Saunders NCLEX Musculoskeletal
A client being measured for crutches asks the nurse why the crutches cannot rest up
underneath the arm for extra support. The nurse responds knowing that which would
most likely result from this improper crutch measurement?
1.
A fall and further injury
2.
Injury to the brachial plexus nerves
3.
Skin breakdown in the area of the axilla
4.
Impaired range of motion while the client ambulates - ANS-Injury to the brachial
plexus nerves
Crutches are measured so that the tops are 2 to 3 fingerwidths from the axillae. This
ensures that the client's axillae are not resting on the crutch or bearing the weight of
the crutch, which could result in injury to the nerves of the brachial plexus. Although
the conditions in options 1, 3, and 4 can occur, they are not the most likely result
from resting the axilla directly on the crutches.
\A client has been diagnosed with gout, and the nurse provides dietary instructions.
The nurse determines that the client needs additional teaching if the client states that
it is acceptable to eat which food?
1.
Carrots
2.
Tapioca
3.
Chocolate
4.
Chicken liver - ANS-Chicken liver
Liver and other organ meats should be omitted from the diet of a client who has gout
because of their high purine content. Purines are a form of protein. The food items
identified in the other options contain negligible amounts of purines and may be
consumed freely by the client with gout.
\A client has been diagnosed with osteomalacia, or adult rickets. The nurse should
anticipate that the health care provider will include a new prescription for which
vitamin supplement?
,1.
A
2.
D
3.
E
4.
K - ANS-D
Osteomalacia technically refers to bone softening that results from demineralization
of bone matrix and failure to calcify. A common cause is vitamin D deficiency in the
diet. Other causes are inadequate exposure to sunlight (to synthesize vitamin D) and
disorders that interfere with absorption and metabolism of vitamin D. Deficiencies of
the vitamins noted in the remaining options are not associated with osteomalacia.
\A client has been diagnosed with subluxation of the shoulder. The nurse explains to
the client that which injury has occurred to the joint?
1.
It is strained.
2.
It is contused.
3.
It has completely dislocated.
4.
It has incompletely dislocated. - ANS-It has incompletely dislocated.
A dislocation is the disruption of a joint to the extent that the articulating surfaces are
no longer in contact. A subluxation is an incomplete dislocation of the joint surfaces.
Because the disruption is less severe, healing time is less prolonged. A strain occurs
when a muscle or ligament is used beyond the limit of its functional ability. It is
characterized by overstretching of the muscle or ligament and also could involve
tearing if the strain is more severe (i.e., second- or third-degree strain versus
first-degree strain). A contusion is a soft tissue injury that results in hemorrhage into
the involved tissue.
\A client has been experiencing muscle weakness over a period of several months.
The health care provider suspects polymyositis. Which client statement correctly
identifies a confirmation of test results and this diagnosis?
1.
"If I have polymyositis, there will be a decrease in elastic tissue."
2.
"I will know I have polymyositis if the muscle fibers are inflamed."
3.
,"The health care provider said there would be more fibers and tissue with
polymyositis."
4.
"The health care provider said if the muscle fibers were thickened, I would have
polymyositis." - ANS-"I will know I have polymyositis if the muscle fibers are
inflamed."
In polymyositis, necrosis and inflammation are seen in muscle fibers and myocardial
fibers. Option 1 refers to the decreased elastic tissue in the aorta seen in Marfan
syndrome. Option 3 refers to increased fibrous tissue seen in ankylosis. Option 4 is
the opposite of what is noted in this disorder.
\A client has been placed in Buck's extension traction. The nurse can provide for
countertraction to reduce shear and friction by performing which action?
1.
Using a footboard
2.
Providing an overhead trapeze
3.
Slightly elevating the foot of the bed
4.
Slightly elevating the head of the bed - ANS-Slightly elevating the foot of the bed
The part of the bed under an area in traction usually is 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. The remaining options are incorrect.
\A client has Buck's extension traction applied to the right leg. Which intervention
should the nurse plan to prevent complications of the device?
1.
Give pin care once a shift.
2.
Inspect the skin on the right leg.
3.
Massage the skin of the right leg with lotion.
4.
Release the weights on the right leg for daily range-of-motion exercises. -
ANS-Inspect the skin on the right leg.
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. There are no
pins to care for with skin traction. Massaging the skin with lotion is not indicated. The
, nurse never releases the weights of traction unless specifically prescribed by the
health care provider.
\A client has had a bone scan done. The nurse determines that the client
demonstrates understanding of postprocedure care when the client makes which
statement?
1.
"Flushing indicates a complication."
2.
"I should stay on liquids for a couple of days."
3.
"I need to ambulate every couple of hours faithfully for a few days."
4.
"I need to drink plenty of water for 1 to 2 days after the procedure." - ANS-"I need to
drink plenty of water for 1 to 2 days after the procedure."
No special restrictions are necessary 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. The very small amount of radioactivity from the isotope presents no hazard
to the client or staff. The remaining options are unrelated to postprocedure care.
\A client has had surgery to repair a fractured left hip. When repositioning the client
from side to side in the bed, what should the nurse plan to use as the most important
item for this maneuver?
1.
Bed pillow
2.
Abductor splint
3.
Adductor splint
4.
Overhead trapeze - ANS-Abductor splint
After surgery to repair a fractured hip, an abductor splint is used to maintain the
affected extremity in good alignment. A bed pillow and an overhead trapeze also are
used, but neither is the priority item to be used in repositioning the client from side to
side.
\A client has just been admitted to the hospital with a fractured femur and pelvic
fractures. The nurse should plan to carefully monitor the client for which
signs/symptoms?
A client being measured for crutches asks the nurse why the crutches cannot rest up
underneath the arm for extra support. The nurse responds knowing that which would
most likely result from this improper crutch measurement?
1.
A fall and further injury
2.
Injury to the brachial plexus nerves
3.
Skin breakdown in the area of the axilla
4.
Impaired range of motion while the client ambulates - ANS-Injury to the brachial
plexus nerves
Crutches are measured so that the tops are 2 to 3 fingerwidths from the axillae. This
ensures that the client's axillae are not resting on the crutch or bearing the weight of
the crutch, which could result in injury to the nerves of the brachial plexus. Although
the conditions in options 1, 3, and 4 can occur, they are not the most likely result
from resting the axilla directly on the crutches.
\A client has been diagnosed with gout, and the nurse provides dietary instructions.
The nurse determines that the client needs additional teaching if the client states that
it is acceptable to eat which food?
1.
Carrots
2.
Tapioca
3.
Chocolate
4.
Chicken liver - ANS-Chicken liver
Liver and other organ meats should be omitted from the diet of a client who has gout
because of their high purine content. Purines are a form of protein. The food items
identified in the other options contain negligible amounts of purines and may be
consumed freely by the client with gout.
\A client has been diagnosed with osteomalacia, or adult rickets. The nurse should
anticipate that the health care provider will include a new prescription for which
vitamin supplement?
,1.
A
2.
D
3.
E
4.
K - ANS-D
Osteomalacia technically refers to bone softening that results from demineralization
of bone matrix and failure to calcify. A common cause is vitamin D deficiency in the
diet. Other causes are inadequate exposure to sunlight (to synthesize vitamin D) and
disorders that interfere with absorption and metabolism of vitamin D. Deficiencies of
the vitamins noted in the remaining options are not associated with osteomalacia.
\A client has been diagnosed with subluxation of the shoulder. The nurse explains to
the client that which injury has occurred to the joint?
1.
It is strained.
2.
It is contused.
3.
It has completely dislocated.
4.
It has incompletely dislocated. - ANS-It has incompletely dislocated.
A dislocation is the disruption of a joint to the extent that the articulating surfaces are
no longer in contact. A subluxation is an incomplete dislocation of the joint surfaces.
Because the disruption is less severe, healing time is less prolonged. A strain occurs
when a muscle or ligament is used beyond the limit of its functional ability. It is
characterized by overstretching of the muscle or ligament and also could involve
tearing if the strain is more severe (i.e., second- or third-degree strain versus
first-degree strain). A contusion is a soft tissue injury that results in hemorrhage into
the involved tissue.
\A client has been experiencing muscle weakness over a period of several months.
The health care provider suspects polymyositis. Which client statement correctly
identifies a confirmation of test results and this diagnosis?
1.
"If I have polymyositis, there will be a decrease in elastic tissue."
2.
"I will know I have polymyositis if the muscle fibers are inflamed."
3.
,"The health care provider said there would be more fibers and tissue with
polymyositis."
4.
"The health care provider said if the muscle fibers were thickened, I would have
polymyositis." - ANS-"I will know I have polymyositis if the muscle fibers are
inflamed."
In polymyositis, necrosis and inflammation are seen in muscle fibers and myocardial
fibers. Option 1 refers to the decreased elastic tissue in the aorta seen in Marfan
syndrome. Option 3 refers to increased fibrous tissue seen in ankylosis. Option 4 is
the opposite of what is noted in this disorder.
\A client has been placed in Buck's extension traction. The nurse can provide for
countertraction to reduce shear and friction by performing which action?
1.
Using a footboard
2.
Providing an overhead trapeze
3.
Slightly elevating the foot of the bed
4.
Slightly elevating the head of the bed - ANS-Slightly elevating the foot of the bed
The part of the bed under an area in traction usually is 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. The remaining options are incorrect.
\A client has Buck's extension traction applied to the right leg. Which intervention
should the nurse plan to prevent complications of the device?
1.
Give pin care once a shift.
2.
Inspect the skin on the right leg.
3.
Massage the skin of the right leg with lotion.
4.
Release the weights on the right leg for daily range-of-motion exercises. -
ANS-Inspect the skin on the right leg.
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. There are no
pins to care for with skin traction. Massaging the skin with lotion is not indicated. The
, nurse never releases the weights of traction unless specifically prescribed by the
health care provider.
\A client has had a bone scan done. The nurse determines that the client
demonstrates understanding of postprocedure care when the client makes which
statement?
1.
"Flushing indicates a complication."
2.
"I should stay on liquids for a couple of days."
3.
"I need to ambulate every couple of hours faithfully for a few days."
4.
"I need to drink plenty of water for 1 to 2 days after the procedure." - ANS-"I need to
drink plenty of water for 1 to 2 days after the procedure."
No special restrictions are necessary 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. The very small amount of radioactivity from the isotope presents no hazard
to the client or staff. The remaining options are unrelated to postprocedure care.
\A client has had surgery to repair a fractured left hip. When repositioning the client
from side to side in the bed, what should the nurse plan to use as the most important
item for this maneuver?
1.
Bed pillow
2.
Abductor splint
3.
Adductor splint
4.
Overhead trapeze - ANS-Abductor splint
After surgery to repair a fractured hip, an abductor splint is used to maintain the
affected extremity in good alignment. A bed pillow and an overhead trapeze also are
used, but neither is the priority item to be used in repositioning the client from side to
side.
\A client has just been admitted to the hospital with a fractured femur and pelvic
fractures. The nurse should plan to carefully monitor the client for which
signs/symptoms?
