ATI MEDSURG 2 MUSCULOSKELETAL AND RESPIRATORY
EXAM 2025 | ALL QUESTIONS AND CORRECT ANSWERS
(DETAILED ANSWERS) | ALREADY GRADED A+ | VERIFIED
ANSWERS | LATEST VERSION
The nursing care plan for a client in traction specifics regular assessments
for venous thromboembolism (VTE). When assessing a client's lower limbs,
what sign or symptom is suggestive of deep vein thrombosis (DVT)?
A. Increased warmth of the calf
B. Decreased circumference of the calf
C. Loss of sensation to the calf
D. Pale-appearing calf ---------CORRECT ANSWER-----------------ANS: A
Signs of DVT include increased warmth, redness, swelling, and calf
tenderness. These findings are promptly reported to the health care
provider for a definitive evaluation and therapy. Signs and symptoms
of a DVT do not include a decreased circumference of the calf, a loss
of sensation in the calf, or a pale-appearing calf.
A nurse is caring for an adult client diagnosed with a back strain. What
health education should the nurse provide to this client?
A. Avoid lifting more than one-third of body weight without assistance
B. Focus on using back muscles efficiently when lifting heavy objects.
C. Lift objects while holding the object a safe distance from the body
D. Tighten the abdominal muscles and lock the knees when lifting an
object. ---------CORRECT ANSWER-----------------ANS: A
The nurse will instruct the client on the safe and correct way to lift
objects -- using the strong quadriceps muscles of the thighs, with
minimal use of the weaker back muscles. To prevent recurrence of
acute low back pain, the nurse may instruct the client to avoid lifting
more than one-third of the client's body weight without help. The
client should be informed to place the feet hip-width apart to provide
a wide base of support. The person should then bend the knees,
tighten the abdominal muscles, and lift the object close to the body
with a smooth motion, avoiding twisting and jerking.
,A client has suffered a muscle strain and is reporting pain at 6 on a 10 point
scale.. The nurse should recommend what action?
A. Taking an opioid and analgesic as prescribed
B. Applying a cold pack to the injury site.
C. Performing a passive ROM exercises
D. Applying a heating pad to the affected muscle. ---------CORRECT
ANSWER-----------------ANS: B
Most pain can be relieved by elevating the involved part, applying
cold packs, and administering analgesics as prescribed. Heat may
exacerbate the pain by increasing blood circulation, and ROM
exercises would likely be painful. Analgesia is likely necessary, but
NSAIDs would be more appropriate than opioids.
A nurse's assessment of a client's knee reveals edema, tenderness,
muscle spasms, and ecchymosis. The client states that 2 days ago the
client ran in a long-distance race and now it "really hurts to stand up." The
nurse should plan care based on the belief that the client has experienced
what injury?
A. A first-degree strain
B. A second-degree strain
C. A first-degree sprain
D. A second-degree sprain ---------CORRECT ANSWER-----------------ANS:
B
A second-degree strain involves tearing of muscle fibers and is
manifested by notable loss of load-bearing strength with
accompanying edema, tenderness, muscle spasm, and ecchymosis. A
first-degree strain reflects tearing of a few muscle fibers and is
accompanied by minor edema, tenderness, and mild muscle spasm,
without noticeable loss of function. However, the client states a loss
of function. A sprain normally involves twisting, which is inconsistent
with the client's overuse injury.
,A client has presented to the emergency department with an injury to the
writs. The client is diagnosed with a third-degree strain. Why would the
health care provider prescribe an x-ray of the wrist?
A. Nerve damage is associated with third-degree strains.
B. Compartment syndrome is associated with third-degree strains.
C. Avulsion fractures are associated with third-degree strains.
D. Greenstick fractures are associated with third-degree strains. ---------
CORRECT ANSWER-----------------ANS: C
A x-ray should be obtained to rule out bone injury because an
avulsion fracture (in which a bone fragment is pulled away from the
bone by a tendon) may be associated with a third-degree strain. Nerve
damage, compartment syndrome, and greenstick fractures are not
associated with third-degree strains.
A nurse in a busy emergency department provides care for many clients
who present with contusions, strains, or sprains. What are treatment
modalities that are common to all of these musculoskeletal injuries? Select
all that apply. (pg 995)
A. Massage
B. Applying ice
C. Compression dressings
D. Resting the affected extremity
E. Corticosteroids
F. Elevating the injured limb ---------CORRECT ANSWER-----------------ANS:
B, C, D, F
Treatment of contusions, strains, and sprains consists of resting and
elevating the affected part, applying cold, and using a compression
bandage. Massage and corticosteroids are not used to treat these
injuries.
A nurse is writing a care plan for a client admitted to the emergency
department (ED) with an open fracture. The nurse will assign priority to
what nursing diagnosis for a client with an open fracture of the radius?
A. Risk for infection
, B. Risk for ineffective role performance
C. Risk for perioperative positioning injury
D. Risk for powerlessness ---------CORRECT ANSWER-----------------ANS: A
The client has a significant risk of osteomyelitis and tetanus due to
the fact that the fracture is open. Powerlessness and ineffective role
performance are psychosocial diagnoses that may or may not apply
and which would be superseded by immediate physiologic threats
such as infection. Surgical positioning injury is not plausible, since
surgery is not likely indicated.
A nurse is caring for a client who has suffered an unstable thoracolumbar
fracture. What goal should the nurse prioritize during nursing care?
A. Preventing skin breakdown
B. Maintaining spinal alignment
C. Maximizing function
D. Preventing increased intracranial pressure. ---------CORRECT
ANSWER-----------------ANS: B
Clients with an unstable fracture must have their spine in alignment at
all times in order to prevent neurologic damage. This is a greater
threat, and higher priority, than promoting function and preventing
skin breakdown, even though these are both valid considerations.
Increased ICP is not a high risk.
A client with a simple arm fracture is receiving discharge education from
the nurse. What would the nurse instruct the client to do?
A. Elevate the affected extremity to shoulder level when at rest.
B. Engage in exercises that strengthen the unaffected muscles.
C. Apply topical anesthetic to accessible skin surfaces as needed.
D. Avoid using analgesics so that further damage is not masked. ---------
CORRECT ANSWER-----------------ANS: B
The nurse will encourage the client to engage in exercises that
strengthen the unaffected muscles. Comfort measures may include
EXAM 2025 | ALL QUESTIONS AND CORRECT ANSWERS
(DETAILED ANSWERS) | ALREADY GRADED A+ | VERIFIED
ANSWERS | LATEST VERSION
The nursing care plan for a client in traction specifics regular assessments
for venous thromboembolism (VTE). When assessing a client's lower limbs,
what sign or symptom is suggestive of deep vein thrombosis (DVT)?
A. Increased warmth of the calf
B. Decreased circumference of the calf
C. Loss of sensation to the calf
D. Pale-appearing calf ---------CORRECT ANSWER-----------------ANS: A
Signs of DVT include increased warmth, redness, swelling, and calf
tenderness. These findings are promptly reported to the health care
provider for a definitive evaluation and therapy. Signs and symptoms
of a DVT do not include a decreased circumference of the calf, a loss
of sensation in the calf, or a pale-appearing calf.
A nurse is caring for an adult client diagnosed with a back strain. What
health education should the nurse provide to this client?
A. Avoid lifting more than one-third of body weight without assistance
B. Focus on using back muscles efficiently when lifting heavy objects.
C. Lift objects while holding the object a safe distance from the body
D. Tighten the abdominal muscles and lock the knees when lifting an
object. ---------CORRECT ANSWER-----------------ANS: A
The nurse will instruct the client on the safe and correct way to lift
objects -- using the strong quadriceps muscles of the thighs, with
minimal use of the weaker back muscles. To prevent recurrence of
acute low back pain, the nurse may instruct the client to avoid lifting
more than one-third of the client's body weight without help. The
client should be informed to place the feet hip-width apart to provide
a wide base of support. The person should then bend the knees,
tighten the abdominal muscles, and lift the object close to the body
with a smooth motion, avoiding twisting and jerking.
,A client has suffered a muscle strain and is reporting pain at 6 on a 10 point
scale.. The nurse should recommend what action?
A. Taking an opioid and analgesic as prescribed
B. Applying a cold pack to the injury site.
C. Performing a passive ROM exercises
D. Applying a heating pad to the affected muscle. ---------CORRECT
ANSWER-----------------ANS: B
Most pain can be relieved by elevating the involved part, applying
cold packs, and administering analgesics as prescribed. Heat may
exacerbate the pain by increasing blood circulation, and ROM
exercises would likely be painful. Analgesia is likely necessary, but
NSAIDs would be more appropriate than opioids.
A nurse's assessment of a client's knee reveals edema, tenderness,
muscle spasms, and ecchymosis. The client states that 2 days ago the
client ran in a long-distance race and now it "really hurts to stand up." The
nurse should plan care based on the belief that the client has experienced
what injury?
A. A first-degree strain
B. A second-degree strain
C. A first-degree sprain
D. A second-degree sprain ---------CORRECT ANSWER-----------------ANS:
B
A second-degree strain involves tearing of muscle fibers and is
manifested by notable loss of load-bearing strength with
accompanying edema, tenderness, muscle spasm, and ecchymosis. A
first-degree strain reflects tearing of a few muscle fibers and is
accompanied by minor edema, tenderness, and mild muscle spasm,
without noticeable loss of function. However, the client states a loss
of function. A sprain normally involves twisting, which is inconsistent
with the client's overuse injury.
,A client has presented to the emergency department with an injury to the
writs. The client is diagnosed with a third-degree strain. Why would the
health care provider prescribe an x-ray of the wrist?
A. Nerve damage is associated with third-degree strains.
B. Compartment syndrome is associated with third-degree strains.
C. Avulsion fractures are associated with third-degree strains.
D. Greenstick fractures are associated with third-degree strains. ---------
CORRECT ANSWER-----------------ANS: C
A x-ray should be obtained to rule out bone injury because an
avulsion fracture (in which a bone fragment is pulled away from the
bone by a tendon) may be associated with a third-degree strain. Nerve
damage, compartment syndrome, and greenstick fractures are not
associated with third-degree strains.
A nurse in a busy emergency department provides care for many clients
who present with contusions, strains, or sprains. What are treatment
modalities that are common to all of these musculoskeletal injuries? Select
all that apply. (pg 995)
A. Massage
B. Applying ice
C. Compression dressings
D. Resting the affected extremity
E. Corticosteroids
F. Elevating the injured limb ---------CORRECT ANSWER-----------------ANS:
B, C, D, F
Treatment of contusions, strains, and sprains consists of resting and
elevating the affected part, applying cold, and using a compression
bandage. Massage and corticosteroids are not used to treat these
injuries.
A nurse is writing a care plan for a client admitted to the emergency
department (ED) with an open fracture. The nurse will assign priority to
what nursing diagnosis for a client with an open fracture of the radius?
A. Risk for infection
, B. Risk for ineffective role performance
C. Risk for perioperative positioning injury
D. Risk for powerlessness ---------CORRECT ANSWER-----------------ANS: A
The client has a significant risk of osteomyelitis and tetanus due to
the fact that the fracture is open. Powerlessness and ineffective role
performance are psychosocial diagnoses that may or may not apply
and which would be superseded by immediate physiologic threats
such as infection. Surgical positioning injury is not plausible, since
surgery is not likely indicated.
A nurse is caring for a client who has suffered an unstable thoracolumbar
fracture. What goal should the nurse prioritize during nursing care?
A. Preventing skin breakdown
B. Maintaining spinal alignment
C. Maximizing function
D. Preventing increased intracranial pressure. ---------CORRECT
ANSWER-----------------ANS: B
Clients with an unstable fracture must have their spine in alignment at
all times in order to prevent neurologic damage. This is a greater
threat, and higher priority, than promoting function and preventing
skin breakdown, even though these are both valid considerations.
Increased ICP is not a high risk.
A client with a simple arm fracture is receiving discharge education from
the nurse. What would the nurse instruct the client to do?
A. Elevate the affected extremity to shoulder level when at rest.
B. Engage in exercises that strengthen the unaffected muscles.
C. Apply topical anesthetic to accessible skin surfaces as needed.
D. Avoid using analgesics so that further damage is not masked. ---------
CORRECT ANSWER-----------------ANS: B
The nurse will encourage the client to engage in exercises that
strengthen the unaffected muscles. Comfort measures may include
