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A patient has had a cast placed for the treatment of a humeral fracture. The nurse's most recent assessment shows signs and symptoms of compartment syndrome. What is the nurse's most appropriate action?
- A. Arrange for a STAT assessment of the patient's serum calcium levels.
- B. Perform active range of motion exercises.
- C. Assess the patient's joint function symmetrically.
- D. Contact the primary care provider immediately.
Correct Answer: D
Rationale: This major neurovascular problem is caused by pressure within a muscle compartment that increases to such an extent that microcirculation diminishes, leading to nerve and muscle anoxia and necrosis. Function can be permanently lost if the anoxic situation continues for longer than 6 hours. Therefore, immediate medical care is a priority over further nursing assessment. Assessment of calcium levels is unnecessary.
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A nurse is caring for a patient with a diagnosis of cancer that has metastasized. What laboratory value would the nurse expect to be elevated in this patient?
- A. Bilirubin
- B. Potassium
- C. Alkaline phosphatase
- D. Creatinine
Correct Answer: C
Rationale: Alkaline phosphatase is elevated during early fracture healing and in diseases with increased osteoblastic activity (e.g., metastatic bone tumors). Elevated bilirubin, potassium, and creatinine would not be expected in a patient with metastatic bone tumors.
A nurse is assessing a patient who is experiencing peripheral neurovascular dysfunction. What assessment findings are most consistent with this diagnosis?
- A. Hot skin with a capillary refill of 1 to 2 seconds
- B. Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin
- C. Pain, diaphoresis, and erythema
- D. Jaundiced skin, weakness, and capillary refill of 3 seconds
Correct Answer: B
Rationale: Indicators of peripheral neurovascular dysfunction include pale, cyanotic, or mottled skin with a cool temperature; capillary refill greater than 3 seconds; weakness or paralysis with motion; and paresthesia, unrelenting pain, pain on passive stretch, or absence of feeling. Jaundice, diaphoresis, and warmth are inconsistent with peripheral neurovascular dysfunction.
A nurse is caring for an older adult who has been diagnosed with geriatric failure to thrive. This patient's prolonged immobility creates a risk for what complication?
- A. Muscle clonus
- B. Muscle atrophy
- C. Rheumatoid arthritis
- D. Muscle fasciculations
Correct Answer: B
Rationale: If a muscle is in disuse for an extended period of time, it is at risk of developing atrophy, which is the decrease in size. Clonus is a pattern of rhythmic muscle contractions and fasciculation is the involuntary twitch of muscle fibers; neither results from immobility. Lack of exercise is a risk factor for rheumatoid arthritis.
A public health nurse is organizing a campaign that will address the leading cause of musculoskeletal-related disability in the United States. The nurse should focus on what health problem?
- A. Osteoporosis
- B. Arthritis
- C. Hip fractures
- D. Lower back pain
Correct Answer: B
Rationale: The leading cause of musculoskeletal-related disability in the United States is arthritis.
A patient injured in a motor vehicle accident has sustained a fracture to the diaphysis of the right femur. Of what is the diaphysis of the femur mainly constructed?
- A. Epiphyses
- B. Cartilage
- C. Cortical bone
- D. Cancellous bone
Correct Answer: C
Rationale: The long bone shaft, which is referred to as the diaphysis, is constructed primarily of cortical bone.