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Med Surg II test 7

Terms in this set (40)

The nurse is discussing actions that can be taken to best prevent osteoporosis with a patient. Which information should the nurse include?
Exercise throughout life.
What does goniometry measure?
Range-of-motion (ROM)
Positioning and range-of-motion (ROM) exercises most help the immobilized patient to prevent which complication?
Contractures
The nurse adds interventions for range-of-motion (ROM) and isometric exercises for the new patient with a stroke. The nurse's reasoning stems from her awareness that contracture formation may begin with how many days of immobilization?
3 days
If muscles are not regularly stretched and contracted, how will the muscles be effected?
Muscles will become shorter and less elastic.
The nurse uses a visual aid to show the pathologic muscle tone changes that result in footdrop. Which changes should the nurse include?
The stretching of flexor muscles
How often should range-of-motion (ROM) exercises be performed?
Three to four times a day
The physician has prescribed isometric exercises for a patient. For which patient should the nurse question this order?
A patient experiencing an acute exacerbation of congestive heart failure
When the patient returns to the unit from having had an arthrogram, which intervention should the nurse perform first?
Apply ice packs to the knee
The nurse encourages the patient to use the four-point crutch gait technique. Which statement indicates that the patient accurately understands the nurse's teaching?
"This way of walking is the most stable gait."
The nurse is assessing the patient's cane for appropriate length. Which observation affirms that an appropriate cane has been selected?
The handgrip is at hip level
The nurse is instructing the patient on quadriceps and gluteal muscle exercises. Which instructions should the nurse include?
In a supine position, straighten the leg and tense leg muscles while raising heel
What is the name for the anatomical structure that joins the bones of a joint together?
A ligament
Which bodily component constantly renews bone?
Osteoblasts
The patient's plan of care includes using the continuous passive motion (CPM) machine. Which statement indicates the patient needs for further teaching?
"I can make my new knee stronger if I reset this thing to go faster and flex my knee more."
When preparing a patient for electromyography (EMG), which instructions should the nurse include?
Refrain from caffeine drinks for 3 hours before the test
The nurse is caring for an older adult patient. Which age-related factor increases this patient's risk for falls?
Increased postural sway
The nurse is changing the position of a person with flaccid paralysis. Which action is most important?
Change the patient's joint position frequently
The nurse is caring for a patient who has had an arthrocentesis. The nurse has completed discharge instructions. Which statement indicates the patient needs further instruction?
"I should avoid moving my knee for at least 2 weeks."
A patient is learning to use crutches on the stairs. Which action indicates that the patient needs further instruction?
The patient places the good leg on the step to be climbed first
The nurse is assessing the patient's crutches. Which observation confirms that the crutches are sized correctly?
The crutches are approximately 16 inches shorter than the patient's height.
A patient at risk for the development of osteoporosis has reported plans to increase calcium intake. Which meal choice is most appropriate for this patient?
Grilled salmon, green beans, and milk
A patient has come to the ambulatory care clinic with a sprain. The nurse correctly differentiates a grade 2 sprain from a grade 3 sprain with the assessment of which finding?
Minor loss of function
An older adult has fallen and sprained his ankle in a local park. Which action should the responder perform first?
Elevate the foot.
When the clinic nurse starts to take the "air cast" off the grade 2 sprain, the patient asks why it is being removed since he still has pain. Which explanation is best?
"Long-term immobilization can cause permanent disability."
Which statement indicates that the patient needs further instruction about application of ice to a sprain?
"I will keep the ice on this knee for the rest of the day."
The industrial nurse examines an employee who complains of right shoulder pain on abduction. He points with one finger to the exact location of the pain and mentions that he won a racquetball tournament yesterday. The nurse suspects the employee is suffering from which problem?
Bursitis
The nurse is caring for a patient who works as a legal secretary. The patient asks the nurse about ways to avoid developing carpal tunnel syndrome (CTS). Which action should the nurse suggest?
"Acquire a pad to support your wrists while typing."
Carpal tunnel syndrome (CTS) is caused when the carpal tunnel compresses which location?
Median nerve
Which vitamin is essential in treating osteoporosis?
Vitamin D
The nurse is caring for a patient who just returned from surgical decompression of the carpal tunnel. Which finding requires the nurse's immediate action?
The capillary refill time is 8 seconds
An 80-year-old man falls and suffers a compound fracture of the femur. Which immediate action is most appropriate?
Carefully splint the leg as it is.
Which major advantage is specific to external fixation devices?
Greater freedom of movement
The patient in a long arm cast (from below the shoulder to the wrist, with a 90-degree elbow flexion) complains of a burning sensation over the elbow. The nurse's initial intervention should be:
Check to see if the cast is properly supported.
The nurse is performing an assessment on the patient who is in bilateral Buck traction. Which finding indicates the need to reposition the patient?
The patient's feet are against the footboard.
A patient in Russell traction with a Pearson attachment for a fracture of the tibia complains of intense pain at the fracture site. The nurse assesses a temperature of 102° F and increased swelling at the fracture site. Which complication do these findings suggest?
Osteomyelitis
The nurse is performing morning care for a patient who sustained a fractured pelvis and bilateral femur fractures yesterday in a motorcycle collision. The patient complains of shortness of breath. Assessment reveals audible wheezes and oxygen saturation of 76%. What action should the nurse take first?
Raise patient to high Fowler position.
The nurse is instructing a patient with rheumatoid arthritis about a prescribed exercise program. Which information should the nurse include?
Perform exercises every day, 3 to 10 times for every joint.
The patient with osteoporosis calls the nurse in the doctor's office to report that she should have taken but has forgotten to take her weekly bisphosphonate (alendronate [Fosamax]) that was due 2 days ago. How should the nurse advise the patient?
"Skip this week and pick up the schedule next week."
When caring for a patient who has an abductor wedge in place after a total hip replacement, for which finding should the nurse assess?
Alteration in peripheral circulation
Sets found in the same folder