Nokea
A hospitalized clients strength of the upper extremities is rated at 3. What does the nurse understand about this clients ability to perform activities of daily living (ADL)?
- A. The client is able to perform ADLs but not for some items.
- B. No difficulties are expected with ADL.
- C. The client is unable to perform ADL alone.
- D. The client would need near-total assistance with ADLs.
Correct Answer: A
Rationale: This rating indicates fair muscle strength with full range of motion against gravity but not resistance. The client could complete ADLs independently unless they required lifting objects.
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The nurse knows that hematopoiesis occurs in what part of the musculoskeletal system?
- A. Cancellous tissue
- B. Cellow tissue
- C. Red marrow
- D. Yellow marrow
Correct Answer: C
Rationale: Hematopoiesis occurs in the red marrow, which is part of the cancellous tissues containing both types of bone tissue.
A school nurse is conducting scoliosis screening. In screening the client, what technique is most appropriate?
- A. Bending forward from the hips
- B. Sitting upright with arms outstretched
- C. Walking across the room and back
- D. Walking with both eyes closed
Correct Answer: A
Rationale: To assess for scoliosis, a spinal deformity, the student should bend forward at the hips. Standing behind the student, the nurse looks for a lateral curve in the spine. The other actions are not correct.
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.
The nurse is assessing four clients with musculoskeletal disorders. The nurse should assess the client with which laboratory result first?
- A. Serum alkaline phosphatase (ALP): 108 units/L.
- B. Serum aspartate aminotransferase (AST): 26 units/L.
- C. Serum calcium: 10.2 mg/dL.
- D. Serum phosphate: 2 mg/dL.
Correct Answer: D
Rationale: A serum phosphorus level of 2 mg/dL is below the normal range (2.5"?4.5 mg/dL), indicating a potential issue such as hypophosphatemia, which can affect bone health and requires immediate assessment. The other lab results are within normal ranges.
A client is having a myologgraphy. What action by the nurse is most important?
- A. Assesses with any nursing microctioning (AST) levels.
- B. Ensure that informed consent is on the chart.
- C. Position the client that after the procedure.
- D. Reinforce the dressing if it becomes saturated.
Correct Answer: B
Rationale: The diagnostic procedure is invasive and requires informed consent. The AST does not need to be assessed prior to the procedure. The client is positioned with the head of the bed elevated after the test to keep the contrast material out of the brain. The dressing should not become saturated; if it does, the nurse calls the provider.