Chapter 39. Promoting Musculoskeletal Function

The nurse plans for an immobilized patient who suffered a cerebrovascular accident to be protected from skin disruption by the use of: (Select all that apply.) a. rubber sheets. b. alcohol rubs to the heels. c. sheepskin pads. d. water mattresses. e. pulsating air pads. ANS: C, D, E Sheepskin pads, water mattresses, and pulsating air pads help protect the immobilized patient from skin disruption. DIF: Cognitive Level: Application REF: p. 796 OBJ: Theory #4 TOP: Pressure Relief Devices KEY: Nursing Pr cess Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 2. A patient has a hip spica cast and will be discharged home to family. The nurse would include in the home education plan information relative to: (Select all that apply.) a. protecting the cast from soiling. b. easing itching under the cast by scratching with a bent coat hanger. c. grasping the cast over the leg to help in turning. d. using the spreader bar to turn the patient. e. turning frequently to the prone position. ANS: A, C, E A patient with a hip spica cast will not be able to walk and will require frequent turning by grasping the cast over the leg to help in the turning process. A challenge is protecting the cast from stool or urine soiling. The patient should be turned frequently, especially to the prone position. DIF: Cognitive Level: Application REF: p. 794 OBJ: Clinical Practice #4 TOP: Hip Spica Cast KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. The nurse designs care for the immobilized patient to help combat the major dangers of immobilization, which include: (Select all that apply.) S - The Marketplace to Buy and Sell your Study Material a. pressure injuries. b. loss of bone mass. c. urinary infection. d. pneumonia. e. permanent loss of function. ANS: A, B, D, E Immobilization can cause pressure injuries, loss of bone mass, pneumonia, and possible permanent loss of function of the immobilized part. Although urinary infections are common, immobility is not their cause. DIF: Cognitive Level: Comprehension REF: p. 790 OBJ: Theory #1 TOP: Effects of Immobility KEY: Nursing Pr ocess Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. When cleaning the pins on a patient in skeletal traction, the nurse should: (Select all that apply.) a. spray pin insertion with antimicrobial solution. b. clean closest to the skin puncture site in a circular motion. c. slightly rotate each pin to prevent adhesion to the bone. d. secure ends of wire with cork or adhesive tape. e. accomplish care with clean technique. ANS: B, D Pins should be cleansed with a sterile swab starting at the skin puncture; the ends of the wire or pin can be secured with a piece of cork or adhesive tape. The process is performed with sterile technique. DIF: Cognitive Level: Application REF: p. 804|Box 39-2 OBJ: Clinical Practice #4 TOP: Pin Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease