaper to take than other possible drugs.”
d. “Methotrexate is very effective and has no more side effects than the other available drugs.”

Answer 106

ANS: B
Disease-modifying antirheumatic drugs are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA.

Question 107

Which of the following is a major problem facing many patients with chronic fatigue syndrome (CFS)?

a. Obesity
b. Malnutrition
c. Financial instability
d. Homelessness

Answer 107

ANS: C
One of the major problems facing many patients with CFS is financial instability. When the illness strikes, they cannot work or must decrease the amount of time spent working. Obtaining disability benefits can be frustrating because of the difficulty in establishing a diagnosis of CFS.

Question 108

The home health care nurse is doing a follow-up visit to a patient with recently diagnosed RA. Which nursing assessment indicates that more patient teaching is needed?

a. The patient sleeps with two pillows under the head.
b. The patient has been taking 16 aspirins daily.
c. The patient requires a 2-hour midday nap.
d. The patient sits on a stool when preparing meals.

Answer 108

ANS: A
The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping.

Question 109

A patient with an acute attack of gout in the left great toe has a new prescription for probenecid (Benuryl). Which information about the patient’s home routine indicates a need for teaching regarding gout management?

a. The patient takes one aspirin a day prophylactically to prevent angina.
b. The patient sleeps about 8 to 10 hours every night.
c. The patient generally drinks about 2.8 L of juice and water daily.
d. The patient usually eats beef once or twice a week.

Answer 109

ANS: A

Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid.

Question 110

When reading the history and physical on a patient with fibromyalgia syndrome, the nurse reads that the lateral epicondyle is a tender point for this patient. Based on knowledge about tender points in fibromyalgia, the nurse would avoid which area of the patient’s body?

a. Back of the neck
b. Upper shoulders
c. Elbow area
d. Knee area

Answer 110

ANS: C

A tender point in the lateral epicondyle is in the area of the elbow.

Question 111

A young man was admitted 2 days ago to the critical care unit (CCU) in critical condition with multiple traumas following an automobile accident. His wife and his parents have been at the hospital constantly since his admission, rotating short visits with the patient. While in the waiting room, they jump up each time the CCU door is opened. To assist the patient’s family members to cope with their anxiety, what should the nurse do?

a. Allow one member of the family most important to the patient to stay with the patient continuously.
b. Provide frequent information about the patient’s condition and the management of his care.
c. Invite the family members to participate in a multidisciplinary care conference for the patient.
d. Refer the family to social services for financial planning to manage the expenses of the patient’s care.

Answer 111

ANS: B

Lack of information is a major source of anxiety for family members and should be addressed first.

Question 112

The nurse identifies a nursing diagnosis of disturbed sensory perception related to sleep deprivation for a patient in the CCU. What is an appropriate nursing intervention for this problem?

a. Cluster nursing activities and plan uninterrupted rest periods.
b. Administer prescribed sedatives or hypnotics at bedtime to promote sleep.
c. Silence the alarms on monitoring equipment to allow the patient to take 30- to 40-minute naps.
d. Explain to the patient the types of noise in the environment and reasons that the noise is necessary.

Answer 112

ANS: A

Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle disruption.

Question 113

To meet the nutritional needs of a patient with extensive burns in the CCU, why should the nurse primarily suggest enteral feedings?

a. Because enteral feedings are less expensive than parenteral nutrition
b. Because complications of enteral feedings are fewer than those associated with parenteral nutrition
c. Because nutrition provided via the gastrointestinal tract helps maintain gut integrity and prevent translocation of bacteria
d. Because the patient has limited vascular access for parenteral nutrition because of other intravenous and arterial lines needed for monitoring

Answer 113

ANS: C
The primary goal of nutritional support is to prevent or correct nutritional deficiencies. This is usually accomplished by the early provision of enteral nutrition (i.e., delivery of calories via the gastrointestinal tract) or parenteral nutrition (i.e., delivery of calories intravenously). Enteral nutrition is thought to preserve the structure and function of the gut mucosa and possibly help prevent the translocation of gut bacteria.

Question 114

During hemodynamic monitoring, the nurse finds that a patient has a decreased cardiac output (CO) without change in pulmonary artery wedge pressure (PAWP) or systemic vascular resistance (SVR). The nurse identifies which of the following factors as most likely responsible for the decreased output?

a. Decreased stroke volume (SV)
b. Decreased heart rate (HR)
c. Increased right atrial pressure
d. Increased mean arterial pressure (MAP)

Answer 114

ANS: B
The formula for CO is SV × HR. Because the PAWP and SVR are unchanged, the patient’s SV is stable, so a drop in HR has occurred to decrease the CO.

Question 115

A patient in heart failure following an acute myocardial infarction has a pulmonary artery flow–directed catheter inserted. Following the administration of medications to decrease preload and afterload, the nurse determines that the medications have been effective when hemodynamic measurements reveal which of the following findings?

a. Increased SVR
b. Increased central venous pressure
c. Increased pulmonary vascular resistance (PVR)
d. Decreased PAWP

Answer 115

ANS: D
Although all of these parameters will change after administration of drugs to reduce preload and afterload, a decrease in PAWP would be the best indicator of a decrease in pressure and volume in the left ventricle at the end of diastole (and of resolving heart failure).

Question 116

A patient with hemodynamic monitoring has a blood pressure of 94/68 mm Hg, HR of 130 beats/min, CO of 4.8 L/min, and mixed venous oxygen saturation (SvO2) of 64%. In analyzing the patient’s hemodynamic measurements, the nurse calculates his SV at which of the following findings?

a. 23 mL/beat
b. 37 mL/beat
c. 42 mL/beat
d. 59 mL/beat

Answer 116

ANS: B
The formula for CO is HR × SV. Because the patient’s CO is 4.8 L/min and the HR is 130 beats/min, the SV must be 37 mL/beat.

Question 117

Which assessment finding is a normal value for a preload right atrial pressure at rest?

a. 0.5 mm Hg
b. 1.5 mm Hg
c. 4.5 mm Hg
d. 10 mm Hg

Answer 117

ANS: C

A normal value for a preload right atrial pressure at rest is between 2 and 8 mm Hg.

Question 118

To ensure accuracy in measurement of blood pressure with an invasive monitoring catheter, what should the nurse do?

a. Balance and calibrate the monitoring equipment every hour.
b. Ensure that the patient is lying supine with the head of the bed flat.
c. Position the zero-reference stopcock line level with the phlebostatic axis.
d. Position the limb with the catheter insertion site at zero reference of the stopcock line.

Answer 118

ANS: C

For accurate measurement of pressures, the zero-reference level should be at the phlebostatic axis.

Question 119

A patient with left ventricular failure is admitted to the CCU. The nurse evaluates that the patient’s condition is improving when hemodynamic monitoring reveals which of the following information?

a. Increased SVR
b. Increased PVR
c. Decreased MAP
d. Decreased pulmonary artery occlusive pressure (PAOP)

Answer 119

ANS: D
PAOP reflects left ventricular end-diastolic pressure (or left ventricular preload). Because the patient in left ventricular failure will have a high PAOP, a decrease in this value will be the best indicator of patient improvement.

Question 120

A patient has an arterial pressure catheter placed in the radial artery for access for frequent arterial sampling for blood gas analysis. When the low-pressure alarm is activated, what should the nurse assess the patient for?

a. Cardiac dysrhythmias
b. Thrombus formation around the catheter
c. Signs of impaired circulation to the hand
d. Signs of inflammation around the insertion site

Answer 120

ANS: A

The low-pressure alarm indicates a drop in the patient’s blood pressure, which may be caused by cardiac dysrhythmias.

Question 121

Which SvO2 value indicates that the patient has a balanced oxygen supply and demand?

a. 20%
b. 35%
c. 60%
d. 90%

Answer 121

ANS: C

A normal SvO2 value is between 60% and 80%.

Question 122

To prevent complications during the insertion of a pulmonary artery flow–directed catheter, it is important for the nurse to monitor which of the following parameters?

a. Cardiac activity
b. Coagulation status
c. Wave pressure tracings
d. Fluid and electrolyte status

Answer 122

ANS: A
Cardiac activity must be carefully monitored because dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it is important for the nurse to monitor for these during insertion.

Question 123

When assisting with insertion of a pulmonary artery catheter, how does the nurse identify that the catheter is correctly placed?

a. A normal pulmonary artery waveform is observed on the monitor.
b. A typical PAOP waveform is observed on the monitor.
c. The systemic arterial pressure tracing appears on the monitor.
d. It has been inserted 22 cm from the jugular vein insertion site.

Answer 123

ANS: B
The purpose of a pulmonary artery line is to measure PAOP, so the catheter is floated through the pulmonary artery until the dilated balloon wedges in a distal branch of the pulmonary artery and the PAOP readings are available. After insertion, the balloon is deflated and the pulmonary artery waveform will be observed.

Question 124

Which assessment data obtained by the nurse when caring for a patient with a left radial arterial line indicates a need for the nurse to take action?

a. The flush bag and tubing were last changed 3 days previously.
b. The left hand is cooler than the right hand.
c. The MAP is 75 mm Hg.
d. The system is delivering only 3 mL of flush solution per hour.

Answer 124

ANS: B

The change in temperature of the left hand suggests that blood flow to the left hand is impaired.

Question 125

The SvO2 is decreasing in a patient with hemodynamic monitoring who has a severe pancreatitis. Arterial blood gases (ABG) indicate that the arterial partial pressure of oxygen (PaO2) is unchanged, and the hemoglobin and CO are stable. To determine the cause of the decreased SvO2, what should the nurse assess in the patient?

a. HR
b. Temperature
c. Urinary output
d. Level of consciousness

Answer 125

ANS: B
Elevated temperature increases metabolic demands and oxygen use by tissues, resulting in a drop in oxygen saturation of mixed venous blood.

Question 126

An intra-aortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which of the following assessment findings indicates to the nurse that the goals of treatment with the IABP are being met?

a. A CO of 2 L/min
b. An SV of 40 mL/beat
c. HR 110 beats/min
d. Urinary output 100 mL/hour

Answer 126

ANS: D

A urinary output of 100 mL/hour indicates good renal perfusion and CO.

Question 127

The nurse identifies a collaborative problem of potential for arterial trauma secondary to displacement of the balloon for a patient with an IABP. What is an appropriate nursing action for this problem?

a. Administer prophylactic heparin as ordered.
b. Check the insertion site for bleeding every hour.
c. Measure the patient’s urinary output every hour.
d. Keep the head of the bed elevated 30 to 45 degrees.

Answer 127

ANS: C

Displacement of the balloon might occlude the renal arteries, which would decrease renal perfusion and urinary output.

Question 128

A patient with severe heart failure has a ventricular assist device (VAD) implanted. Which of the following should be included when developing the plan of care?

a. Teaching the patient the reason for continuous bed rest
b. Preparing the patient to have the VAD in place permanently
c. Monitoring the surgical incision for signs of infection
d. Administering immunosuppressive medications

Answer 128

ANS: C
The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring.

Question 129

A patient is admitted to the emergency department comatose with suspected head and neck injuries after falling from a roof. Which of the following devices does the nurse anticipate will maintain the airway patency in the patient?

a. A tracheostomy tube
b. An oropharyngeal airway
c. A nasal endotracheal (ET) tube
d. An oral ET tube

Answer 129

ANS: C
An ET tube would be inserted through the patient’s nose when a head and neck injury is suspected to avoid further trauma.

Question 130

How often should all oral suction equipment and tubing be changed for a patient who is on a mechanical ventilator?

a. Every 4 hours
b. Every 12 hours
c. Every 24 hours
d. Every 72 hours

Answer 130

ANS: C

All oral suction equipment and suction tubing should be changed every 24 hours.

Question 131

To inflate the cuff of an ET when the patient is on mechanical ventilation, what should the nurse do?

a. Inflate the cuff with 10 mL of air.
b. Inject air into the cuff to a pressure of 20 mm Hg.
c. Inject air into the cuff until no leak is heard at peak inspiratory pressure.
d. Inflate the cuff until the pilot balloon cannot be easily compressed with the fingers.

Answer 131

ANS: C
The minimal occluding volume technique involves injecting air into the cuff until no air leak is present at the peak inspiratory pressure.

Question 132

When the ventilator alarm sounds, the nurse finds the patient sitting up in bed holding the ET. What is the first intervention the nurse should initiate?

a. Establish a patent airway.
b. Call the physician to reinsert the tube.
c. Activate the resuscitation protocol of the institution.
d. Manually ventilate the patient with 100% oxygen and a bag-valve-mask.

Answer 132

ANS: D

The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system.

Question 133

While suctioning a patient with an ET, the nurse notes the occurrence of premature ventricular contractions on the patient’s cardiac monitor. What is the most appropriate nursing action on observing this finding?

a. Lower the suction pressure to 60 mm Hg.
b. Ventilate the patient with 100% oxygen with a bag-valve-mask.
c. Notify the physician of the need for antidysrhythmic medications.
d. Provide an explanation of the suctioning procedure to decrease the patient’s anxiety.

Answer 133

ANS: B
Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation, and the nurse should stop suctioning and ventilate the patient with 100% oxygen.

Question 134

Which assessment information obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning?

a. The patient has not been suctioned for the last 6 hours.
b. The lungs have occasional audible expiratory wheezes.
c. The respiratory rate is 32 breaths/min.
d. The pulse oximeter shows arterial oxygenation of 95%.

Answer 134

ANS: C

The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning.

Question 135

A patient with an oral endotracheal tube has a nursing diagnosis of risk for aspiration related to presence of artificial airway. What is an appropriate nursing intervention for the patient?

a. Perform oral suctioning frequently and before cuff deflation.
b. Remove the bite block and perform oral hygiene every 2 hours.
c. Maintain cuff pressure at minimal occluding volume to prevent gastric secretions from entering the trachea.
d. Use chest physiotherapy to move secretions to large airways, where they can be suctioned.

Answer 135

ANS: A
Performing oral suctioning frequently and especially before cuff deflation decreases the risk for secretions accumulating above the ET cuff and moving past the cuff into the lungs.

Question 136

Which of the following is a measurement that would indicate to the nurse that the patient is ready to be weaned off of mechanical ventilation?

a. Respiratory rate 22 beats/min
b. Minute ventilation of 12 L/min
c. Negative inspiratory force of –85 cm H2O
d. Positive expiratory pressure of 50 cm H2O

Answer 136

ANS: C
A negative inspiratory force of –85 cm H2O is within the normal limits of –75 to –100 cm H2O to wean a patient from a mechanical ventilator.

Question 137

Which finding represents a normal SV when monitoring hemodynamic parameters?

a. 25 mL/beat
b. 50 mL/beat
c. 100 mL/beat
d. 200 mL/beat

Answer 137

ANS: C

A normal SV when monitoring hemodynamic parameters is a value between 60 and 150 mL/beat.

Question 138

The charge nurse evaluates the care that a new registered nurse (RN) staff member provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education?

a. Turns the FIO2 up to 100% before suctioning
b. Asks for assistance to turn the patient to the prone position
c. Secures a bite block in place using adhesive tape
d. Positions the patient with the head of the bed at 10 degrees

Answer 138

ANS: D
The head of the patient’s bed should be positioned at 30 to 45 degrees, rather than 10 degrees, to prevent ventilator-associated pneumonia.

Question 139

A patient with chronic obstructive pulmonary disease (COPD) is in acute respiratory failure and has been placed on mechanical ventilation. Four hours after mechanical ventilation is initiated, the patient’s ABG results include a pH of 7.50, PaO2 of 80 mm Hg, arterial partial pressure of carbon dioxide (PaCO2) of 29 mm Hg, and bicarbonate of 23 mmol/L. The nurse will anticipate the need to do which of the following?

a. Increase the FIO2.
b. Increase the tidal volume.
c. Decrease the respiratory rate.
d. Leave the ventilator on the current settings.

Answer 139

ANS: C

The patient’s PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate.

Question 140

A patient has a nursing diagnosis of risk for injury related to asynchrony with the ventilator secondary to anxiety. Initially, what should the nurse do?

a. Verbally coach the patient to breathe with the ventilator.
b. Sedate the patient with morphine or lorazepam (Ativan).
c. Use a manual resuscitation bag with 100% oxygen to rapidly ventilate the patient.
d. Increase the ventilator rate to override the patient’s efforts at breathing.

Answer 140

ANS: A
The nurse’s initial response should be to try to decrease the patient’s anxiety by verbally coaching the patient to breathe because anxiety is the major contributing factor placing the patient at risk for injury.

Question 141

A patient with acute respiratory failure is receiving assist-control mechanical ventilation with a PEEP of 10 cm H2O and has an artery line and pulmonary artery catheter. Which of the following indicates that a change in the ventilator settings may be required?

a. Decreased pulmonary artery pressure (PAP)
b. Decreased MAP
c. Increased PAOP
d. Increased HR

Answer 141

ANS: B
The hypotension indicates that the high intrathoracic pressure caused by the PEEP may be decreasing venous return and CO.

Question 142

Which action by a new RN working in the CCU indicates that the education regarding care of the patient receiving manual ventilation with 10 cm of PEEP has been effective?

a. Suctions the patient every 2 hours
b. Tapes the connection between the ventilator tubing and the endotracheal tube
c. Uses a closed-suction technique to suction the patient
d. Changes the ventilator circuit tubing routinely every 24 hours

Answer 142

ANS: C
The closed-suction technique is suggested when patients require high levels of PEEP to prevent the loss of PEEP that occurs when disconnecting the patient from the ventilator.

Question 143

When weaning a patient who has COPD from mechanical ventilation, which patient assessment indicates that the weaning protocol should be discontinued?

a. The patient HR is 98 beats/min.
b. The patient’s spontaneous tidal volume is 500 mL.
c. The patient’s oxygen saturation is 91%.
d. The patient respiratory rate is 32 breaths/min.

Answer 143

ANS: D

Tachypnea is a sign that the patient’s work of breathing is too high to allow weaning to proceed.

Question 144

A patient with a subarachnoid hemorrhage is intubated and placed on a mechanical volume-cycled ventilator in the spontaneous intermittent mandatory volume mode, FIO2 40%, rate 14, tidal volume 700, with 10 cm of PEEP. Which of the following indicates a need for the nurse to notify the physician?

a. Respiratory rate of 18 breaths/min
b. O2 saturation of 94%
c. Increased jugular vein distension
d. Greenish brown nasogastric tube drainage

Answer 144

ANS: C
Increases in jugular vein distension in a patient with a subarachnoid hemorrhage may indicate an increase in intracranial pressure and that the PEEP is too high for this patient.

Question 145

The nurse is caring for a patient receiving a continuous norepinephrine (Levophed) intravenous infusion. Which patient assessment information indicates that the infusion rate may be too high?

a. HR is 58 beats/min.
b. MAP is 55 mm Hg.
c. SVR is elevated.
d. PAOP is low.

Answer 145

ANS: C
Vasoconstrictors such as norepinephrine will increase SVR, and this will increase the work of the heart and decrease peripheral perfusion.

Question 146

When caring for the patient with a PAP catheter, the nurse notes that the pulmonary artery waveform indicates that the catheter is in the wedged position. Which action should the nurse take?

a. Zero-balance the transducer.
b. Inflate the pulmonary artery balloon.
c. Notify the physician.
d. Change the flush system.

Answer 146

ANS: C
When the catheter is in the wedge position, blood flow past the catheter is obstructed, placing the patient at risk for pulmonary infarction. A physician should be called to reposition the catheter, not the CCU nurse.

Question 147

Which action by a new RN who is caring for a patient with an intra-aortic balloon catheter inserted in the left femoral artery will require immediate intervention by the CCU charge nurse?

a. Checks the patient’s pedal pulses every 30 minutes
b. Elevates the head of the patient’s bed to 90 degrees
c. Turns the patient onto the left side
d. Informs the patient to take deep breaths

Answer 147

ANS: B

The head of the bed should not be elevated more than 45 degrees to avoid kinking the IABP catheter.

Question 148

While assessing a patient with a central venous catheter in place in the left subclavian vein, the nurse notes that the catheter insertion site is red and tender and that the patient’s temperature is 38.8°C. The nurse will plan to implement which of the following?

a. Change the flush system and monitor the site.
b. Administer analgesics and antibiotics.
c. Discontinue the catheter, and culture the tip.
d. Check the site frequently for any swelling.

Answer 148

ANS: C
The information indicates that the patient has a local and systemic infection caused by the catheter, and the catheter should be discontinued.

Question 149

An older adult patient who has been in the CCU for a week is preparing for transfer to the step-down unit when the nurse notices that the patient has new-onset restlessness and confusion. The patient’s physiological status is stable and otherwise unchanged. What should the nurse do?

a. Inform the receiving nurse, and proceed with the transfer.
b. Notify the health care provider, and postpone the transfer.
c. Administer as-needed lorazepam, and proceed with the transfer.
d. Obtain an order to restrain the patient, and proceed with the transfer.

Answer 149

ANS: A
The patient’s history and symptoms most likely indicate delirium associated with the sleep deprivation and sensory overload in the CCU environment, and informing the receiving nurse and transferring the patient are appropriate.