Nokea
A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to be pale and cool, with 1+ pedal pulses. What action by the nurse is best?
- A. Assess the neurovascular status of the right leg.
- B. Document the findings in the clients chart.
- C. Elevate the left leg on at least two pillows.
- D. Notify the provider of the findings immediately.
Correct Answer: A
Rationale: The nurse should compare findings of the two legs as these findings may be normal for the client. If a difference is observed, the nurse notifies the provider. Documentation should occur after the nurse has all the data. Elevating the left leg will not improve perfusion if there is a problem.
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The clients chart indicates genu varum. What does the nurse understand this to mean?
- A. Bow-legged
- B. Fluid accumulation
- C. Knock-kneed
- D. Spinal curvature
Correct Answer: A
Rationale: Genu varum is a bow-legged deformity. A fluid accumulation is an effusion. Genu valgum is knock-kneed. A spinal curvature could be kyphosis or scoliosis.
A client is distressed at body changes related to kyphosis. What response by the nurse is best?
- A. Ask the client to explain more about these feelings.
- B. Explain that these changes are irreversible.
- C. Offer to help select clothes to hide the deformity.
- D. Tell the client safety is more important than looks.
Correct Answer: A
Rationale: Assessment is the first step of the nursing process, and the nurse should begin by getting as much information about the client's feelings as possible. Explaining that the changes are irreversible discounts the client's feelings. Depending on the extent of the deformity, clothing will not hide it. While safety is more objectively important than looks, the client is worried about looks and the nurse needs to address this issue.
A nurse is providing community education about preventing traumatic musculoskeletal injuries related to car crashes. Which group does the nurse target as the priority for this education?
- A. High school football team
- B. High school home room
- C. Middle-aged men
- D. Older adult women
Correct Answer: A
Rationale: Young men are at highest risk for musculoskeletal injury due to trauma, especially due to motor vehicle crashes. The high school football team, with its roster of young males, is the priority group.
A client is undergoing computed tomography (CT) of a joint. What action by the nurse is most important before the test?
- A. Administer sedation as prescribed.
- B. Assess for seafood or iodine allergy.
- C. Ensure that the client has no metal on the body.
- D. Reinforce the dressing if it becomes saturated.
Correct Answer: B
Rationale: Because CT uses iodine-based contrast material, the nurse assesses the client for allergies to iodine or seafood (which often contains iodine). The other actions are not needed.
A student nurse learns about changes that occur to the musculoskeletal system due to aging. Which changes clearly lead to increased safety risks?
- A. Increased bone density leads to stiffness.
- B. Increased joint flexibility enhances mobility.
- C. Osteoporosis is a universal occurrence.
- D. Decreased muscle mass reduces strength.
Correct Answer: D
Rationale: Decreased muscle mass reduces strength, which increases the risk of falls and injuries in older adults. Increased bone density is not typical with aging; osteoporosis, not universal, increases fracture risk but is not guaranteed. Increased joint flexibility is not a common aging change.