CPC - Medical-Surgical Musculoskeletal,
Gastrointestinal, Immune and Infectious
Exam Test 2.
A nurse is planning discharge teaching for a client who has systemic lupus erythematous (SLE). Which
B B B B B B B B B B B B B B B
of the following instructions should the nurse plan to include?
B B B B B B B B B B
A. "Avoid the use of NSAIDs."
B B B B B
B. "Stop taking the corticosteroids when your symptoms resolve."
B B B B B B B B
C. "Exposure to ultraviolet light will help control the skin rashes."
B B B B B B B B B B
D. "Monitor your body temperature and report any elevations promptly." - ANS >> Monitor your body
B B B B B B B B B B B B B B B
temperature and report any elevations promptly."
B B B B B B
SLE is a chronic autoimmune disorder that can affect any organ of the body. With SLE, the body's
B B B B B B B B B B B B B B B B B
immune system becomes hyperactive, forming antibodies that attack tissues and organs, including the
B B B B B B B B B B B B B
skin, joints, kidneys, brain, heart, lungs, and blood. SLE is characterized by periods of exacerbation
B B B B B B B B B B B B B B B
and remissions. The nurse should teach the client to monitor body temperature and report any
B B B B B B B B B B B B B B B
elevations promptly, as fever can suggest either an exacerbation or a potentially life-threatening
B B B B B B B B B B B B B
infection.
B
A nurse is caring for a client who has systemic lupus erythematosus (SLE) and is concerned about skin
B B B B B B B B B B B B B B B B B
lesions on the face and neck. The client asks the nurse, "what should I do about these spots?" which
B B B B B B B B B B B B B B B B B B B
of the following nursing responses should the nurse give?
B B B B B B B B B
A. "Keep the lesions covered with a light sterile dressing when going outdoors"
B B B B B B B B B B B B
B. "There is not much you can do. The lesions will go away when your disease is in remission"
B B B B B B B B B B B B B B B B B B
C. "Apply moisturizer after bathing the lesions with warm water"
B B B B B B B B B
D. "Apply antibiotic cream twice a day until scabs form on the lesions" - ANS >> "Apply moisturizer
B B B B B B B B B B B B B B B B B
after bathing the lesions with warm water."
B B B B B B B
The nurse should instruct the client to clean, dry, and moisturize the skin using warm (not hot) water,
B B B B B B B B B B B B B B B B B
along with an unscented lotion.
B B B B B
A nurse is caring for a client who is 3 days postoperative following a right total hip arthroplasty. While
B B B B B B B B B B B B B B B B B B
transferring to a chair, the client cries out in pain. The nurse should assess the client for which of the
B B B B B B B B B B B B B B B B B B B B
following manifestations of dislocation of the hip prosthesis?
B B B B B B B B
A. Bulging in the area over the surgical incision
B B B B B B B B
B. Shortening of the right leg
B B B B B
C. Sensation of warmth over the surgical incision
B B B B B B B
,D. Pallor following elevation of the right leg - ANS >> Shortening of the right leg
B B B B B B B B B B B B B B B
-----
The nurse should monitor the client for shortening of the affected leg as an indication of dislocation of
B B B B B B B B B B B B B B B B B
Bthe prosthesis. Other findings include increased hip pain, inability to move the extremity, and rotation
B B B B B B B B B B B B B B
Bof the hip internally or externally.
B B B B B
A nurse is caring for a client who has a pelvic fracture. The client reports sudden shortness of breath,
B B B B B B B B B B B B B B B B B B
Bstabbing chest pain, and feelings of doom. The nurse should identify that the client is experiencing
B B B B B B B B B B B B B B B
Bwhich of the following complications?
B B B B
A. Pneumonia
B
B. Pulmonary embolus
B B
C. Tension pneumothorax
B B
D. Tuberculosis - ANS >> Pulmonary embolus
B B B B B B
-----
Immobility following musculoskeletal trauma places the client at an increased risk for pulmonary
B B B B B B B B B B B B
Bembolus. The client might also exhibit tachycardia, chest petechiae, and have a decreased SaO2. The
B B B B B B B B B B B B B B
Bnurse should notify the rapid response team immediately.
B B B B B B B
A nurse is caring for a client who is in skeletal traction following a femur fracture. The nurse finds the
B B B B B B B B B B B B B B B B B B B
Bclient has slid down toward the foot of the bed and the traction weight is resting on the floor. Which
B B B B B B B B B B B B B B B B B B B
Bof the following actions should the nurse take?
B B B B B B B
A. Remove the weight temporarily to reposition the client to the correct alignment in bed.
B B B B B B B B B B B B B B
B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely.
B B B B B B B B B B B B B B B B
C. Lift the rope off the pulley while the client rocks back and forth to reposition.
B B B B B B B B B B B B B B B
D. Lift the weight manually while another staff member moves the client up in bed. - ANS >> Have the
B B B B B B B B B B B B B B B B B B B
Bclient use a trapeze to pull himself up while ensuring the weight hangs freely.
B B B B B B B B B B B B B
-----
The nurse should ensure that traction weight is hanging freely. The client can use an overhead trapeze
B B B B B B B B B B B B B B B B
Bbar to move up in bed, or the nurse can assist the client up, making sure to maintain proper
B B B B B B B B B B B B B B B B B B
Balignment of the extremity. B B B
A nurse is providing preoperative teaching for a client who is scheduled for total knee arthroplasty.
B B B B B B B B B B B B B B B
BWhich of the following statements by the client should the nurse identify as understanding of the
B B B B B B B B B B B B B B B
Bteaching?
A. "I will wear a continuous movement machine on my knee for 24 hours a day."
B B B B B B B B B B B B B B B
B. "I should avoid taking NSAID medications for pain after surgery."
B B B B B B B B B B
C. "I should wear elastic stockings on both of my legs."
B B B B B B B B B B
D. "I will begin exercising my legs the day after surgery." - ANS >> "I should wear elastic stockings on
B B B B B B B B B B B B B B B B B B B
Bboth of my legs." B B B
------
, The purpose of elastic stockings is to prevent venous thromboembolism, which is a common
B B B B B B B B B B B B B
complication following orthopedic surgery. Therefore, the nurse should identify this statement as
B B B B B B B B B B B B
understanding of the teaching.
B B B B
A nurse is discussing the difference between rheumatoid arthritis (RA) and osteoarthritis with a newly
B B B B B B B B B B B B B B
licensed nurse. Which of the following information should the nurse include about osteoarthritis?
B B B B B B B B B B B B B
A. "Osteoarthritis is caused by autoimmune processes."
B B B B B B
B. "Osteoarthritis leads to a decreased erythrocyte sedimentation rate."
B B B B B B B B
C. "Osteoarthritis affects other organ systems."
B B B B B
D. "Osteoarthritis can impair a joint on a single side of the body." - ANS >> "Osteoarthritis can impair
B B B B B B B B B B B B B B B B B B
Ba joint on a single side of the body."
B B B B B B B B
------
The nurse should identify unilateral joint involvement as a finding of osteoarthritis. A client who has
B B B B B B B B B B B B B B B
BRA experiences symmetrical joint impairment.
B B B B
A nurse is assessing a client who is 24 hr postoperative following an above-the-elbow amputation.
B B B B B B B B B B B B B B
BWhich of the following findings should the nurse identify as the priority?
B B B B B B B B B B B
A. Report of muscle spasms
B B B B
B. Inability to get dressed without assistance
B B B B B B
C. Report of feelings of anger
B B B B B
D. Refusal to look at the affected limb - ANS >> Report of muscle spasms
B B B B B B B B B B B B B B
-----
The nurse should consider Maslow's hierarchy of needs, which includes five levels of priority. The first
B B B B B B B B B B B B B B B
Blevel consists of physiological needs; the second level consists of safety and security needs; the third
B B B B B B B B B B B B B B B
Blevel consists of love and belonging needs; the fourth level consists of personal achievement and self-
B B B B B B B B B B B B B B B
esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve
B B B B B B B B B B B B B B B B
Band cope with life situations. When applying Maslow's hierarchy of needs priority-setting framework,
B B B B B B B B B B B B
Bthe nurse should review physiological needs first. The nurse should then address the client's needs by
B B B B B B B B B B B B B B B
Bfollowing the remaining four hierarchal levels. It is important, however, for the nurse to consider all
B B B B B B B B B B B B B B B
Bcontributing client factors, as higher levels of the pyramid can compete with those at the lower levels,
B B B B B B B B B B B B B B B B
Bdepending on the specific client situation. The fourth level of Maslow's hierarchy of needs includes
B B B B B B B B B B B B B B
Busefulness, self-worth, and self-confidence in fulfilling self-esteem needs. Therefore, the nurse should
B B B B B B B B B B B
Bidentify the report of muscle spasms, a physiological need, as the priority client finding.
B B B B B B B B B B B B B
A nurse in the emergency department is preparing to discharge a client following a Grade II
B B B B B B B B B B B B B B B
B(moderate) ankle sprain. Which of the following instructions should the nurse plan to give to the
B B B B B B B B B B B B B B B
Bclient?
A. Perform passive range-of-motion exercises of the ankle hourly.
B B B B B B B B
B. Keep the affected extremity in a dependent position.
B B B B B B B B
C. Wrap a loose dressing around the affected ankle.
B B B B B B B B
D. Apply cold compresses to the extremity intermittently. - ANS >> Apply cold compresses to the
B B B B B B B B B B B B B B B
extremity intermittently.
B B
Gastrointestinal, Immune and Infectious
Exam Test 2.
A nurse is planning discharge teaching for a client who has systemic lupus erythematous (SLE). Which
B B B B B B B B B B B B B B B
of the following instructions should the nurse plan to include?
B B B B B B B B B B
A. "Avoid the use of NSAIDs."
B B B B B
B. "Stop taking the corticosteroids when your symptoms resolve."
B B B B B B B B
C. "Exposure to ultraviolet light will help control the skin rashes."
B B B B B B B B B B
D. "Monitor your body temperature and report any elevations promptly." - ANS >> Monitor your body
B B B B B B B B B B B B B B B
temperature and report any elevations promptly."
B B B B B B
SLE is a chronic autoimmune disorder that can affect any organ of the body. With SLE, the body's
B B B B B B B B B B B B B B B B B
immune system becomes hyperactive, forming antibodies that attack tissues and organs, including the
B B B B B B B B B B B B B
skin, joints, kidneys, brain, heart, lungs, and blood. SLE is characterized by periods of exacerbation
B B B B B B B B B B B B B B B
and remissions. The nurse should teach the client to monitor body temperature and report any
B B B B B B B B B B B B B B B
elevations promptly, as fever can suggest either an exacerbation or a potentially life-threatening
B B B B B B B B B B B B B
infection.
B
A nurse is caring for a client who has systemic lupus erythematosus (SLE) and is concerned about skin
B B B B B B B B B B B B B B B B B
lesions on the face and neck. The client asks the nurse, "what should I do about these spots?" which
B B B B B B B B B B B B B B B B B B B
of the following nursing responses should the nurse give?
B B B B B B B B B
A. "Keep the lesions covered with a light sterile dressing when going outdoors"
B B B B B B B B B B B B
B. "There is not much you can do. The lesions will go away when your disease is in remission"
B B B B B B B B B B B B B B B B B B
C. "Apply moisturizer after bathing the lesions with warm water"
B B B B B B B B B
D. "Apply antibiotic cream twice a day until scabs form on the lesions" - ANS >> "Apply moisturizer
B B B B B B B B B B B B B B B B B
after bathing the lesions with warm water."
B B B B B B B
The nurse should instruct the client to clean, dry, and moisturize the skin using warm (not hot) water,
B B B B B B B B B B B B B B B B B
along with an unscented lotion.
B B B B B
A nurse is caring for a client who is 3 days postoperative following a right total hip arthroplasty. While
B B B B B B B B B B B B B B B B B B
transferring to a chair, the client cries out in pain. The nurse should assess the client for which of the
B B B B B B B B B B B B B B B B B B B B
following manifestations of dislocation of the hip prosthesis?
B B B B B B B B
A. Bulging in the area over the surgical incision
B B B B B B B B
B. Shortening of the right leg
B B B B B
C. Sensation of warmth over the surgical incision
B B B B B B B
,D. Pallor following elevation of the right leg - ANS >> Shortening of the right leg
B B B B B B B B B B B B B B B
-----
The nurse should monitor the client for shortening of the affected leg as an indication of dislocation of
B B B B B B B B B B B B B B B B B
Bthe prosthesis. Other findings include increased hip pain, inability to move the extremity, and rotation
B B B B B B B B B B B B B B
Bof the hip internally or externally.
B B B B B
A nurse is caring for a client who has a pelvic fracture. The client reports sudden shortness of breath,
B B B B B B B B B B B B B B B B B B
Bstabbing chest pain, and feelings of doom. The nurse should identify that the client is experiencing
B B B B B B B B B B B B B B B
Bwhich of the following complications?
B B B B
A. Pneumonia
B
B. Pulmonary embolus
B B
C. Tension pneumothorax
B B
D. Tuberculosis - ANS >> Pulmonary embolus
B B B B B B
-----
Immobility following musculoskeletal trauma places the client at an increased risk for pulmonary
B B B B B B B B B B B B
Bembolus. The client might also exhibit tachycardia, chest petechiae, and have a decreased SaO2. The
B B B B B B B B B B B B B B
Bnurse should notify the rapid response team immediately.
B B B B B B B
A nurse is caring for a client who is in skeletal traction following a femur fracture. The nurse finds the
B B B B B B B B B B B B B B B B B B B
Bclient has slid down toward the foot of the bed and the traction weight is resting on the floor. Which
B B B B B B B B B B B B B B B B B B B
Bof the following actions should the nurse take?
B B B B B B B
A. Remove the weight temporarily to reposition the client to the correct alignment in bed.
B B B B B B B B B B B B B B
B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely.
B B B B B B B B B B B B B B B B
C. Lift the rope off the pulley while the client rocks back and forth to reposition.
B B B B B B B B B B B B B B B
D. Lift the weight manually while another staff member moves the client up in bed. - ANS >> Have the
B B B B B B B B B B B B B B B B B B B
Bclient use a trapeze to pull himself up while ensuring the weight hangs freely.
B B B B B B B B B B B B B
-----
The nurse should ensure that traction weight is hanging freely. The client can use an overhead trapeze
B B B B B B B B B B B B B B B B
Bbar to move up in bed, or the nurse can assist the client up, making sure to maintain proper
B B B B B B B B B B B B B B B B B B
Balignment of the extremity. B B B
A nurse is providing preoperative teaching for a client who is scheduled for total knee arthroplasty.
B B B B B B B B B B B B B B B
BWhich of the following statements by the client should the nurse identify as understanding of the
B B B B B B B B B B B B B B B
Bteaching?
A. "I will wear a continuous movement machine on my knee for 24 hours a day."
B B B B B B B B B B B B B B B
B. "I should avoid taking NSAID medications for pain after surgery."
B B B B B B B B B B
C. "I should wear elastic stockings on both of my legs."
B B B B B B B B B B
D. "I will begin exercising my legs the day after surgery." - ANS >> "I should wear elastic stockings on
B B B B B B B B B B B B B B B B B B B
Bboth of my legs." B B B
------
, The purpose of elastic stockings is to prevent venous thromboembolism, which is a common
B B B B B B B B B B B B B
complication following orthopedic surgery. Therefore, the nurse should identify this statement as
B B B B B B B B B B B B
understanding of the teaching.
B B B B
A nurse is discussing the difference between rheumatoid arthritis (RA) and osteoarthritis with a newly
B B B B B B B B B B B B B B
licensed nurse. Which of the following information should the nurse include about osteoarthritis?
B B B B B B B B B B B B B
A. "Osteoarthritis is caused by autoimmune processes."
B B B B B B
B. "Osteoarthritis leads to a decreased erythrocyte sedimentation rate."
B B B B B B B B
C. "Osteoarthritis affects other organ systems."
B B B B B
D. "Osteoarthritis can impair a joint on a single side of the body." - ANS >> "Osteoarthritis can impair
B B B B B B B B B B B B B B B B B B
Ba joint on a single side of the body."
B B B B B B B B
------
The nurse should identify unilateral joint involvement as a finding of osteoarthritis. A client who has
B B B B B B B B B B B B B B B
BRA experiences symmetrical joint impairment.
B B B B
A nurse is assessing a client who is 24 hr postoperative following an above-the-elbow amputation.
B B B B B B B B B B B B B B
BWhich of the following findings should the nurse identify as the priority?
B B B B B B B B B B B
A. Report of muscle spasms
B B B B
B. Inability to get dressed without assistance
B B B B B B
C. Report of feelings of anger
B B B B B
D. Refusal to look at the affected limb - ANS >> Report of muscle spasms
B B B B B B B B B B B B B B
-----
The nurse should consider Maslow's hierarchy of needs, which includes five levels of priority. The first
B B B B B B B B B B B B B B B
Blevel consists of physiological needs; the second level consists of safety and security needs; the third
B B B B B B B B B B B B B B B
Blevel consists of love and belonging needs; the fourth level consists of personal achievement and self-
B B B B B B B B B B B B B B B
esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve
B B B B B B B B B B B B B B B B
Band cope with life situations. When applying Maslow's hierarchy of needs priority-setting framework,
B B B B B B B B B B B B
Bthe nurse should review physiological needs first. The nurse should then address the client's needs by
B B B B B B B B B B B B B B B
Bfollowing the remaining four hierarchal levels. It is important, however, for the nurse to consider all
B B B B B B B B B B B B B B B
Bcontributing client factors, as higher levels of the pyramid can compete with those at the lower levels,
B B B B B B B B B B B B B B B B
Bdepending on the specific client situation. The fourth level of Maslow's hierarchy of needs includes
B B B B B B B B B B B B B B
Busefulness, self-worth, and self-confidence in fulfilling self-esteem needs. Therefore, the nurse should
B B B B B B B B B B B
Bidentify the report of muscle spasms, a physiological need, as the priority client finding.
B B B B B B B B B B B B B
A nurse in the emergency department is preparing to discharge a client following a Grade II
B B B B B B B B B B B B B B B
B(moderate) ankle sprain. Which of the following instructions should the nurse plan to give to the
B B B B B B B B B B B B B B B
Bclient?
A. Perform passive range-of-motion exercises of the ankle hourly.
B B B B B B B B
B. Keep the affected extremity in a dependent position.
B B B B B B B B
C. Wrap a loose dressing around the affected ankle.
B B B B B B B B
D. Apply cold compresses to the extremity intermittently. - ANS >> Apply cold compresses to the
B B B B B B B B B B B B B B B
extremity intermittently.
B B
