Diya Coaching Centre for Nurses

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Unit-16 Test-1 Answer

1. Correct Answer: 1
Rationale : Immobility and the weight of a casted arm may cause the shoulder above an arm fracture to
become stiff. The shoulder of a casted arm should be lifted over the head periodically as a preventive
measure. The use of slings further immobilizes the shoulder and may be contraindicated. Making fists with
the left hand provides good isometric exercise to maintain muscle strength. Range of motion of the
affected fingers is also a useful general measure. Lifting the right arm is of no particular value.

2. Correct Answer: 1
Rationale : A fiberglass cast is made of water-activated polyurethane materials that are dry to the touch
within minutes and reach full rigid strength in about 20 minutes. Because of this, the client can bear weight
on the cast within 20 to 30 minutes.

3. Correct Answer: 4
Rationale : Client instructions should include avoiding walking on wet, slippery floors to prevent falls.
Surface soil on a cast can be removed with a damp cloth. If the cast gets wet, it can be dried with a hair
dryer set to a cool setting to prevent skin breakdown. If the skin under the cast itches, cool air from a hair
dryer may be used to relieve it. The client should never scratch under a cast because of the risk of skin
breakdown and ulcer formation.

4. Correct Answer: 2
Rationale : Buck's extension traction is a type of skin traction often applied after hip fracture before the
fracture is reduced in surgery. It reduces muscle spasms and helps to immobilize the fracture. It does not
lengthen the leg for the purpose of preventing blood vessel severance. It also does not allow for bony
healing to begin.

5. Correct Answer: 4
Rationale : If the client in skeletal traction may not turn from side to side, the nurse should have the
client pull up on a trapeze and try to lift the hips off the bed for skin care, bed pan use, and linen changes.
If the client is unable to pull up on a trapeze, the nurse can push down on the mattress with one hand while
administering care with the other.

6. Correct Answer: 2
Rationale : A small amount of serous oozing is expected at pin insertion sites. Signs of infection such as
inflammation, purulent drainage, and pain at the pin site are not expected findings, and should be reported
to the physician.

7. Correct Answer: 1
Rationale : A major defining characteristic of Diversional Activity Deficit is expression of boredom by
the client. The question does not identify difficulties with coordination, range of motion, or muscle
strength, which would indicate Impaired Physical Mobility. The question also does not relate client
feelings of inability to perform activities of daily living (Self-Care Deficit) or lack of control
(Powerlessness).

8. Correct Answer: 3
Rationale : Buck's extension traction is a type of skin traction. The nurse inspects the skin of the limb in
traction at least once every 8 hours for irritation or inflammation. Massaging the skin with lotion is not
indicated. The nurse never releases the weights of traction unless specifically ordered by the physician.
There are no pins to care for with skin traction.

9. Correct Answer: 4

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Rationale : A client who complains of severe pain may need realignment, or may have traction weights
ordered that are too heavy. The nurse realigns the client, and if that is ineffective, then calls the physician.
Severe leg pain, once traction has been established, indicates a problem. Medicating the client should be
done after one has tried to determine and treat the cause. Providing pin care is unrelated to the problem as
described.
10. Correct Answer: 2
Rationale : Signs and symptoms of infection under a casted area include odor or purulent drainage from
the cast, or the presence of "hot spots," which are areas of the cast that are warmer than others. The
physician should be notified if any of these occur. Signs of impaired circulation in the distal limb include
coolness and pallor of the skin, diminished arterial pulse, and edema.

11. Correct Answer: 1

Rationale : Most pain associated with fractures can be minimized with rest, elevation, application of
cold, and administration of analgesics. Pain that is not relieved by these measures should be reported to the
physician, because it may result from impaired tissue perfusion, tissue breakdown, or necrosis. Since this is
a new closed fracture and cast, infection would not have had time to set in.

12. Correct Answer: 3

Rationale : A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling
and to promote venous drainage. Options 1, 2, and 4 are incorrect.

13. Correct Answer: 3

Rationale : With an open fracture, the client is at risk of developing osteomyelitis, gas gangrene, and
tetanus. The nurse assesses for the date of the last tetanus immunization to ensure that the client has tetanus
prophylaxis.

14. Correct Answer: 2

Rationale : Clients who use cadaver bone can develop psychological problems due to worry about
contracting the HIV virus or hepatitis from cadaver bone. Clients need reassurance and information about
the donor screening that is done to ensure that this does not occur. The level of pain that will be
experienced in the postoperative period should be included as part of the basic preparation of the client for
surgery.

15. Correct Answer: 1

Rationale : Clients who experience fractures of the femur, pelvis, thorax, and spine are at risk for
hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal
cavity and the thigh. This can occur with closed fractures as well as open fractures. Signs of hypovolemic
shock include tachycardia and hypotension.

16. Correct Answer: 4

Rationale : A window may be cut in a dried cast to relieve pressure, assess pulses, relieve discomfort, or
remove drains. Bivalving the cast involves splitting the cast along both sides to allow space for swelling, to
facilitate taking x-ray films, or to make a half-cast for use as an intermittent splint. Padding is not placed
on top of a cast. The use of an air splint is not indicated.

17. Correct Answer: 4

Rationale : Clients may be fearful of having a cast removed because of their misconceptions about the
cast-cutting blade. The nurse should show the cast cutter to the client before it is used and explain that the
client may feel heat, vibration, and pressure. The cast cutter resembles a small electric saw with a circular
blade. The nurse should reassure the client that the blade does not cut like a saw, but instead cuts the cast
by vibrating side to side.

18. Correct Answer: 2

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Rationale : The skin under a casted area may be discolored and crusted with dead skin layers. The client
should gently soak and wash the skin for the first few days. The skin should be patted dry, and a
lubricating lotion should be applied. Clients often want to scrub the dead skin away, which irritates the
skin. The client should avoid overexposing the skin to the sunlight.

19. Correct Answer: 4

Rationale : Common areas that are under pressure and are at risk for breakdown include the elbows (if
they are used for repositioning instead of a trapeze) and the heel of the good leg (which is used as a brace
when pushing up in bed). Other pressure points caused by the traction include the ischial tuberosity,
popliteal space, and Achilles tendon.

20. Correct Answer: 4

Rationale : The nurse petals the edges of the cast with tape to minimize skin irritation. If a client has a
cast applied and returns home, the client can be taught to do the same.

21. Correct Answer: 3

Rationale : The use of an overhead trapeze is extremely helpful in helping a client to move about in bed,
and to get on and off the bedpan. This device has the greatest value in increasing overall bed mobility. A
fracture bedpan is useful in reducing discomfort with elimination. Television and reading materials are
helpful in reducing boredom and providing distraction.

22. Correct Answer: 1

Rationale : A plaster cast must remain dry to keep its strength. The cast should be handled with the palms
of the hands, not the fingertips, until fully dry. Air should circulate freely around the cast to help it dry; the
cast also gives off heat as it dries. The client should never scratch under the cast; a cool hair dryer may be
used to eliminate an itch.

23. Correct Answer: 4

Rationale : Expected outcomes for Impaired Physical Mobility for the client in traction include absence
of thrombophlebitis (measurable by negative Homan's sign), active baseline ROM to uninvolved joints,
clear lung sounds, intact skin, and bowel movement every other day.

24. Correct Answer: 3

Rationale : Crutches are measured so that the tops are 3 to 4 fingerbreadths or 1 to 2 inches from the
axillae. This assures that the client's axillae are not resting on the crutch or bearing the weight of the
crutch. This could result in injury to the nerves of the brachial plexus.

25. Correct Answer: 1

Rationale : Risk factors associated with osteoporosis include a diet that is deficient in calcium. Options 2,
3, and 4 include risk factors associated with osteoporosis. Additional risk factors include sedentariness,
cigarette smoking, excessive alcohol consumption, chronic illness, and long-term use of anticonvulsants
and furosemide.

26. Correct Answer: 1

Rationale : The classic tripod position is taught to the client before one gives instructions on gait. The
crutches are placed anywhere from 6 to 10 inches in front and to the side of the client, depending on the
client's body size. This provides a wide enough base of support to the client and improves balance.
27. Correct Answer: 4
Rationale : Foods high in calcium include plain yogurt, dairy products, seafood, sardines, green
vegetables, calcium-fortified orange juice, and cereal. Of the items listed, option 4 contains the least
amount of calcium.

28. Correct Answer: 2

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Rationale : Crutch tips should remain dry. Water could cause slipping by decreasing the surface friction
of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel.
The client should use only crutches measured for the client. The tips should be inspected for wear, and
spare crutches and tips should be available if needed.

29. Correct Answer: 1

Rationale : Ample fluid intake is encouraged to promote the excretion of uric acid. The client is placed
on bed rest until the pain subsides. A diet low in purine is normally prescribed. NSAIDs are used to reduce
pain and inflammation. Colchicine, which also may be prescribed, reduces the migration of leukocytes to
the synovial fluid.

30. Correct Answer: 1

Rationale : Rheumatoid arthritis is characterized by chronic joint pain of varying intensity, which is more
severe upon rising in the morning. The nurse would note that joint involvement is symmetrical and the
joints are swollen, shiny, reddened, and painful. Rheumatoid nodules, which are painless subcutaneous
movable skin nodules near bony prominences, may occur anywhere on the body.

31. Correct Answer: 3

Rationale : The client is taught to hold the cane on J the side opposite from the weakness. The reason is
that, with normal walking," the opposite arm and leg move together (called reciprocal motion). The cane is
placed 6 inches lateral to the fifth toe.

32. Correct Answer: 3

Rationale : The cane is held on the stronger side to minimize stress on the affected extremity and provide
a wide base of support. The cane is held 6 inches lateral to the great toe. The cane is moved forward with
the affected leg. The client leans on the cane for added support while the stronger side swings through.

33. Correct Answer: 3

Rationale : Disturbed Body Image is characterized by negative verbalizations or feelings about a body
part. This is a common response after amputation. The nurse supports the client and assists the client to
work through these feelings. The client also may have the other nursing diagnoses listed in options 1, 2,
and 4, but Disturbed Body Image is the nursing diagnosis that correlates best with the client's statement.

34. Correct Answer: 2

Rationale : A key feature of fat embolism is a significant degree of hypoxemia, with a PaO2 often less
than 60 mm Hg. Options 1, 3, and 4 are normal blood gas results.

35. Correct Answer: 3

Rationale : Respiratory failure is the most common cause of death after fat embolus. The client may be
intubated and mechanically ventilated with PEEP to treat the significant hypoxemia and pulmonary edema.
Corticosteroids are given to treat inflammatory lung reactions and control cerebral edema.

36. Correct Answer: 1

Rationale : Skin lesions or rash on the face across the bridge of the nose and on the cheeks is a
characteristic sign of SLE. Fever and fatigue may potentially occur before and during exacerbation.
Anemia is most likely to occur in SLE.

37. Correct Answer: 3

Rationale : A clear chest radiograph is a good indicator that fat embolus is resolving. When fat embolism
occurs, there is a "snowstorm" appearance to the chest radiograph. Eupnea, not minimal dyspnea, is a
normal sign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be greater than
95%.

38. Correct Answer: 3

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Rationale : To help reduce fatigue in the client with SLE, the nurse should instruct the client to sit
whenever possible, to avoid hot baths, to schedule moderate low-impact exercises when not fatigued, and
to maintain a balanced diet. The client is instructed not to rest for long periods because it promotes joint
stiffness.

39. Correct Answer: 4

Rationale : Compartment syndrome is caused by bleeding and swelling within a compartment, which is
lined by fascia and does not expand. The bleeding and swelling put pressure on the nerves, muscles, and
blood vessels in the compartment, triggering the symptoms. Options 1,2, and 3 are inaccurate descriptions
of compartment syndrome.

40. Correct Answer: 1

Rationale : When going down the stairs with crutches, the client should be instructed to move the
crutches and the affected leg, then move the unaffected leg down. To go up the stairs, the client should
move the unaffected leg up first, then the affected leg and crutches up.

41. Correct Answer: 4

Rationale : The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the
fingers). Other symptoms include pain unrelieved by narcotics, pain that increases with limb elevation, and
pallor and coolness to the distal limb. Cyanosis is a late sign.

42. Correct Answer: 4

Rationale : In a three-point gait, the client is instructed to simultaneously move both crutches and the
affected leg forward; then the unaffected leg should be moved forward. Options 1 and 2 identify a four-
point gait. Option 3 identifies a swing-through gait.

43. Correct Answer: 1

Rationale : Following internal fixation of a hip fracture, the client is turned to the affected side or the
unaffected side as prescribed by the surgeon. Before moving the client, the nurse places a pillow between
the client's legs to keep the affected leg in abduction. The client is then repositioned while proper
alignment and abduction are maintained. A trochanter roll is useful in preventing external rotation, but it is
used once the client has been repositioned. It is not used while the client is being turned.
44. Correct Answer: 4
Rationale : Soft-tissue injuries such as sprains are treated with RICE-rest, ice, compression, and
elevation-for the first 24 hours after the injury. Ice is applied intermittently for 20 to 30 minutes at a time.
The client should rest, not walk around, and the foot should be elevated, not placed in a dependent
position. Heat is not used for the first 24 hours, because this could cause venous congestion and increase
edema and pain. Blankets would produce heat to the affected area.

45. Correct Answer: 1

Rationale : The nurse assists the client to get out of bed after putting a knee immobilizer on the affected
joint for stability. The surgeon orders the weight-bearing limits on the affected leg. To minimize edema,
the leg is elevated while the client is sitting in the chair. The CPM machine is used while the client is in
bed.

46. Correct Answer: 1

Rationale : The major dietary source of calcium is from dairy products, including milk, yogurt, and a
variety of cheeses. Calcium can also be added to certain products such as orange juice, which are then
advertised as being fortified with calcium. Calcium supplements are also available and recommended for
those with typically low calcium intake. Options 2, 3, and 4 are not high-calcium products.

47. Correct Answer: 2

Rationale : A stiff or frozen shoulder can develop as a complication of a cast on an upper extremity. The
client should be instructed to lift the shoulder of the casted arm over the head periodically throughout the

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day to prevent this complication. The client should not keep a sling on the arm at all times or wear the
sling at night. Range of motion exercises to the casted extremity will assist in preventing this complication.

48. Correct Answer: 4

Rationale : A small amount of serous oozing is expected at the pin insertion site. The nurse would
document the findings. It is not necessary to notify the physician. The nurse would not add or remove any
weight from the client's traction setup, because this would disrupt the alignment of the fracture.

49. Correct Answer: 2

Rationale : After TKR, the client should report signs and symptoms of infection and any changes in the
shape of the knee. Any of these could indicate developing complications. With a metal implant, the client
must be on anticoagulant therapy and should report adverse effects of this therapy, including bleeding from
a variety of sources. With a metal implant, the client must notify caregivers, because certain diagnostic
tests (magnetic resonance imaging) will need to be avoided, and the client will need antibiotic prophylaxis
for invasive procedures.

50. Correct Answer: 2

Rationale : A client at risk for osteoporosis needs to increase intake of calcium. The major dietary source
of calcium is dairy food, including milk, yogurt, and a variety of cheeses. Calcium may also be added to
certain products, such as orange juice, which is then advertised as being "fortified" with calcium. Calcium
supplements are available and recommended for those with typically low calcium intake. Options 1, 3, and
4 are not food sources high in calcium.

51. Correct Answer: 3

Rationale : Clients with diabetes mellitus are more prone to wound infection and delayed wound healing
due to the disease. Postoperative stump edema and hemorrhage are complications in the immediate
postoperative period that apply to any client with an amputation. Slight redness of the incision is
considered normal, as long it is dry and intact.

52. Correct Answer: 1

Rationale : Phantom limb sensations are felt in the area of the amputated limb. These can include itching,
warmth, and cold. The sensations are due to intact peripheral nerves in the area amputated. Whenever
possible, the client should be prepared for these sensations. The client may also feel painful sensations in
the amputated limb, called phantom limb pain. The origin of the pain is less well understood, but the client
should be prepared for this, too, whenever possible.

53. Correct Answer: 4

Rationale : A stump sock must be worn at all times to absorb perspiration and is changed daily. The
residual limb is washed, dried, and inspected for breakdown twice each day. The socket of the prosthesis is
cleansed with a mild detergent and rinsed and dried carefully each day. A harsh bactericidal agent would
not be used.

54. Correct Answer: 2

Rationale : If the client with an amputation has a cast or elastic compression bandage that slips off, the
nurse must immediately wrap the stump with another elastic compression bandage. Otherwise, excessive
edema will rapidly form, which could cause a significant delay in rehabilitation. If the client had a cast that
slipped off, the nurse would also have to call the physician so a new one could be applied. Elevation on
one pillow is not going to greatly impede the development of edema once compression is released. Ice
would be of limited value in controlling edema from this cause. If the physician were called, the order
would likely be to reapply the compression dressing anyway.

55. Correct Answer: 3

Rationale : Low back pain that radiates into one leg (sciatica) is consistent with herniated lumbar disc.
The nurse assesses the client to see if the pain is aggravated either by events that increase intraspinal

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pressure, such as bending, lifting, sneezing, coughing, or by lifting the leg straight up while supine
(straight leg raising test).

56. Correct Answer: 4

Rationale : After spinal fusion, the head of bed is generally kept flat. The client is logrolled from side to
side as ordered. Pillows may be placed under the entire length of the legs by surgeon preference to relieve
tension on the lower back. The use of an overhead trapeze is contraindicated because its use could promote
twisting of the spine after surgery.

57. Correct Answer: 1

Rationale : Clients are taught to get out of bed by sliding near the edge of the mattress. The client then
rolls onto one side and pushes up from the bed using one or both arms. The back is kept straight and the
legs are swung over the side. Increasing fluids and dietary fiber helps prevent straining at stool, thereby
preventing increases in intraspinal pressure. Walking and swimming are excellent exercises for
strengthening lower back muscles. Proper body mechanics includes bending at the knees, not the waist, to
lift objects.

58. Correct Answer: 2

Rationale : The nursing assessment conducted after spinal surgery is similar to that done after other
surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the
lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence
of cerebrospinal fluid leakage (drainage is clear, tests positive for glucose). A mild temperature is expected
after insertion of hardware, but a temperature over 101.6r F should be reported.

59. Correct Answer: 1

Rationale : The client experiences a Body Image Disturbance related to a change in the structure and
function of the affected leg. There are no data in the question to support a diagnosis of (actual) Activity
Intolerance or Social Isolation. The client does have an actual Impaired Physical Mobility because of the
fixation device.

60. Correct Answer: 2

Rationale : The part of the bed under an area in traction is usually elevated to aid in countertraction. For
the client in Buck's extension traction (which is applied to a leg), the foot of the bed is elevated.

61. Correct Answer: 3

Rationale : Risk factors for osteoporosis include being female, postmenopausal, of advanced age, low
calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of
corticosteroids, anticonvulsants, and furosemide also increases risk.

62. Correct Answer: 3

Rationale : Home modifications to reduce the risk for falls include use of railings on all staircases, ample
lighting, removing scatter rugs, and placing hand rails in the bathroom. Removal of wall-to-wall carpeting
is not necessary.

63. Correct Answer: 1

Rationale : In addition to the presence of clinical manifestations, gout is diagnosed by the presence of
persistent hyperuricemia of greater than 7 mg/dL. Options 2, 3, and 4 all indicate normal laboratory values.
Additionally, the presence of uric acid in an aspirated sample of synovial fluid confirms the diagnosis.

64. Correct Answer: 3

Rationale : The stiffness and joint pain that occur in osteoarthritis increase with lack of activity, are
usually more severe in the morning, and may be aggravated by cold, damp weather. No specific laboratory
findings are useful in diagnosing osteoarthritis. The client may have a normal or slightly elevated
sedimentation rate. Dull aching pain occurs in the affected joints and, unlike rheumatoid arthritis, systemic

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manifestations are absent and joint involvement is not symmetric. Elevated white blood cell counts,
platelet counts, and antinuclear antibodies occur in rheumatoid arthritis.

65. Correct Answer: 2

Rationale : Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, and
hematoma formation. The biopsy site is elevated for 24 hours to reduce edema. The vital signs are
monitored every 4 hours for 24 hours. The client usually requires mild analgesics; more severe pain
usually indicates that complications are arising.

66. Correct Answer: 1

Rationale : After surgery to repair a fractured hip, an abductor splint is used to maintain the affected
extremity in good alignment when the client is turned side to side. An overhead trapeze and bed pillow
may also be used in the postoperative period, but they are not the priority items to be used in repositioning.

67. Correct Answer: 4

Rationale : After arthroscopy, the client can usually walk carefully on the leg once sensation has
returned. The client is instructed to avoid strenuous exercise for at least a few days. The client may resume
the usual diet. Signs and symptoms of infection should be reported to the physician.

68. Correct Answer: 3

Rationale : Edema in the extremity indicates impaired venous return. Signs of impaired arterial
circulation in the limb include coolness and pallor of the skin and a diminished arterial pulse. Signs of
infection under a cast area would include odor or purulent drainage from the cast, or the presence of "hot
spots," which are areas of the cast that are warmer than others.

69. Correct Answer: 4

Rationale : Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on
the tissues of the leg by the elastic bandage used to secure this type of traction. This type of traction does
not use pins; rather, it is secured by elastic bandages or a prefabricated boot. Therefore options 2 and 3 are
incorrect. Hypotension is not directly associated with the use of this traction.

70. Correct Answer: 1

Rationale : Because of the risk of allergy to contrast dye, the nurse places highest priority on assessing
whether the client has an allergy to iodine or shellfish. The nurse also reinforces information about the test,
tells the client about the need to remain still during the procedure, and encourages the client to void before
the procedure for comfort.

71. Correct Answer: 2

Rationale : The client should avoid positions or activities that place strain on the lower back. The client
should not sleep on the abdomen (prone), or on the side if the hips and knees are straight. The client should
not lean forward without bending the knees, stand in one position for lengthy amounts of time, or lift
anything above elbow level. It may be helpful for the client to stand with a foot elevated on a stool, or sit
using a form of lumbar support.

72. Correct Answer: 2

Rationale : A radiograph is a photographic image of a part of the body on a special film, which is used to
diagnose a wide variety of conditions. The x-ray itself is painless; any discomfort would arise from
repositioning a painful part for filming. The nurse may want to premedicate a client who is at risk for pain.
Any radiopaque objects such as jewelry or other metal must be removed. The client is asked to breathe in
deeply, and then hold the breath while the chest radiograph is taken. To minimize risk of radiation
exposure, the x-ray technologist stands in a separate area protected by a lead wall. The client also wears a
lead shield over the gonads.

73. Correct Answer: 4

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Rationale : A small amount of clear fluid drainage is expected at pin insertion sites. Signs of infection
such as inflammation, purulent drainage, and pain at the pin sites are not expected findings and should be
reported to the physician. Options 1, 2, and 3 are inappropriate nursing actions.

74. Correct Answer: 2

Rationale : To achieve proper traction, weights need to be free-hanging with knots kept away from the
pulleys. Weights are not to be kept resting on a firm surface. The head of the bed is usually kept low to
provide countertraction.

75. Correct Answer: 4

Rationale : There are no special restrictions after a bone scan. The client is encouraged to drink large
amounts of water for 24 to 48 hours to flush the radioisotope from the system. There are no hazards to the
client or staff from the minimal amount of radioactivity of the isotope.

76. Correct Answer: 4

Rationale : Carisoprodol, a centrally-acting skeletal muscle relaxant, may cause central nervous system
(CNS) side effects of drowsiness and dizziness. For this reason, the client avoids other CNS depressants,
such as alcohol, while taking this medication. Driving or other activities requiring mental alertness should
also be avoided until the client's reaction to the medication is known. The medication is used to reduce
muscle spasticity and pain. Missed doses should be taken if remembered within 1 hour.

77. Correct Answer: 2

Rationale : A comminuted fracture is a complete fracture across the shaft of a bone with splintering of
the bone into fragments. A greenstick fracture is an incomplete fracture, which occurs through part of the
cross section of a bone; one side of the bone is fractured, and the other side is bent. A compound fracture,
also called an open or complex fracture, is one in which the skin or mucous membrane has been broken,
and the wound extends to the depth of the fractured bone. A simple fracture is a fracture of the bone across
its entire shaft with some possible displacement, but without breaking the skin.

78. Correct Answer: 2

Rationale : Typical signs and symptoms of fracture include pain, loss of function in the area, deformity,
shortening of the extremity, crepitus, swelling, and ecchymosis. Not all fractures lead to the development
of every sign. A contusion results from a blow to soft tissue and causes pain, swelling, and ecchymosis. A
sprain is an injury to a ligament caused by a wrenching or twisting motion. Symptoms include pain,
swelling, and inability to use the joint or bear weight normally. A strain results from a pulling force on the
muscle. Symptoms include soreness and pain with muscle use.

79. Correct Answer: 4

Rationale : An inactive elderly person may become disoriented due to lack of sensory stimulation. The
most appropriate nursing intervention would be to frequently reorient the client and to place objects such
as a clock and a calendar in the client's room to maintain orientation. The family can assist with orientation
of the client but it is not appropriate to ask the family to stay with the client. It is not within the scope of
nursing practice to prescribe laboratory studies. Restraints may cause further disorientation and should not
be applied unless specifically prescribed and agency policies and procedures should be followed before the
application of restraints.

80. Correct Answer: 1

Rationale : With a suspected fracture, the client is not moved unless it is dangerous to remain in that spot.
The nurse should remain with the client and have someone else call for emergency help. A fracture is not
reduced at the scene. Before the client is moved, the site of fracture is immobilized to prevent further
injury.

81. Correct Answer: 2

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Rationale : Osteomalacia technically refers to bone softening resulting from demineralization of bone
matrix and failure to calcify. A common cause is vitamin D deficiency. Other causes are inadequate
exposure to sunlight (to synthesize vitamin D) and disorders that interfere with absorption and metabolism
of vitamin D.

82. Correct Answer: 3

Rationale : Skin traction is achieved by ace wraps, boots, and slings that apply a direct force on the
client's skin. Skin traction is usually removed and reapplied once a day. Traction is maintained with 5 to 8
pounds of weight and this type of traction can cause skin breakdown. There are no pin sites with skin
traction. Urinary incontinence is not related to the use of skin traction. Although constipation can occur as
a result of immobility and that assessment of bowel sounds may be a component of the assessment, this
intervention is not the priority assessment.

83. Correct Answer: 1

Rationale : A fiberglass cast is made of water-activated polyurethane materials that are dry to the touch
within minutes; it and reaches full rigid strength in about 20 minutes. Because of this, the client can bear
weight on the cast within 20 to 30 minutes. Options 2, 3, and 4 are incorrect.

84. Correct Answer: 1

Rationale : Paget's disease is characterized by skeletal deformities caused by abnormal bone resorption,
followed by abnormal regeneration. Paget's disease is not due to problems with muscles, joints, or nervous
system functioning.

85. Correct Answer: 4

Rationale : The nurse can best assist the client in skeletal traction with repositioning by providing a
trapeze on the bed for the client's use. Encouraging the client to pull himself up by pushing with the
unaffected leg on the bed mattress may cause skin breakdown on the unaffected heel area. Although a draw
sheet is helpful and client movement may be more easily facilitated with four nurses, these actions will not
promote repositioning by the client.

86. Correct Answer: 3

Rationale : A psychosocial assessment of the client who is immobilized would most appropriately
include the need for sensory stimulation. This assessment should also include such factors as body image,
past and present coping skills, and the coping methods used during the period of immobilization. Although
transportation, home care support, and the ability to perform activities of daily living are components of an
assessment, they are not as specifically related to psychosocial adjustment, as is the need for sensory
stimulation.

87. Correct Answer: 3

Rationale : A client who complains of severe pain may need realignment or may have traction weights
that are too heavy. The nurse realigns the client; if this is ineffective, the nurse calls the physician. Severe
leg pain, once traction has been established, indicates a problem. Medicating the client should be done
after trying to determine and treat the cause. The nurse should never remove the weights from the traction
without a specific order to do so. Providing pin care is unrelated to the problem as described.

88. Correct Answer: 3

Rationale : Vitals signs provide a baseline to determine how well the client will tolerate activity.
Assessing muscle strength will help determine if the client has enough strength for crutch walking and if
muscle-strengthening exercises are necessary. Previous activity level will provide information related to
the tolerance of activity. Options 1,2, and 4 are also a component of the assessment but physiological
needs take precedence over psychosocial needs.

89. Correct Answer: 4

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Rationale : If a client with a cast has skin irritation from the edges of the cast, the nurse would petal the
edges of the cast with tape to minimize the irritation. Massaging the skin will not eliminate the problem.
Placing a small face cloth in the cast around the edges of the cast is not appropriate. It is not necessary to
contact the physician.

90. Correct Answer: 2

Rationale : Redness and heat are associated with musculoskeletal inflammation, infection, or a recent
injury. Degenerative disease is accompanied by pain, but there is no redness. Swelling may or may not
occur.

91. Correct Answer: 3

Rationale : Prolonged exposure to the sun (including indoor tanning), unusual cold, or other conditions
can damage the skin and pose the highest risk for skin disorders. An elderly client may be at a higher risk
than a younger individual. An adolescent may be prone to the development of acne, but this does not occur
in all adolescents. An athlete is at low risk for developing an integumentary problem.

92. Correct Answer: 1

Rationale : A gallium scan is similar to a bone scan, but with injection of gallium isotope instead of
technetium Tc 99m. Gallium is injected 2 to 3 hours before the procedure. The procedure takes 30 to 60
minutes to perform. The client must lie still during the procedure. There is no special aftercare.

93. Correct Answer: 1

Rationale : CPK is a cellular enzyme that can be fractionated into three isoenzymes. The MM band
reflects CPK from skeletal muscle. This band would be elevated in skeletal muscle disease. The MB band
reflects CPK from myocardial muscle. The BB band reflects CPK from the brain. There is no MS band.

94. Correct Answer: 4

Rationale : When a fracture is suspected, it is imperative that the area be splinted before the client is
moved. Emergency help should be called for if the client is not hospitalized, and a physician is called for
the hospitalized client. The nurse should remain with the client and provide realistic reassurance.

95. Correct Answer: 2

Rationale : After total knee replacement, the client should report signs and symptoms of infection and
any changes in the shape of the knee. These could indicate developing complications. With a metal
implant, the client must be on anticoagulant therapy and should report adverse effects of this therapy,
including bleeding from a variety of sources. With a metal implant, the client must inform other caregivers
of its presence, because certain tests and procedures will need to be avoided, and the client will need
antibiotic prophylaxis for invasive procedures.

96. Correct Answer: 3

Rationale : Before a fracture is reduced, the client is informed about the procedure, and consent is
obtained. An analgesic is given as prescribed, because the procedure is painful. Administration of
anesthesia may or may not be done, depending on severity. Closed reductions may be done in the
emergency room without anesthesia. If anesthesia is used, the procedure is done in the operating room.

97. Correct Answer: 3

Rationale : Following arthroscopy, the client is instructed to avoid excessive use of the joint for several
days, to elevate the knee while sitting, to avoid twisting the knee, and to return for suture removal in about
7 days. Ice is applied to the affected joint for pain and swelling, and analgesics are administered as
prescribed.

98. Correct Answer: 4

Rationale : The procedure for casting involves washing and drying the skin and placing a stockinette
material over the area to be casted. A roll of padding is then applied smoothly and evenly. The plaster is

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rolled onto the padding, and the edges are trimmed or smoothed as needed. A plaster cast gives off heat as
it dries. A plaster cast can tolerate weight bearing once it is dry, which varies from 24 to 72 hours,
depending on the nature and thickness of the cast.

99. Correct Answer: 1

Rationale : The early signs of the complication of fat embolism include changes in the client's mental
status or signs of impaired respiratory function due to impaired perfusion distal to the site of the embolus.
Cardiovascular and renal impairment is likely to occur secondary to impaired respiratory function. The
client's mobility status is unrelated to the signs of fat embolism.

100. Correct Answer: 3

Rationale : Exercise is indicated within therapeutic limits for the client in skeletal traction to maintain
muscle strength and range of motion. The client may pull up on the trapeze, perform active ROM with
uninvolved joints, and do isometric muscle-setting exercises (such as quadriceps- and gluteal-setting
exercises). The client may also flex and extend the feet.

101. Correct Answer: 2

Rationale : Clients with fractures are at risk for fat embolism. If the nurse suspects fat embolism, the
nurse would position the client in a sitting (Fowler's) position to relieve dyspnea. Supplemental oxygen is
indicated to reduce the signs of hypoxia. The physician needs to be notified. A neurological assessment
needs to be performed, but this would not be the initial nursing action. Vital signs will need to be taken,
but this action may delay initial and required interventions.

102. Correct Answer: 4

Rationale : A three-point gait requires good balance and arm strength. The crutches are advanced with
the affected leg, and then the unaffected leg is moved forward. Option 1 describes a two-point gait. Option
2 describes a swing-to gait. Option 3 describes the three-point gait used for a right leg problem.

103. Correct Answer: 3

Rationale : The signs of fat embolism will be associated with alterations in respiratory status or
neurological status. Dyspnea, petechiae, and chest pain are signs of fat embolism. The sign in option 1 is
indicative of the hip fracture itself. Option 2 indicates signs of infection, and option 4 indicates signs of
severe circulatory impairment.

104. Correct Answer: 4

Rationale : A straight leg cane is useful for a client with slight weakness in one leg. A walker is
beneficial to a client who has greater or bilateral weakness, or is at risk for falls. Wooden crutches are
often used by clients with leg casts. Lofstrand crutches aid clients who need crutches but have limited arm
strength.

105. Correct Answer: 3

Rationale : Fat embolism commonly causes signs and symptoms related to respiratory or neurological
impairment. Because the client is unable to speak, it may be difficult to immediately assess early changes
in neurological status. However, adventitious in breath sounds and an increased heart rate may be observed
easily and quickly, even before the client demonstrates labored breathing. Options 1, 2, and 4 are incorrect.

106. Correct Answer: 1

Rationale : A client requiring greater support and stability than is provided by a straight leg cane may use
a quad-cane. The quad-cane provides a four-point base of support and is indicated for use by clients with
partial or complete hemiplegia. Neither crutches nor a wheelchair is indicated for use with a client such as
described in the question.

107. Correct Answer: 2

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Rationale : A cane should have a slightly flared tip with flexible concentric rings. This tip acts as a shock
absorber and provides optimal stability. Options 1, 3, and 4 are unrelated to the issue of providing
reassurance about safety.

108. Correct Answer: 4

Rationale : The nurse always speaks to the client calmly and provides reassurance to the anxious client.
Morphine sulfate is often prescribed for pain and anxiety for the client receiving mechanical ventilation. In
option 1 the nurse does nothing to reassure or help the client. Family members are also stressed, not just
because of the complication, but because of the original injury. It is not beneficial to ask the family to take
on the burden of remaining with the client at all times. Succinylcholine (option 3) is a paralyzing agent, but
has no antianxiety properties.

109. Correct Answer: 1

Rationale : Compartment syndrome is prevented by controlling edema. This is achieved most optimally
with the use of elevation and application of ice. Options 2, 3, and 4 are incorrect.

110. Correct Answer: 4

Rationale : An increase in pain level in an extremity at risk for neurovascular compromise (compartment
syndrome) is often the first sign of increasing pressure in a compartment, in this case, the casted extremity.
The nurse needs to obtain additional assessment data in order to determine if the physician needs to be
notified immediately or if other interventions are appropriate. Options 1, 2, and 3 are inappropriate and
would delay necessary treatment.

111. Correct Answer: 2

Rationale : The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is
covered with moist sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema
subsides, the wound is debrided and closed.

112. Correct Answer: 2

Rationale : Confusion in the elderly client with a hip fracture could result from the unfamiliar hospital
setting, stress due to the fracture, concurrent systemic diseases, cerebral ischemia or side effects of
medications. Use of eyeglasses and hearing aids enhance the client's interaction with the environment, and
can reduce disorientation.

113. Correct Answer: 3

Rationale : Typical signs and symptoms following femoral neck fracture include shortening of the
affected leg, adduction, and external rotation. The client may report slight groin pain, or pain in the medial
side of the knee. Moving the fractured extremity significantly increases the pain.

114. Correct Answer: 4

Rationale : Safe nursing actions intended to prevent injury to the client include keeping side rails up, bed
in low position, and providing a call bell that is within the client's reach. Responding promptly to the
client's use of the call light minimizes the chance that the client will try to get up alone, which could result
in a fall.

115. Correct Answer: 3

Rationale : The client should use the walker by placing the hands on the handgrips for stability. The
client lifts the walker to advance it, and leans forward slightly while moving it. The client walks into the
walker, supporting the body weight on the hands while moving the weaker leg. A disadvantage of the
walker is that it does not allow for reciprocal walking motion. If the client were to try to use reciprocal
motion with a walker, the walker would advance forward one side at a time as the client walks; thus, the
client would not be supporting the weaker leg with the walker during ambulation.

116. Correct Answer: 1

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Rationale : The pressure in compartment syndrome, if unrelieved, will cause permanent damage to nerve
and muscle tissue distal to the pressure. Circulatory damage can result in necrosis. Nerve and muscle
damage can result in permanent contractures, deformity of the extremity, and functional impairment. The
skin under the cast is not necessarily at risk for infection. The signs of other complications, such as fat
embolism and skin infection are not monitored by assessment of the neurovascular status of the casted
extremity, but by other observations. The risk of compartment syndrome is related to internal or external
causes of increased pressure in muscle compartments, not due to the cast being wet.

117. Correct Answer: 3

Rationale : Pain with knee extension is a common complaint of clients after knee replacement. This is
because preoperatively the client placed the knee in flexion to reduce pain, and flexion contracture has
resulted. The nurse should encourage the client to keep the knee extended, and administer analgesics as
needed.

118. Correct Answer: 2

Rationale : To prevent injury to the brachial nerve plexus and still provide sufficient support, there
should be a distance of 1/2 to 2 inches between the client's axilla and the top crutch pad. This measurement
is determined with the client holding the crutches with the elbows bent at a 30-degree angle.

119. Correct Answer: 3

Rationale : Following surgery to repair a fractured hip, an abductor splint is used to maintain the affected
extremity in good alignment. An overhead trapeze and bed pillow are also used, but they are not the
priority item to be used in repositioning.

120. Correct Answer: 4

Rationale : The client should wear a clean woolen stump sock each day. The stump is cleansed daily with
a gentle soap and water, and is dried carefully. Alcohol is avoided because it could cause drying or
cracking of the skin. Oils and creams are also avoided because they are too softening to the skin for safe
prosthesis use. The client should inspect all surfaces of the stump daily for irritation, blisters, or
breakdown. Nylon is a synthetic material that does not allow the best air circulation and holds in moisture.

121. Correct Answer: 4

Rationale : Traction, analgesics, and heat may all be used to relieve the pain of muscle spasm in the
client with a vertebral fracture. The use of ice is incorrect; ice is applied only to a site for the first 24 hours
after an injury. Application of ice to the spine of a client could be uncomfortable and result in feelings of
being chilled.

122. Correct Answer: 1

Rationale : Compression of a nerve results in inflammation, which then irritates adjacent muscles,
putting them into spasm. The pain of muscle spasm is continuous, knife-like, and localized in the affected
area. Pressure on a spinal nerve root causes the symptoms of sciatica. Pressure on the spinal cord itself
could result in a variety of manifestations, depending on the area involved.

123. Correct Answer: 1

Rationale : The client who has had an insertion of a femoral head prosthesis should use a raised toilet
seat. The client should also maintain the leg in a neutral, straight position when lying, sitting, or walking.
The leg should not be adducted, internally rotated, or flexed more than 90 degrees. The client should sit in
chairs that have arms so that there will be assistance when the client is ready to rise from the sitting
position. The client should avoid putting on own socks and shoes for 8 weeks after surgery, because it
would force the leg into acute flexion.

124. Correct Answer: 2

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Rationale : Clients with low-back pain are often more comfortable when placed in Williams' position.
The bed is placed in semi-Fowler's position with the knee gatch raised sufficiently to flex the knees. This
relaxes the muscles of the lower back and relieves pressure on the spinal nerve root.

125. Correct Answer: 3

Rationale : Following spinal surgery, concerns about finances and employment are best handled by
referral to a social worker. This person has the best, well-rounded information about resources available to
the client. The physical therapist has the best knowledge of techniques for increasing mobility and
endurance. An occupational therapist would have knowledge of techniques for activities of daily living and
items related to occupation. The clinical nurse specialist and physician do not have information related to
financial resources.

126. Correct Answer: 3

Rationale : Body Image Disturbance is characterized by negative verbalizations or feelings about a body
part. This is a common response after amputation. The nurse supports the client and assists him or her to
work through these feelings. The client may also have the other nursing diagnoses listed in options 1 , 2,
and 4, but Body Image Disturbance is the nursing diagnosis that correlates best with the client statement.

127. Correct Answer: 2

Rationale : A back brace or thoracolumbosacral orthosis is individually fitted to the client. The brace
should not irritate the skin with proper fitting. The client applies the brace in the morning before getting
out of bed. The closures should be secure, but not overly loose or tight. A layer of clothing is worn
between the orthosis and the skin.

128. Correct Answer: 4

Rationale : The client who has been placed in a body cast is at risk for developing cast syndrome. This
results from pressure on the mesenteric artery and can lead to intestinal obstruction. The most important
action of the nurse is to correctly interpret the client's symptoms and report them to the physician. Cast
syndrome is usually treated with nasogastric decompression, intravenous therapy for hydration, and
possibly application of a new cast.

129. Correct Answer: 4

Rationale : After spinal fusion, with or without instrumentation, the client is transferred from the
stretcher to bed with a slider board and the assistance of 4 people. This permits optimal stabilization and
support of the spine, while allowing the client to be moved smoothly and gently.

130. Correct Answer: 4

Rationale : The major signs and symptoms of compartment syndrome include pallor or cyanosis; pain,
even following the administration of narcotic analgesics; vascular compromise demonstrated by weakened
or absent pulses and poor capillary refill; and edema of the extremity distal to the area of the fracture.
Options 1,2, and 3 are not assessments related to compartment syndrome.

131. Correct Answer: 1

Rationale : Stair climbing may be restricted or limited for several weeks after spinal fusion with
instrumentation. The nurse assures that resources are in place prior to discharge so that the client may sleep
and perform all activities of daily living on a single living level.

132. Correct Answer: 3

Rationale : Signs of a fracture include shortening and deformity. In a fracture, the affected leg externally
rotates because of discontinuation of the femur and loss of alignment and muscle control. Options 1 , 2,
and 4 are incorrect.

133. Correct Answer: 3

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Rationale : Salicylate serum levels are monitored on a regular basis in the client taking salicylates for
rheumatoid arthritis. The normal therapeutic level ranges from 10 to 20 mg/dL. Options 1 and 2 indicate a
less than adequate therapeutic level. Option 4 indicates a high level.

134. Correct Answer: 3

Rationale : Sulindac is a nonsteroidal antiinflammatory drug (NSAID). Misoprostol, a synthetic
prostaglandin E1 analog, may be prescribed to be taken concurrently with sulindac to prevent gastric
complications such as peptic ulcer disease. Options 1, 2, and 4 are incorrect.

135. Correct Answer: 1

Rationale : In the use of a CPM machine, the leg should be kept in a neutral position and not rotated
either internally or externally. The knee should be positioned at the hinge joint of the machine. The nurse
should monitor for pressure areas at the knee and the groin, and should follow the physician's orders and
institutional protocol about extension, flexion, and speed of the CPM machine.

136. Correct Answer: 1

Rationale : The client should be instructed to use pain or fatigue as indicators and a guide to increase,
maintain, or decrease activity level. Whenever possible, the client should use large joints instead of small
joints for activities and use the joints in their most natural position. The client should not remain in the
same position for a long period of time and should learn to slide objects rather than lift them.

137. Correct Answer: 2

Rationale : Following total hip replacement, the client should be instructed to keep the legs apart while
sitting or lying, using a blanket or a pillow between the legs. The client should be instructed to sit on a
high, firm chair. The use of an elevated toilet seat will prevent discomfort and pressure at the operative
site. The physician should be notified if the client develops any redness, irritation, or any drainage at the
incision site.

138. Correct Answer: 4

Rationale : The nurse should instruct the client taking probenecid to increase fluid intake to minimize
calculus formation. Serum uric acid levels should also be monitored. The client should be instructed to
take the medication with food or an antacid and to avoid the use of salicylates because they decrease the
uricosuric effects of probenecid.

139. Correct Answer: 3

Rationale : The client taking allopurinol should be instructed to return to the clinic for monitoring of liver
and renal function studies, particularly in the first month of therapy. The client should also take the
medication with food and maintain an adequate fluid intake. The client needs to be instructed to maintain
an alkaline urine and should avoid large doses of vitamin C.

140. Correct Answer: 4

Rationale : Some of the risk factors related to osteoporosis in the female gender are small skeletal
frames, low dietary intake of calcium, and diets high in sodium, animal proteins, and wheat bran. Elevated
thyroid and parathyroid hormone levels are also risk factors for osteoporosis.

141. Correct Answer: 2

Rationale : Bone pain is the most common symptom of Paget's disease and may manifest in areas close
to a joint. It is a progressive enlargement and deformity of the bone. Hearing loss, numbness of the face, or
(more rarely) blindness can occur when the thickened bone of Paget's disease compresses vital nerves in
the skull. Fatigue and difficulty with ambulation may occur but would not be the most common symptoms.

142. Correct Answer: 2

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Rationale : Diagnostic laboratory findings for Paget's disease include an elevated serum alkaline
phosphatase and urinary hydroxyproline excretion. Options 1 , 3, and 4 are unrelated to diagnostic
evaluation of this disease.

143. Correct Answer: 3

Rationale : Leech therapy is used to promote bleeding in the congested area and facilitate venous outflow
during the time that collateral circulation and microvascular knitting develop. The regimen for Leech
therapy is to apply the leech for 10 minutes to 2 hours or until the leech is engorged with blood. The usual
schedule is intermittent reapplication of the leech at 4- to 8-hour intervals. The nurse's role during the leech
therapy is to monitor the leech until it is fully distended. The leech loosens its hold after 20 to 30 minutes
of feeding. The nurse then disposes of the leech in a biohazard container. The client requires reassurance
during the therapy.

144. Correct Answer: 1

Rationale : Osteomyelitis is most frequently caused by direct contamination of bone through an open
wound. Other less frequent factors include spread from local infection, such as a boil, poor nutrition, or
unhygienic conditions.

145. Correct Answer: 1

Rationale : Paget's disease is characterized by skeletal deformities due to abnormal bone resorption,
followed by abnormal regeneration. It is not due to problems with muscles, joints, or nervous system
functioning.

146. Correct Answer: 2

Rationale : The client is most likely at risk for fractures as a result of this disorder. It is estimated that up
to 85% of postmenopausal females will develop osteoporosis, and 25% to 30% of these will experience
fracture related to the loss of bone. Although other complications can occur as a result of osteomalacia, the
client is most likely at risk for fractures.

147. Correct Answer: 1

Rationale : Liver should be omitted from the diet of a client who has gout because of its high purine
content. The food items identified in the other options contain negligible amounts of purines and may be
consumed freely by the client with gout.

148. Correct Answer: 1

Rationale : Soft tissue injuries such as sprains are treated by RICE (rest, ice, compression, and elevation)
for the first 24 hours after the injury. Ice is applied intermittently for 20 to 30 minutes at a time. Heat is not
used in the first 24 hours because it could increase venous congestion, which would increase edema and
pain.

149. Correct Answer: 4

Rationale : A successful outcome for the nursing diagnosis of Self-Care Deficit is for the client to do as
much of the self-care as possible. The nurse should promote independence in the client and allow the client
to perform as much self-care as is optimal considering the client's condition. The nurse would determine
that the outcome is unsuccessful if the client refused care or allows others to do the care.

150. Correct Answer: 3

Rationale : A psychosocial assessment of the client who is immobilized most appropriately would
include the need for sensory stimulation. This assessment also should include factors such as body image,
past and present coping skills, and the coping methods used during the period of immobilization. Although
transportation, home care support, and the ability to perform activities of daily living are components of an
assessment, they are not as specifically related to psychosocial adjustment as is the need for sensory
stimulation.

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