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1. A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every 1 to 2 hours?

  • Maintain comfort
  • Prevent pressure ulcers
  • Prevent flexion contractures of the extremities
  • Improve venous circulation in the lower extremities

2. What should the nurse do to control edema of the residual limb 1 week after a client has an above-the-knee amputation?

  • Administer the prescribed diuretic.
  • Restrict the clients oral fluid intake.
  • Rewrap the elastic bandage as necessary.
  • Keep the residual limb elevated on a pillow.

3. A client who had a total hip replacement asks the nurse about the continuous regional analgesia being used. What information should the nurse include when explaining the benefits of this treatment over conventional methods to control pain?

  • Adjusting the dose is easily done.
  • Neuropathic pain can be relieved.
  • Systemic side effects are minimal.
  • The need for parenteral medication is avoided.

4. A health care provider orders the application of warm compresses for a client with arthritis. What is the appropriate temperature range for the compresses that the nurse applies?

  • 65° to 79° F (18.3° to 26.1° C)
  • 80° to 92° F (26.6° to 33.3° C)
  • 93° to 97° F (33.8° to 36.1° C)
  • 98° to 105° F (36.6° to 40.5° C)

5. Which position should a nurse avoid placing a client who had surgery for a total hip replacement?

  • Supine
  • Lateral
  • Orthopneic
  • Semi-Fowler

6. A client is admitted with a fracture of the neck of the femur. In what position should the nurse maintain the client’s affected extremity?

  • Internal rotation with flexion of the knee and hip
  • External rotation with flexion of the knee and hip
  • Internal rotation with extension of the knee and hip
  • External rotation with extension of the knee and hip

7. A client has a long leg cast. What instructions should the nurse give the client in preparation for crutch walking?

  • Use the trapeze to strengthen the biceps
  • Keep the affected limb in extension and abduction
  • Sit up straight in a chair to develop the back muscles
  • Do exercises in bed to strengthen the upper extremitie

8. Nursing care of a client with a fractured hip should include the assessment of pedal pulses. The nurse should assess for which important characteristics of the pedal pulses?

  • Contractility and rate
  • Color of skin and rhythm
  • Amplitude and symmetry
  • Local temperature and visible pulsations

9. A client is admitted with acute gouty arthritis. Which medication does the nurse anticipate the health care provider may prescribe to prevent and treat an acute attack of gout?

  • Ibuprofen (Motrin)
  • Colchicine (Colsalide)
  • Probenecid (Benemid)
  • Hydrocortisone (Cortef)

10. What should the nurse consider as the goal of therapy when administering allopurinol (Zyloprim) to a client with gout?

  • Increase bone density
  • Decrease synovial swelling
  • Decrease uric acid production
  • Prevent crystallization of uric acid

11. After an above-the-knee amputation of a leg, a client reports pain in the foot that is no longer there. What should the nurse include about phantom limb pain in a discussion with the client?

  • Tactile illusions associated with severed blood vessels
  • Nerve endings in the limb are still intact and react to stimuli
  • An unconscious phenomenon to aid with grieving over the lost body part
  • Hallucinations secondary to emotional symptoms associated with the distress of amputation

12. A nurse should expect a client with a spinal cord injury to have some spasticity of the lower extremities. What should the nurse include in the plan of care for this client to prevent the development of lower extremity contractures?

  • Deep massage
  • Active exercise
  • Use of a tilt board
  • Proper positioning

13. A client with a fractured hip is placed in traction until surgery can be performed. What should the nurse explain is the purpose of the traction?

  • Relieve muscle spasm and pain
  • Prevent contractures from developing
  • Keep the client from turning and moving in bed
  • Maintain the limb in a position of external rotation

14. On the first postoperative day after a total hip replacement a client asks for assistance onto the bedpan. What should the nurse instruct the client to do?

  • Use the elbows and hands to lift the pelvis off the bed.
  • Extend both legs and pull on the trapeze to lift the pelvis.
  • Turn gently toward the operative side while lifting the pelvis off the bed.
  • Flex the knee on the unoperated leg and pull on the trapeze to lift the pelvis.

15. A client is in skin traction while awaiting surgery for repair of a fractured femur. The client reports leg discomfort and asks the nurse to release the traction. Which is the nurse’s best initial response?

  • “I can’t because the weights are needed to keep the bone aligned.”
  • “I will remove half of the weights and notify your health
  • “I’ll get your prescribed pain medication to help relieve your discomfort.”
  • “I have to follow the health care provider’s directions, and releasing weights is not ordered.”

16. A client with quadriplegia is placed on a tilt table daily. Each day the angle of the head of the table gradually is increased. What should the nurse identify as its purpose when the client asks the reason for the tilt table?

  • Facilitates turning
  • Prevents pressure ulcers
  • Promotes hyperextension of the spine
  • Limits loss of calcium from the bones

17. A nurse in a rehabilitation center teaches clients with quadriplegia to use an adaptive wheelchair. Why is it important that the nurse provide this instruction?

  • They usually will never walk.
  • It prepares them for wearing braces.
  • It assists them in overcoming orthostatic hypotension.
  • They have the strength in the upper extremities for self-transfer.

18. What intervention should the nurse avoid to prevent con-tractures of the joints of the lower extremities in a client with paraplegia?

  • Changing the client’s bed position hourly
  • Using supportive devices to maintain alignment
  • Providing the client with active exercise instructions
  • Performing passive range-of-motion exercises several times daily

19. Which principle should the nurse consider when assisting a client with crutches to learn the four-point gait?

  • Elbows should be kept in rigid extension.
  • Most of the weight should be supported by axillae.
  • The client must be able to bear weight on both legs.
  • The affected extremity should be kept off the ground.

20. Which is an example of the principles of body mechanics that the nurse uses when caring for immobilized clients?

  • Bending at the waist to provide the power for lifting
  • Placing the feet apart to increase the stability of the body
  • Keeping the body straight when lifting to reduce pressure on the abdomen
  • Relaxing the abdominal muscles while using the extremities to prevent strain

21. A nurse is caring for a client who had a total hip replacement. What nursing action should be incorporated into the plan of care to prevent thrombus formation?

  • Turning the client from side to side
  • Encouraging the client to perform ankle exercises
  • Getting the client up to sit in a chair for as long as tolerated
  • Ambulating the client when the effects of anesthesia subside

22. To reduce a hip fracture, the client is placed in traction before surgery for an open reduction and internal fixation. Because the client keeps slipping down in bed, increased countertraction is ordered. How does the nurse increase the countertraction?

  • Elevate the head of the bed
  • Add more weight to the traction
  • Use a slight Trendelenburg position
  • Tie a chest restraint around the client

23. A nurse is caring for a client who had a total hip replacement. What is the priority assessment when monitoring the client for hemorrhage?

  • Checking vital signs every four hours
  • Examining the bedding under the client
  • Measuring the circumference of the thigh
  • Observing for ecchymosis at the operative site

24. A client is placed into a whirlpool tub for range-of-motion exercises. The client asks the nurse about the need to exercise in water. The nurse should explain that rehabilitating exer-cises carried out underwater utilize the water’s:

  • pressure
  • temperature
  • buoyant force
  • vapor production

25. A nurse is caring for a client who had an open reduction and internal fixation of a femoral neck fracture. The client has an order for ambulation with slight weight-bearing on the affected extremity. During the physical assessment the nurse identifies that the client has kyphosis and strong upper arm strength. What assistive devise does the nurse expect the health care provider to order for this client?

  • Crutches
  • Quad cane
  • Straight cane
  • Standard walker

26. A nurse is caring for a client who developed aseptic necrosis after a fracture of the head of the femur. The nurse understands that aseptic necrosis is associated with which factor?

  • Infection at the site of the wound
  • Weight-bearing before the fracture is healed
  • Immobilization after reduction of the fracture
  • Loss of blood supply to the head of the femur

27. Which nursing action is contraindicated when caring for a client with a newly applied long leg cast?

  • Elevating the cast on a pillow
  • Drying the cast by using a fan
  • Leaving the cast exposed to air
  • Handling the cast with fingertips

28. A client had an above-the-knee amputation of the left leg because of trauma from a motor vehicle collision. The health care provider orders ambulation with crutches until the residual limb is healed and the client can be fitted with a prosthesis. What should be the nurse’s first intervention?

  • Demonstrate the swing-through crutch walking gait.
  • Determine if the client has ever used crutches before.
  • Introduce the client to another client who is using crutches.
  • Provide a pamphlet that has information about using crutches.

29. When should the nurse begin the process of rehabilitation when a client is scheduled for an amputation?

  • Before the surgery
  • During the convalescent phase
  • On discharge from the hospital
  • When it is time for a prosthesis

30. A client with a spinal cord injury has paraplegia. The nurse assesses for which major problem the client may experience early in the recovery period?

  • Bladder control
  • Nutritional intake
  • Quadriceps setting
  • Use of aids for ambulation

31. Which crutch gait should the nurse teach the client wearing a prosthesis after a single-leg amputation?

  • Tripod
  • Four-point
  • Three-point
  • Swing-through

32. When a client is in the right side-lying position after the insertion of a left hip prosthesis, the nurse ensures that the client has a pillow placed between the thighs and that the entire length of the upper leg is supported. What does this pillow prevent?

  • Strain on the operative site
  • Thrombus formation in the leg
  • Flexion contractures of the hip joint
  • Skin surfaces from rubbing together

33. What instructions should the nurse provide when the client is allowed out of bed after an above-the-knee amputation?

  • Keep the hip in extension and alignment.
  • Keep the hip raised with the residual limb elevated.
  • Lift the shoulder and hip of the affected side when taking a step.
  • Use the ordered crutches until the residual limb is completely healed.

34. A nurse suspects the development of compartment syndrome for a client who has sustained blunt trauma to the forearm. For which early sign of compartment syndrome should the nurse assess the client?

  • Warm skin at site of injury
  • Escalating pain in the fingers
  • Rapid capillary refill in affected hand
  • Bounding radial pulse in the injured arm

35. What should be included in the nurse’s instructions to help a client prepare for walking with crutches?

  • Use of the trapeze to strengthen the biceps muscles
  • Exercises with or without weights to strengthen the muscles of the upper extremities
  • The importance of keeping the affected limb in extension and abduction to prevent contractures
  • Isometric exercises of the hamstring muscles while sitting in a chair until circulatory status is stable

36. A client experiences a traumatic amputation of a leg in a motor vehicle accident. Which nursing intervention initially should receive the lowest priority?

  • Teaching residual limb care
  • Monitoring hemoglobin levels
  • Maintaining the compression dressing
  • Using therapeutic interviewing techniques

37. A client who has been immobilized for an extended period questions the need for a tilt table. The nurse’s best response is “The tilt table is used to help:

  • prevent hypertension.”
  • encourage increased activity.”
  • maintain circulation to the skin.”
  • prevent loss of calcium from long bones.”

38. What should the nurse do to promote early and efficient ambulation after a client has a midthigh amputation?

  • Keep the head of the bed elevated.
  • Place the residual limb on a pillow.
  • Turn the client to the prone position routinely.
  • Encourage the client to lie on the unaffected side.

39. What does the nurse determine is the most likely cause of renal calculi in clients with paraplegia?

  • High fluid intake
  • Increased intake of calcium
  • Inadequate kidney function
  • Accelerated bone demineralization

40. After a client is treated for a spinal cord injury, the health care provider informs the family that the client is a paraplegic. The family asks the nurse what this means. What explanation should the nurse provide?

  • Lower extremities are paralyzed.
  • Upper extremities are paralyzed.
  • One side of the body is paralyzed.
  • Both lower and upper extremities are paralyzed.

41. A nurse finds a victim under the wreckage of a collapsed building. The individual is conscious, supine, breathing satisfactorily, and reporting back pain and an inability to move the legs. Which action should the nurse take first?

  • Leave the individual lying on the back with instructions not to move, and seek additional help.
  • Roll the individual onto the abdomen, place a pad under the head, and cover with any material available.
  • Gently raise the individual to a sitting position to see whether the pain either diminishes or increases in intensity.
  • Gently lift the individual onto a flat piece of lumber and, using any available transportation, rush to the closest medical institution.

42. A client has a total knee replacement, and a continuous passive motion device is being used. The nurse concludes that the teaching was effective when the client states, “The goal of this therapy is to:

  • improve joint flexion.”
  • maintain muscle tone.”
  • prevent tissue breakdown.”
  • avoid formation of a blood clot.”

43. What problem is the nurse primarily attempting to prevent when encouraging a client with a spinal cord injury to increase oral fluid intake?

  • Dehydration
  • Skin breakdown
  • Electrolyte imbalances
  • Urinary tract infections

44. What should the nurse assess for when a client with a cervical injury reports a severe headache and nasal congestion?

  • Suprapubic distention
  • Increased spinal reflexes
  • Adventitious breath sounds
  • Imminent development of shock

45. A client with a fractured hip is helped from the bed to a chair after surgery. The nurse instructs the client to bear most of the weight on the unaffected leg before sitting in a chair. What should the nurse explain is the benefit of bearing most of the weight on the unaffected leg?

  • Can increase circulation in the lower extremities
  • Will help maintain the strength of the unaffected limb
  • Is the quickest method of getting the client to and from the bed
  • Reduces the amount of help necessary to lift the client from the bed to the chair

46. The care plan for a client with a fractured hip includes nursing actions to prevent which type of contracture?

  • Flexion of the hip
  • Abduction of the hip
  • Hyperextension of the hip
  • Internal rotation of the hip

47. After a traumatic spinal cord severance, a young client is having difficulty accepting the paralysis. One day the client has severe leg spasms and says, “My strength is coming back, and I know I will walk again.” The nurse’s response should be based on what understanding?

  • The nerves are regenerating and motor function is returning.
  • Motor function may be returning now that the edema is subsiding.
  • Spinal shock has subsided and the client’s reflexes are hyperactive.
  • The client has developed thrombophlebitis and is experiencing pain.

48. Which clinical indicator should the nurse expect to identify when assessing a client with a fracture of the neck of the femur?

  • Adduction with internal rotation
  • Abduction with external rotation
  • Shortening of the affected extremity with external rotation
  • Lengthening of the affected extremity with internal rotation

49. What does the nurse do for a client with a cervical laminectomy that differs from the nursing care for a client with a lumbar laminectomy?

  • Assist with the removal of oral secretions.
  • Maintain the client’s head in a flexed position.
  • Elevate the head of the client’s bed to a 45-degree angle.
  • Provide range-of-motion exercise early during the postoperative period.

50. A client has an amputation of a lower limb. What instructions should the nurse give the client to prevent a hip flexion contracture?

  • Turn from side to side every 1 to 2 hours.
  • Sit in a chair for 30 minutes three times a day.
  • Lie on the abdomen 30 minutes four times daily.
  • Perform quadriceps muscle setting exercises twice daily.