Nokea
A bone biopsy has just been completed on a patient with suspected bone metastases. What assessment should the nurse prioritize in the immediate recovery period?
- A. Assessment for dehiscence at the biopsy site
- B. Assessment for pain
- C. Assessment for hematoma formation
- D. Assessment for infection
Correct Answer: B
Rationale: Bone biopsy can be painful and the nurse should prioritize relevant assessments. Dehiscence is not a possibility, since the incision is not linear. Signs and symptoms of infection would not be evident in the immediate recovery period and hematoma formation is not a common complication.
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A patient has just had an arthroscopy performed to assess a knee injury. What nursing intervention should the nurse implement following this procedure?
- A. Wrap the joint in a compression dressing.
- B. Perform passive range of motion exercises.
- C. Maintain the knee in flexion for up to 30 minutes.
- D. Apply heat to the knee.
Correct Answer: A
Rationale: Interventions to perform following an arthroscopy include wrapping the joint in a compression dressing, extending and elevating the joint, and applying ice or cold packs. Passive ROM exercises, static flexion, and heat are not indicated.
A nurse is caring for a patient who has just had an arthroscopy as an outpatient and is getting ready to go home. The nurse should teach the patient to monitor closely for what postprocedure complication?
- A. Fever
- B. Crepitus
- C. Fasciculations
- D. Synovial fluid leakage
Correct Answer: A
Rationale: Following arthroscopy, the patient and family are informed of complications to watch for, including fever. Synovial fluid leakage is unlikely and crepitus would not develop as a postprocedure complication. Fasciculations are muscle twitches and do not involve joint integrity or function.
A nurse is taking a health history on a patient with musculoskeletal dysfunction. What is the primary focus of this phase of the nurse's assessment?
- A. Evaluating the effects of the musculoskeletal disorder on the patient's function
- B. Evaluating the patient's adherence to the existing treatment regimen
- C. Evaluating the presence of genetic risk factors for further musculoskeletal disorders
- D. Evaluating the patient's active and passive range of motion
Correct Answer: A
Rationale: The nursing assessment of the patient with musculoskeletal dysfunction includes an evaluation of the effects of the musculoskeletal disorder on the patient. This is a vital focus of the health history and supersedes the assessment of genetic risk factors and adherence to treatment, though these are both valid inclusions to the interview. Assessment of ROM occurs during the physical assessment, not the interview.
A patient's fracture is healing and callus is being deposited in the bone matrix. This process characterizes what phase of the bone healing process?
- A. The reparative phase
- B. The reactive phase
- C. The remodeling phase
- D. The revascularization phase
Correct Answer: A
Rationale: Callus formation takes place during the reparative phase of bone healing. The reactive phase occurs immediately after injury and the remodeling phase builds on the reparative phase. There is no discrete revascularization phase.
A nurse's assessment of a teenage girl reveals that her shoulders are not level and that she has one prominent scapula that is accentuated by bending forward. The nurse should expect to read about what health problem in the patient's electronic health record?
- A. Lordosis
- B. Kyphosis
- C. Scoliosis
- D. Muscular dystrophy
Correct Answer: C
Rationale: Scoliosis is evidenced by an abnormal lateral curve in the spine, shoulders that are not level, an asymmetric waistline, and a prominent scapula, accentuated by bending forward. Lordosis is the curvature in the lower back; kyphosis is an exaggerated curvature of the upper back. This finding is not suggestive of muscular dystrophy.