Muscoskeletal Final

Front 1

A patient complains of pain during circumduction of the shoulder when the nurse moves the arm behind the patient. Which question should the nurse ask?
a. “Do you have difficulty in putting on a jacket?”
b. “Are you able to feed yourself without difficulty?”
c. “Are you able to sleep through the night without waking?”
d. “Do you ever have trouble lowering yourself to the toilet?”

Back 1

ANS: A
The patient’s pain will make it more difficult to accomplish tasks like putting on a shirt or jacket. This pain should not affect the patient’s ability to feed himself or herself or use the toilet because these tasks do not involve moving the arm behind the patient. The arm will not usually be positioned behind the patient during sleeping.

Front 2

A patient with knee pain who is diagnosed with bursitis asks the nurse to explain just what bursitis is. The nurse will respond that bursitis is an inflammation of
a. a small, fluid-filled sac found at many joints.
b. the synovial membrane that lines the joint area.
c. the fibrocartilage that acts as a shock absorber in the knee joint.
d. any connective tissue that is found supporting the joints of the body.

Back 2

ANS: A
Bursae are fluid-filled sacs that cushion joints and bony prominences. Fibrocartilage is a solid tissue that cushions some joints. Bursae are a specific type of connective tissue. The synovial membrane lines many joints but is not a bursa.

Front 3

When assessing a 64-year-old woman, the nurse notes that the patient has lost 1 inch in height since the previous visit 2 years ago. The nurse will plan to teach the patient about
a. discography studies.
b. myelographic testing.
c. magnetic resonance imaging (MRI).
d. dual-energy x-ray absorptiometry (DEXA).

Back 3

ANS: D
The decreased height and the patient’s age suggest that the patient may have osteoporosis and that bone density testing is needed. Discography, MRI, and myelography are typically done for patients with current symptoms caused by musculoskeletal dysfunction and are not the initial diagnostic tests for osteoporosis.

Front 4

Which information in a 60-year-old woman’s health history will alert the nurse to the need for a more focused assessment of the musculoskeletal system?
a. The patient experienced a sprained ankle at age 13.
b. The patient’s mother became much shorter with aging.
c. The patient’s father died of complications of miliary tuberculosis.
d. The patient reports taking ibuprofen (Advil) for occasional headaches.

Back 4

ANS: B
A family history of height loss with aging may indicate osteoporosis, and the nurse should perform a more thorough assessment of the patient’s current height and other risk factors for osteoporosis. A sprained ankle during adolescence does not place the patient at increased current risk for musculoskeletal problems. A family history of tuberculosis is not a risk factor. Occasional nonsteroidal anti-inflammatory drug (NSAID) use does not indicate any increased musculoskeletal risk.

Front 5

Which information obtained during the nurse’s assessment of the patient’s nutritional-metabolic pattern may indicate the risk for musculoskeletal problems?
a. The patient takes a multivitamin daily.
b. The patient dislikes fruits and vegetables.
c. The patient is 5 ft 2 in and weighs 180 lb.
d. The patient prefers whole milk to nonfat milk.

Back 5

ANS: C
The patient’s height and weight indicate obesity, which places stress on weight-bearing joints. The use of whole milk, avoiding fruits and vegetables, and use of a daily multivitamin are not risk factors for musculoskeletal problems.

Front 6

When the nurse is assessing a new patient in the clinic, which information about the patient’s medications will be of most concern?
a. The patient takes a daily multivitamin and calcium supplement.
b. The patient has migraine headaches that are treated with nonsteroidal anti-inflammatory drugs (NSAIDs).
c. The patient has severe asthma and requires frequent therapy with oral steroids.
d. The patient takes hormone replacement therapy (HRT) to prevent “hot flashes.”

Back 6

ANS: C
Corticosteroid use may lead to skeletal problems such as avascular necrosis and osteoporosis. The use of HRT and calcium supplements will help prevent osteoporosis. NSAID use does not increase the risk for musculoskeletal problems.

Front 7

While testing the patient’s muscle strength, the nurse finds that the patient can flex the arms when no resistance is applied but is unable to flex when the nurse applies light resistance. The nurse should document the patient’s muscle strength as level
a. 1.
b. 2.
c. 3.
d. 4.

Back 7

ANS: C
A level 3 indicates that the patient is unable to move against resistance but can move against gravity. Level 1 indicates minimal muscle contraction, level 2 indicates that the arm can move when gravity is eliminated, and level 4 indicates active movement with some resistance.

Front 8

When assessing the musculoskeletal system, the nurse’s initial action will usually be to
a. feel for the presence of crepitus during joint movement.
b. have the patient move the extremities against resistance.
c. observe the patient’s body build and muscle configuration.
d. check active and passive range of motion for the extremities.

Back 8

ANS: C
The usual technique in the physical assessment is to begin with inspection. Abnormalities in muscle mass or configuration will allow the nurse to perform a more focused assessment of abnormal areas. The other assessments also are included in the assessment but are usually done after inspection.

Front 9

Which nursing action is correct when the nurse is assessing the straight-leg raising test for a patient with back pain?
a. Raise the patient’s legs to a 60-degree angle from the bed.
b. Have the patient dangle the legs over the edge of the exam table.
c. Place the patient initially in the prone position on the bed or exam table.
d. Instruct the patient to elevate the legs while tightening the abdominal muscles.

Back 9

ANS: A
When performing the straight leg-raising test, the patient is in the supine position and the nurse passively lifts the patient’s legs to a 60-degree angle. The other actions would not be correct for this test.

Front 10

A patient with kyphosis is scheduled for dual-energy x-ray absorptiometry (DEXA) testing. The nurse will plan to
a. give an oral sedative.
b. start an intravenous line.
c. teach the patient about DEXA.
d. screen the patient for shellfish allergies.

Back 10

ANS: C
DEXA testing is painless and noninvasive. No IV access is necessary. Contrast medium is not used. Because the procedure is painless, no antianxiety medications are required.

Front 11

A patient has a new order for magnetic resonance imaging (MRI) to evaluate for right femur osteomyelitis. Which patient information indicates that the nurse should consult with the health care provider before scheduling the MRI?
a. The patient has a pacemaker.
b. The patient is claustrophobic.
c. The patient wears a hearing aid.
d. The patient is allergic to shellfish.

Back 11

ANS: A
Patients with permanent pacemakers cannot have MRI because of the force exerted by the magnetic field on metal objects. An open MRI will not cause claustrophobia. The patient will need to be instructed to remove the hearing aid before the MRI, but this does not require consultation with the health care provider. Since contrast medium will not be used, shellfish allergy is not a contraindication to MRI.

Front 12

When assessing the movement of a patient’s elbow, the nurse notes crackling sounds and a grating sensation with palpation. How will this be documented?
a. Torticollis
b. Crepitation
c. Subluxation
d. Epicondylitis

Back 12

ANS: B
Crackling sounds and a grating sensation that accompany movement are described as crepitus or crepitation. Torticollis is a twisting of the neck to one side, subluxation is a partial dislocation of the joint, and epicondylitis is an inflammation of the elbow that causes a dull ache that increases with movement.

Front 13

The nurse obtains this information when assessing a 74-year-old patient in the outpatient clinic. Which finding is of highest priority when the nurse is planning care for the patient?
a. Symmetrical joint swelling of fingers
b. Decreased right knee range of motion
c. History of recent loss of balance and fall
d. Complaint of left hip aching when jogging

Back 13

ANS: C
A history of falls requires further assessment and development of fall prevention strategies. The other changes are more typical of bone and joint changes associated with normal aging.

Front 14

A patient is seen in the clinic complaining of knee pain following an arthroscopic procedure 7 days previously and the health care provider performs arthrocentesis. Which finding will be of most concern to the nurse?
a. Scant thin fluid
b. Sanguineous fluid
c. Straw-colored fluid
d. Purulent appearing fluid

Back 14

ANS: D
The presence of purulent fluid suggests a possible joint infection. Bloody fluid might be expected after an arthroscopic procedure. Normal synovial fluid is scant in amount and straw-colored.

Front 15

When counseling an older patient about ways to prevent fractures, which information will the nurse include?
a. Tack down scatter rugs in the home.
b. Most falls happen outside the home.
c. Buy shoes that provide good support and are comfortable to wear.
d. Range-of-motion exercises should be taught by a physical therapist.

Back 15

ANS: C
Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range of motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries.

Front 16

A checkout clerk in a grocery store has repetitive strain syndrome in the left elbow. The nurse will plan to teach the patient about
a. surgical options.
b. elbow injections.
c. utilization of a left wrist splint.
d. modifications in arm movement.

Back 16

ANS: D
Treatment for repetitive strain syndrome includes changing the ergonomics of the activity. Elbow injections and surgery are not initial options for this type of injury. A wrist splint might be used for hand or wrist pain.

Front 17

When working with a patient whose job involves many hours of word processing, the nurse will teach the patient about the need to
a. do stretching and warm-up exercises before starting work.
b. wrap the wrists with a compression bandage every morning.
c. use acetaminophen (Tylenol) instead of nonsteroidal anti-inflammatory drugs (NSAIDs) for wrist pain.
d. obtain a keyboard pad to support the wrist while word processing.

Back 17

ANS: D
Repetitive strain injuries caused by prolonged times working at a keyboard can be prevented by the use of a pad that will keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to use to decrease swelling.

Front 18

Which information will the nurse include when discharging a patient with a sprained wrist from the emergency department?
a. Keep the wrist loosely wrapped with gauze.
b. Apply a heating pad to reduce muscle spasms.
c. Use pillows to elevate the arm above the heart.
d. Gently move the wrist through the range of motion.

Back 18

ANS: C
Elevation of the arm will reduce the amount of swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to 48 hours, cold packs are used to reduce swelling. The wrist should be rested and kept immobile to prevent further swelling or injury.

Front 19

A 20-year-old baseball pitcher has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included?
a. “You have an appointment with a physical therapist for tomorrow.”
b. “You can still play baseball but you will not be able to return to pitching.”
c. “The doctor will use the drop-arm test to determine the success of surgery.”
d. “Leave the shoulder immobilizer on for the first few days to minimize pain.”

Back 19

ANS: A
Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent “frozen shoulder.” A shoulder immobilizer is used immediately after the surgery, but leaving the arm immobilized for several days would lead to loss of range of motion (ROM). The drop-arm test is used to test for rotator cuff injury, but not after surgery. The patient may be able to return to pitching after rehabilitation.

Front 20

A patient who has a cast in place after fracturing the radius asks when the cast can be removed. The nurse will instruct the patient that the cast will need to remain in place
a. for several months.
b. for at least 3 weeks.
c. until swelling of the wrist has resolved.
d. until x-rays show complete bony union.

Back 20

ANS: B
Bone healing starts immediately after the injury, but since ossification does not begin until 3 weeks postinjury, the cast will need to be worn for at least 3 weeks. Complete union may take up to a year. Resolution of swelling does not indicate bone healing.

Front 21

A patient with a comminuted fracture of the right femur has Buck’s traction in place while waiting for surgery. To assess for pressure areas on the patient’s back and sacral area and to provide skin care, the nurse should
a. loosen the traction and have the patient turn onto the unaffected side.
b. place a pillow between the patient’s legs and turn gently to each side.
c. turn the patient partially to each side with the assistance of another nurse.
d. have the patient lift the buttocks by bending and pushing with the left leg.

Back 21

ANS: D
The patient can lift the buttocks off the bed by using the left leg without changing the right-leg alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the traction will interrupt the weight needed to immobilize and align the fracture.

Front 22

After a patient with a left femur fracture has a hip spica cast applied, which nursing intervention will be included in the plan of care?
a. Avoid placing the patient in the prone position.
b. Use the cast support bar to reposition the patient.
c. Ask the patient about any abdominal discomfort or nausea.
d. Discuss the reasons for remaining on bed rest for several weeks.

Back 22

ANS: C
Assessment of bowel tones, abdominal pain, and nausea and vomiting will detect the development of cast syndrome. To avoid breakage, the support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical therapy personnel and may be turned to the prone position.

Front 23

A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should
a. keep the left arm in a dependent position.
b. handle the cast with the palms of the hands.
c. place gauze around the cast edge to pad any roughness.
d. cover the cast with a small blanket to absorb the dampness.

Back 23

ANS: B
Until a plaster cast has dried, placing pressure on the cast should be avoided to prevent creating areas inside the cast that could place pressure on the arm. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying.

Front 24

After a patient has a short-arm plaster cast applied in the emergency department, which statement by the patient indicates a good understanding of the nurse’s discharge teaching?
a. “I can get the cast wet as long as I dry it right away with a hair dryer.”
b. “I should avoid moving my fingers and elbow until the cast is removed.”
c. “I will apply an ice pack to the cast over the fracture site for the next 24 hours.”
d. “I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast.”

Back 24

ANS: C
Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.

Front 25

Which of the following observations made by the nurse who is evaluating the crutch-walking technique of a patient who is to have no weight bearing on the right leg indicates that the patient can safely ambulate independently?
a. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.
b. The patient advances the right leg and both crutches together and then advances the left leg.
c. The patient moves the left crutch with the left leg and then the right crutch with the right leg.
d. The patient uses the bedside chair to assist in balance as needed when ambulating in the room.

Back 25

ANS: B
When using crutches, patients are usually taught to move the assistive device and the injured leg forward at the same time and then to move the unaffected leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid nerve damage. If the 2- or 4-point gaits are to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg.

Front 26

A patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures complains of constant severe pain in the leg, which is unrelieved by the prescribed morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next?
a. Notify the health care provider.
b. Assess the incision for redness.
c. Reposition the left leg on pillows.
d. Check the patient’s blood pressure.

Back 26

ANS: A
The patient’s clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.

Front 27

When the nurse is caring for a patient who is on bed rest after having a complex pelvic fracture, which assessment finding is most important to report to the health care provider?
a. The patient states that the pelvis feels unstable.
b. Abdominal distention is present and bowel tones are absent.
c. There are ecchymoses on the abdomen and hips.
d. The patient complains of pelvic pain with palpation.

Back 27

ANS: B
The abdominal distention and absent bowel tones may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal bruising would be expected with this type of injury.

Front 28

Which action will the nurse take in order to evaluate the effectiveness of Buck’s traction for a patient who has an intracapsular fracture of the left femur?
a. Assess for hip contractures.
b. Monitor for hip dislocation.
c. Check the peripheral pulses.
d. Ask about left hip pain level.

Back 28

ANS: D
Buck’s traction keeps the leg immobilized and reduces painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Buck’s traction

Front 29

A patient with lower leg fracture has an external fixation device in place and is scheduled for discharge. Which information will the nurse include in the discharge teaching?
a. “You will need to assess and clean the pin insertion sites daily.”
b. “The external fixator can be removed during the bath or shower.”
c. “You will need to remain on bed rest until bone healing is complete.”
d. “Prophylactic antibiotics are used until the external fixator is removed.”

Back 29

ANS: A
Pin insertion sites should be cleaned daily to decrease the risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given when an external fixator is used.

Front 30

The nurse is preparing to assist a patient who has had an open reduction and internal fixation (ORIF) of a hip fracture out of bed for the first time. Which action should the nurse take?
a. Use a mechanical lift to transfer the patient from the bed to the chair.
b. Check the postoperative orders for the patient’s weight-bearing status.
c. Avoid administration of pain medications before getting the patient up.
d. Delegate the transfer of the patient out of bed to nursing assistive personnel (NAP).

Back 30

ANS: B
The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given, since the movement is likely to be painful for the patient. The RN should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish this skill.

Front 31

When doing discharge teaching for a patient who has had a repair of a fractured mandible, the nurse will include information about
a. when and how to cut the immobilizing wires.
b. self-administration of nasogastric tube feedings.
c. the use of sterile technique for dressing changes.
d. the importance of including high-fiber foods in the diet.

Back 31

ANS: A
The jaw will be wired for stabilization, and the patient should know what emergency situations require that the wires be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge the patient will swallow liquid through a straw.

Front 32

After the health care provider has recommended an amputation for a patient who has ischemic foot ulcers, the patient tells the nurse, “If they want to cut off my foot, they should just shoot me instead.” Which response by the nurse is best?
a. “Many people are able to function normally with a foot prosthesis.”
b. “I understand that you are upset, but you may lose the foot anyway.”
c. “Tell me what you know about what your options for treatment are.”
d. “If you do not want the surgery, you do not have to have an amputation.”

Back 32

ANS: C
The initial nursing action should be to assess the patient’s knowledge level and feelings about the options available. Discussion about the patient’s option to not have the procedure, the seriousness of the condition, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patient’s current level of knowledge and emotional state.

Front 33

On the first postoperative day, a patient with a below-the-knee amputation complains of pain in the amputated limb. Which action is best for the nurse to take?
a. Explain the reasons for the phantom limb pain.
b. Administer prescribed analgesics to relieve the pain.
c. Loosen the compression bandage to decrease incisional pressure.
d. Remind the patient that this phantom pain will diminish over time.

Back 33

ANS: B
Phantom limb pain is treated like any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. The compression bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it still requires treatment now.

Front 34

Which statement by a patient who has had an above-the-knee amputation indicates that the nurse’s discharge teaching has been effective?
a. “I should lay on my abdomen for 30 minutes 3 or 4 times a day.”
b. “I should elevate my residual limb on a pillow 2 or 3 times a day.”
c. “I should change the limb sock when it becomes soiled or stretched out.”
d. “I should use lotion on the stump to prevent drying and cracking of the skin.”

Back 34

ANS: A
The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage flexion contracture.

Front 35

A patient is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. A statement by the patient that indicates a need for additional discharge instructions is
a. “I should not cross my legs while sitting.”
b. “I will use a toilet elevator on the toilet seat.”
c. “I will have someone else put on my shoes and socks.”
d. “I can sleep in any position that is comfortable for me.”

Back 35

ANS: D
The patient needs to sleep in a position that prevents excessive internal rotation or flexion of the hip. The other patient statements indicate that the patient has understood the teaching.

Front 36

Which nursing action will the nurse include in the plan of care for a patient who has had a total knee arthroplasty?
a. Avoid extension of the knee beyond 120 degrees.
b. Use a compression bandage to keep the knee flexed.
c. Start progressive knee exercises to obtain 90-degree flexion.
d. Teach about the need to avoid weight bearing for 4 weeks.

Back 36

ANS: C
After knee arthroplasty, active or passive flexion exercises are used to obtain a 90-degree flexion of the knee. The goal for extension of the knee will be 180 degrees. A compression bandage is used to hold the knee in an extended position after surgery. Full weight bearing is expected before discharge.

Front 37

A patient with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for an arthroplasty of the hand. Which patient statement to the nurse indicates realistic expectation for the surgery?
a. “I will be able to use my fingers to grasp objects better.”
b. “I will not have to do as many hand exercises after the surgery.”
c. “This procedure will prevent further deformity in my hands and fingers.”
d. “My fingers will appear more normal in size and shape after this surgery.”

Back 37

ANS: A
The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Hand exercises will be prescribed after the surgery.

Front 38

When giving home care instructions to a patient who has multiple forearm fractures and a long-arm cast on the right arm, which information should the nurse include?
a. Keep the hand immobile to prevent soft tissue swelling.
b. Keep the right shoulder elevated on a pillow or cushion.
c. Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for the first 48 hours after the injury.
d. Call the health care provider for increased swelling or numbness.

Back 38

ANS: D
Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling.
NSAIDs are appropriate to treat pain after a fracture.

Front 39

A patient who has a proximal humerus fracture that is immobilized with a left-sided long-arm cast and a sling is admitted to the medical-surgical unit. Which nursing intervention will be included in the plan of care?
a. Use surgical net dressing to hang the arm from an IV pole.
b. Immobilize the fingers on the left hand with gauze dressings.
c. Assess the left axilla and change absorbent dressings as needed.
d. Assist the patient in passive range of motion (ROM) for the right arm.

Back 39

ANS: C
The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side.

Front 40

A patient has hip replacement surgery using the posterior approach. Which patient action requires rapid intervention by the nurse?
a. The patient uses crutches with a swing-to gait.
b. The patient leans over to pull shoes and socks on.
c. The patient sits straight up on the edge of the bed.
d. The patient bends over the sink while brushing the teeth.

Back 40

ANS: B
Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient.

Front 41

A patient who has been hospitalized for 3 days with a hip fracture has sudden onset shortness of breath and tachypnea. The patient tells the nurse, “I feel like I am going to die!” Which action should the nurse take first?
a. Stay with the patient and offer reassurance.
b. Administer the prescribed PRN oxygen at 4 L/min.
c. Check the patient’s legs for swelling or tenderness.
d. Notify the health care provider about the symptoms.

Back 41

ANS: B
The patient’s clinical manifestations and history are consistent with a pulmonary embolus, and the nurse’s first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for fat embolus or venous thromboembolism (VTE) are obtained.

Front 42

A patient is seen at the urgent care center after falling on the right arm and shoulder. Which finding is most important for the nurse to communicate to the health care provider?
a. There is bruising at the shoulder area.
b. The right arm appears shorter than the left.
c. There is decreased range of motion of the shoulder.
d. The patient is complaining of arm and shoulder pain.

Back 42

ANS: B
A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion also should be reported, but these do not indicate that emergent treatment is needed to preserve function.

Front 43

A patient arrives in the emergency department with ankle swelling and severe pain after twisting the ankle playing soccer. Which of these prescribed collaborative interventions will the nurse implement first?
a. Wrap the ankle and apply an ice pack.
b. Administer naproxen (Naprosyn) 500 mg PO.
c. Give acetaminophen with codeine (Tylenol #3).
d. Take the patient to the radiology department for x-rays.

Back 43

ANS: A
Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied

Front 44

When planning care for a patient who has had hip replacement surgery, which nursing action can the nurse delegate to experienced nursing assistive personnel (NAP)?
a. Teach quadriceps-setting exercises.
b. Reposition the patient every 1 to 2 hours.
c. Assess for skin irritation on the patient’s back.
d. Determine the patient’s pain level and tolerance.

Back 44

ANS: B
Repositioning of patients is within the scope of practice of NAP (after they have been trained and evaluated in this skill). The other actions should be done by licensed nursing staff members.

Front 45

A patient in the emergency department who is experiencing severe pain is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for
a. a knee immobilizer.
b. gentle knee flexion.
c. activity restrictions.
d. monitored anesthesia care (conscious sedation).

Back 45

ANS: D
The first goal of collaborative management is realignment of the knee to its original anatomic position, which will require anesthesia or monitored anesthesia care (MAC), formerly called conscious sedation. Immobilization, gentle range of motion (ROM) exercises, and discussion about activity restrictions will be implemented after the knee is realigned.

Front 46

Following a motor vehicle accident, a patient arrives in the emergency department with massive right lower leg swelling. Which action will the nurse take first?
a. Elevate the leg on pillows.
b. Apply a compression bandage.
c. Check leg pulses and sensation.
d. Place ice packs on the lower leg.

Back 46

ANS: C
The initial action by the nurse will be to assess the circulation to the leg and to observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment.

Front 47

A patient is admitted to the emergency department with possible left lower leg fractures. The initial action by the nurse should be to
a. elevate the left leg.
b. splint the lower leg.
c. obtain information about the tetanus immunization status.
d. check the popliteal, dorsalis pedis, and posterior tibial pulses.

Back 47

ANS: D
The initial nursing action should be assessment of the neurovascular status of the injured leg. After assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be done if there is an open wound.

Front 48

In developing a care plan for a patient with an open reduction and internal fixation (ORIF) of an open, displaced fracture of the tibia, the priority nursing diagnosis is
a. activity intolerance related to deconditioning.
b. risk for constipation related to prolonged bed rest.
c. risk for impaired skin integrity related to immobility.
d. risk for infection related to disruption of skin integrity.

Back 48

ANS: D
A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis. After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused by immobility are not as likely.

Front 49

The second day after admission with a fractured pelvis, a patient develops acute onset confusion. Which action should the nurse take first?
a. Take the blood pressure.
b. Assess patient orientation.
c. Check pupil reaction to light.
d. Assess the oxygen saturation.

Back 49

ANS: D
The patient’s history and clinical manifestations suggest a fat embolus. The most important assessment is oxygenation. The other actions also are appropriate but will be done after the nurse assesses gas exchange.

Front 50

Which information obtained by the emergency department nurse when admitting a patient with a left femur fracture is most important to report to the health care provider?
a. Bruising of the left thigh
b. Complaints of left thigh pain
c. Outward pointing toes on the left foot
d. Prolonged capillary refill of the left foot

Back 50

ANS: D
Prolonged capillary refill may indicate complications such as arterial damage or compartment syndrome. The other findings are typical with a left femur fracture

Front 51

A patient is hospitalized for initiation of regional antibiotic irrigation for acute osteomyelitis of the right femur. Which intervention will be included in the plan of care?
a. Immobilization of the right leg
b. Frequent weight-bearing exercise
c. Avoiding administration of nonsteroidal anti-inflammatory drugs (NSAIDs)
d. Support of the right leg in a flexed position

Back 51

ANS: A
Immobilization of the affected leg helps decrease pain and reduce the risk for pathologic fractures. Weight-bearing exercise increases the risk for pathologic fractures. NSAIDs are frequently prescribed to treat pain. Flexion of the affected limb is avoided to prevent contractures.

Front 52

A patient is being discharged after 2 weeks of IV antibiotic therapy for acute osteomyelitis in the left leg. Which information will be included in the discharge teaching?
a. How to apply warm packs safely to the leg to reduce pain
b. How to monitor and care for the long-term IV catheter site
c. The need for daily aerobic exercise to help maintain muscle strength
d. The reason for taking oral antibiotics for 7 to 10 days after discharge

Back 52

ANS: B
The patient will be on IV antibiotics for several months, and the patient will need to recognize signs of infection at the IV site and how to care for the catheter during daily activities such as bathing. IV antibiotics rather than oral antibiotics are used for acute osteomyelitis. Patients are instructed to avoid exercise and heat application because these will increase swelling and the risk for spreading infection.

Front 53

A patient has chronic osteomyelitis of the left femur, which is being managed at home with administration of IV antibiotics. The nurse chooses a nursing diagnosis of ineffective health maintenance when the nurse finds that the patient
a. takes and records the oral temperature twice a day.
b. is unable to plantar flex the foot on the affected side.
c. uses crutches to avoid weight bearing on the affected leg.
d. is irritable and frustrated with the length of treatment required.

Back 53

ANS: B
Foot drop is an indication that the foot is not being supported in a neutral position by a splint. Using crutches and monitoring the oral temperature are appropriate self-care activities. Frustration with the length of treatment is not an indicator of ineffective health maintenance of the osteomyelitis.

Front 54

Which statement by a patient who is scheduled for an above-the-knee amputation for treatment of an osteosarcoma of the right tibia indicates that patient teaching is needed?
a. “I did not have this bone cancer until my leg broke a week ago.”
b. “I wish that I did not have to have chemotherapy after this surgery.”
c. “I know that I will need to participate in physical therapy after surgery.”
d. “I will use the patient-controlled analgesia (PCA) to control postoperative pain.”

Back 54

ANS: A
Osteogenic sarcoma may be diagnosed following a fracture, but it is not caused by the injury. The other patient statements indicate that patient teaching has been effective.

Front 55

A 20-year-old patient with a history of muscular dystrophy is hospitalized with a respiratory tract infection. Which nursing action will be included in the plan of care?
a. Assist the patient with ambulation.
b. Logroll the patient every 1 to 2 hours.
c. Discuss the need for genetic testing with the patient.
d. Teach the patient about the muscle biopsy procedure.

Back 55

ANS: A
Since the goal for the patient with muscular dystrophy is to keep the patient active for as long as possible, assisting the patient to ambulate will be part of the care plan. The patient will not require logrolling. Muscle biopsies are necessary to confirm the diagnosis but are not necessary for a patient who already has a diagnosis. There is no need for genetic testing since the patient already knows the diagnosis.

Front 56

A patient has muscle spasms and acute low back pain. An appropriate nursing intervention for this problem is to teach the patient to
a. avoid the use of cold because it will exacerbate the muscle spasms.
b. keep both feet flat on the floor when prolonged standing is required.
c. keep the head elevated slightly and flex the knees when resting in bed.
d. twist gently from side to side to maintain range of motion in the spine.

Back 56

ANS: C
Resting with the head elevated and knees flexed will reduce the strain on the back and decrease muscle spasms. Twisting from side to side will increase tension on the lumbar area. A pillow placed under the upper back will cause strain on the lumbar spine. Alternate application of cold and heat should be used to decrease pain.

Front 57

A patient whose work involves lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates that the teaching has been effective?
a. “I plan to start doing exercises to strengthen the muscles of my back.”
b. “I will try to sleep with my hips and knees extended to prevent back strain.”
c. “I can tell my boss that I need to change to a job where I can work at a desk.”
d. “I will keep my back straight when I need to lift anything higher than my waist.”

Back 57

ANS: A
Exercises can help to strengthen the muscles that support the back. Flexion of the hips and knees places less strain on the back. Modifications in the way the patient lifts boxes are needed, but sitting for prolonged periods can aggravate back pain. The patient should not lift above the level of the
elbows.

Front 58

A patient with a herniated intravertebral disk undergoes a laminectomy and discectomy. Following the surgery, the nurse should position the patient on the side by
a. instructing the patient to move the legs before turning the rest of the body.
b. having the patient turn by grasping the side rails and pulling the shoulders over.
c. placing a pillow between the patient’s legs and turning the entire body as a unit.
d. turning the patient’s head and shoulders first, followed by the hips, legs, and feet.

Back 58

ANS: C
The spine should be kept in correct alignment after laminectomy. The other positions will create misalignment of the spine.

Front 59

After teaching a patient with a bunion about how to prevent further problems, the nurse will determine that more teaching is needed if the patient says,
a. “I will throw away my high heel shoes.”
b. “I will use the bunion pad to relieve the pain.”
c. “I will need to wear open sandals at all times.”
d. “I will take ibuprofen (Motrin) when I need it.”

Back 59

ANS: C
The patient can wear shoes that have a wide forefoot. The other patient statements indicate that the teaching has been effective.

Front 60

An assessment finding that alerts the nurse to the presence of osteoporosis in a middle-aged patient is
a. measurable loss of height.
b. the presence of bowed legs.
c. an aversion to dairy products.
d. statements about frequent falls.

Back 60

ANS: A
Osteoporosis occurring in the vertebrae produces a gradual loss of height. Bowed legs are associated with osteomalacia. Low intake of dairy products is a risk factor for osteoporosis, but it does not indicate that osteoporosis is present. Frequent falls increase the risk for fractures but are not an indicator of osteoporosis.

Front 61

A 58-year-old woman who has a family history of osteoporosis is diagnosed with osteopenia following densitometry testing. In teaching the woman about her osteoporosis, the nurse explains that
a. estrogen replacement therapy must be started to prevent rapid progression to osteoporosis.
b. continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis.
c. with a family history of osteoporosis, there is no way to prevent or slow gradual bone resorption.
d. calcium loss from bones can be slowed by increasing calcium intake and weight-bearing exercise.

Back 61

ANS: D
Progression of osteoporosis can be slowed by increasing calcium intake and weight-bearing exercise. Estrogen replacement therapy does help prevent osteoporosis, but it is not the only treatment and is not appropriate for some patients. Corticosteroid therapy increases the risk for osteoporosis.

Front 62

Which menu choice by a patient with osteoporosis indicates that the nurse’s teaching about appropriate diet has been effective?
a. Pancakes with syrup and bacon
b. Whole wheat toast and fruit jelly
c. Two-egg omelet and a half grapefruit
d. Oatmeal with skim milk and fruit yogurt

Back 62

ANS: D
Skim milk and yogurt are high in calcium. The other choices do not contain any high calcium foods.

Front 63

Which assessment information will the nurse obtain to evaluate the effectiveness of the prescribed calcitonin (Cibacalcin) and ibandronate (Boniva) for a patient with Paget’s disease?
a. Pain level
b. Oral intake
c. Daily weight
d. Grip strength

Back 63

ANS: A
Bone pain is one of the common early manifestations of Paget’s disease, and the nurse should assess the pain level to determine whether the treatment is effective. The other information will also be collected by the nurse, but will not be used in evaluating the effectiveness of the therapy.

Front 64

A patient is receiving gentamicin (Garamycin) 80 mg IV twice daily for acute osteomyelitis. Which action should the nurse take before administering the gentamicin?
a. Ask the patient about any nausea.
b. Obtain the patient’s oral temperature.
c. Change the prescribed wet-to-dry dressing.
d. Review the patient’s blood urea nitrogen (BUN) and creatinine levels.

Back 64

ANS: D
Gentamicin is nephrotoxic and can cause renal failure. Monitoring the patient’s temperature before gentamicin administration is not necessary. Nausea is not a common side effect of IV gentamicin. There is no need to change the dressing before gentamicin administration.

Front 65

The nurse is caring for a patient who has had a surgical reduction of an open fracture of the left tibia. Which assessment finding is most important to report to the health care provider?
a. Left leg muscle spasms
b. Serous wound drainage
c. Left leg pain with movement
d. Temperature 101.4° F (38.6° C)

Back 65

ANS: D
An elevated temperature is suggestive of possible osteomyelitis. The other clinical manifestations are typical after a repair of an open fracture.

Front 66

Following a laminectomy with a spinal fusion, a patient reports numbness and tingling of the right lower leg. The first action indicated by the nurse is to
a. report the patient’s complaint to the surgeon.
b. check the vital signs for indications of hemorrhage.
c. turn the patient to the side to relieve pressure on the right leg.
d. check the chart for preoperative neuromuscular assessment data.

Back 66

ANS: D
The postoperative movement and sensation of the extremities should be unchanged (or improved) from the preoperative assessment. If the numbness and tingling are new, this information should be immediately reported to the surgeon. Numbness and tingling are not symptoms associated with hemorrhage at the site. Turning the patient will not relieve the numbness.

Front 67

When administering alendronate (Fosamax) to a patient, the nurse will first
a. be sure the patient has recently eaten.
b. ask about any leg cramps or hot flashes.
c. assist the patient to sit up at the bedside.
d. administer the ordered calcium carbonate.

Back 67

ANS: C
To avoid esophageal erosions, the patient taking bisphosphonates should be upright for at least 30 minutes after taking the medication. Fosamax should be taken on an empty stomach, not after taking other medications or eating. Leg cramps and hot flashes are not side effects of bisphosphonates.

Front 68

Which of these nursing actions included in the care of a patient after laminectomy can the nurse delegate to experienced nursing assistive personnel (NAP)?
a. Ask about pain control with the patient-controlled analgesia (PCA).
b. Determine the patient’s readiness to ambulate.
c. Check ability to plantar and dorsiflex the foot.
d. Turn the patient from side to side every 2 hours.

Back 68

ANS: D
Repositioning a patient is included in the education and scope of practice of NAP, and experienced NAP will be familiar with how to maintain alignment in the postoperative patient. Evaluation of the effectiveness of pain medications, assessment of neurologic function, and evaluation of a patient’s readiness to ambulate after surgery require higher level nursing education and scope of practice.

Front 69

Which finding will the nurse expect when assessing a 60-year-old patient who has osteoarthritis (OA) of the left knee?
a. Heberden’s nodules
b. Pain upon joint movement
c. Redness and swelling of the knee joint
d. Stiffness that increases with movement

Back 69

ANS: B
Initial symptoms of OA include pain with joint movement. Heberden’s nodules occur on the fingers. Redness of the joint is more strongly associated with rheumatoid arthritis (RA), and stiffness in OA is worse right after the patient rests and decreases with joint movement.

Front 70

Which assessment finding about a patient who has been using naproxen (Naprosyn) for 3 weeks to treat osteoarthritis is most important for the nurse to report to the health care provider?
a. The patient has dark colored stools.
b. The patient’s pain has not improved.
c. The patient is using capsaicin cream (Zostrix).
d. The patient has gained 3 pounds over 3 weeks.

Back 70

ANS: A
Dark colored stools may indicate that the patient is experiencing gastrointestinal bleeding caused by the naproxen. The information about the patient’s ongoing pain and weight gain also will be reported and may indicate a need for a different treatment and/or counseling about avoiding weight gain, but these are not as large a concern as the possibility of gastrointestinal bleeding. Use of capsaicin cream with oral medications is appropriate.

Front 71

After the nurse has finished teaching a patient with osteoarthritis (OA) of the left hip and knee about how to manage the OA, which patient statement indicates a need for more education?
a. “I can take glucosamine to help decrease my knee pain.”
b. “I will take 1 g of acetaminophen (Tylenol) every 4 hours.”
c. “I will take a shower in the morning to help relieve stiffness.”
d. “I can use a cane to decrease the pressure and pain in my hip.”

Back 71

ANS: B
No more than 4 g of acetaminophen should be taken daily to avoid liver damage. The other patient statements are correct and indicate good understanding of OA management.

Front 72

When caring for a patient who has osteoarthritis, the nurse will anticipate the need to teach the patient about which of these medications?
a. Adalimumab (Humira)
b. Prednisone (Deltasone)
c. Capsaicin cream (Zostrix)
d. Sulfasalazine (Azulfidine)

Back 72

ANS: C
Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with RA.

Front 73

A patient who has rheumatoid arthritis is seen in the outpatient clinic and the nurse notes that rheumatoid nodules are present on the patient’s elbows. Which action will the nurse take?
a. Draw blood for rheumatoid factor analysis.
b. Teach the patient about injection of the nodule.
c. Assess the nodules for skin breakdown or infection.
d. Discuss the need for surgical removal of the nodule.

Back 73

ANS: C
Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence.

Front 74

When caring for a patient with a new diagnosis of rheumatoid arthritis, which action will the nurse include in the plan of care?
a. Instruct the patient to purchase a soft mattress.
b. Teach patient to use lukewarm water when bathing.
c. Suggest that the patient take a nap in the afternoon.
d. Suggest exercise with light weights several times daily.

Back 74

ANS: C
Adequate rest helps decrease the fatigue and pain that are associated with rheumatoid arthritis. Patients are taught to avoid stressing joints, to use warm baths to relieve stiffness, and to use a firm mattress.

Front 75

A home health patient with rheumatoid arthritis (RA) complains to the nurse about having chronically dry eyes. Which action by the nurse is most appropriate?
a. Reassure the patient that dry eyes are a common problem with RA.
b. Teach the patient more about adverse affects of the RA medications.
c. Suggest that the patient start using over-the-counter (OTC) artificial tears.
d. Ask the health care provider about lowering the methotrexate (Rheumatrex) dose.

Back 75

ANS: C
The patient’s dry eyes are consistent with Sjögren’s syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes are not a side effect of methotrexate. Although dry eyes are common in RA, it is more helpful to offer a suggestion to relieve these symptoms than to offer reassurance. The dry eyes are not caused by RA treatment, but by the disease itself.

Front 76

Which information will the nurse include when teaching range-of-motion exercises to a patient with an exacerbation of rheumatoid arthritis?
a. Affected joints should not be exercised when pain is present.
b. Application of cold packs before exercise may decrease joint pain.
c. Exercises should be performed passively by someone other than the patient.
d. Walking may substitute for range-of-motion (ROM) exercises on some days.

Back 76

ANS: B
Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints as well as improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises.

Front 77

Prednisone (Deltasone) is prescribed for a patient with an acute exacerbation of rheumatoid arthritis. Which laboratory result will the nurse monitor to determine whether the medication has been effective?
a. Blood glucose test
b. Liver function tests
c. C-reactive protein level
d. Serum electrolyte levels

Back 77

ANS: C
C-reactive protein is a marker for inflammation, and a decrease would indicate that the corticosteroid therapy was effective. Blood glucose and serum electrolyte levels also will be monitored to check for side effects of prednisone. Liver function is not routinely monitored for patients receiving steroids.

Front 78

When teaching a patient who has rheumatoid arthritis (RA) about how to manage activities of daily living, the nurse instructs the patient to
a. stand rather than sit when performing household chores.
b. avoid activities that require continuous use of the same muscles.
c. strengthen small hand muscles by wringing sponges or washcloths.
d. protect the knee joints by sleeping with a small pillow under the knees.

Back 78

ANS: B
Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase the joint stress. Patients are encouraged to position joints in the extended position, and sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion (ROM).

Front 79

When helping a patient with rheumatoid arthritis (RA) plan a daily routine, the nurse informs the patient that it is most helpful to start the day with
a. a warm bath followed by a short rest.
b. a short routine of isometric exercises.
c. active range-of-motion (ROM) exercises.
d. stretching exercises to relieve joint stiffness.

Back 79

ANS: A
Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased.

Front 80

Anakinra (Kineret) is prescribed for a patient who has rheumatoid arthritis (RA). When teaching the patient about this drug, the nurse will include information about
a. self-administration of subcutaneous injections.
b. taking the medication with at least 8 oz of fluid.
c. avoiding concurrently taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDs).
d. symptoms of gastrointestinal (GI) irritation or bleeding.

Back 80

ANS: A
Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this medication. Because the medication is injected, instructions to take it with 8 oz of fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or NSAIDs, and these should not be discontinued.

Front 81

A 35-year-old patient with three school-age children who has recently been diagnosed with rheumatoid arthritis (RA) tells the nurse that the inability to be involved in many family activities is causing stress at home. Which response by the nurse is most appropriate?
a. “You may need to see a family therapist for some help.”
b. “Tell me more about the situations that are causing stress.”
c. “Perhaps it would be helpful for you and your family to get involved in a support group.”
d. “Your family may need some help to understand the impact of your rheumatoid arthritis.”

Back 81

ANS: B
The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment.

Front 82

Which information will the nurse include when teaching a patient with newly diagnosed ankylosing spondylitis (AS) about the management of the condition?
a. Exercise by taking long walks.
b. Do daily deep breathing exercises.
c. Sleep on the side with hips flexed.
d. Take frequent naps during the day.

Back 82

ANS: B
Deep breathing exercises are used to decrease the risk for pulmonary complications that may occur with the reduced chest expansion that can occur with ankylosing spondylitis (AS). Patients should sleep on the back and avoid flexed positions. Prolonged standing and walking should be avoided. There is no need for frequent naps.

Front 83

A 22-year-old patient hospitalized with a fever and red, hot, and painful knees is suspected of having septic arthritis. Information obtained during the nursing history that indicates a risk factor for septic arthritis is that the patient
a. has a parent who has reactive arthritis.
b. is sexually active and has multiple partners.
c. recently returned from a trip to South America.
d. had several sports-related knee injuries as a teenager.

Back 83

ANS: B
Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults. The other information does not point to any risk for septic arthritis.

Front 84

While working at a summer camp, the nurse notices a circular lesion with a red border and clear center on the arm of a patient who is in the camp clinic complaining of chills and muscle aches. Which action should the nurse take next?
a. Palpate the abdomen.
b. Auscultate the heart sounds.
c. Ask the patient about recent outdoor activities.
d. Question the patient about immunization history.

Back 84

ANS: C
The patient’s clinical manifestations suggest possible Lyme disease. A history of recent outdoor activities such as hikes will help confirm the diagnosis. The patient’s symptoms do not suggest cardiac or abdominal problems or lack of immunization.

Front 85

A 26-year-old patient with urethritis and knee pain is diagnosed with reactive arthritis. The nurse will plan to teach the patient about the need for several months of therapy with
a. anakinra (Kineret).
b. etanercept (Enbrel).
c. doxycycline (Vibramycin).
d. methotrexate (Rheumatrex).

Back 85

ANS: C
Reactive arthritis associated with urethritis is usually caused by infection with Chlamydia trachomatis and requires 3 months of treatment with doxycycline. The other medications are used for chronic inflammatory problems such as rheumatoid arthritis.

Front 86

A patient with an acute attack of gout is treated with colchicine. The nurse determines that the drug is effective upon finding
a. relief of joint pain.
b. increased urine output.
c. elevated serum uric acid.
d. decreased white blood cells (WBC).

Back 86

ANS: A
Colchicine produces pain relief in 24 to 48 hours by decreasing inflammation. The recommended increase in fluid intake of 2 to 3 L/day would increase urine output but would not indicate the effectiveness of colchicine. Elevated uric acid levels would result in increased symptoms. The WBC count might decrease with decreased inflammation, but this would not be as useful in determining the effectiveness of colchicine as a decrease in pain.

Front 87

A patient with gout tells the nurse that he takes losartan (Cozaar) for control of the condition. The nurse will plan to monitor
a. blood glucose.
b. blood pressure.
c. erythrocyte count.
d. lymphocyte count.

Back 87

ANS: B
Losartan, an angiotensin II receptor antagonist, will lower blood pressure. It does not affect blood glucose, red blood cell count (RBC), or lymphocytes.

Front 88

A long-term care patient who takes multiple medications develops acute gouty arthritis. The nurse will consult with the health care provider before giving the prescribed dose of
a. sertraline (Zoloft).
b. famotidine (Pepcid).
c. oxycodone (Roxycodone).
d. hydrochlorothiazide (HydroDiuril).

Back 88

ANS: D
Diuretic use increases uric acid levels and can precipitate gout attacks. The other medications are safe to administer.

Front 89

Which statement by a 24-year-old woman with systemic lupus erythematosus (SLE) indicates that the patient has understood the nurse’s teaching about management of the condition?
a. “I will use a sunscreen whenever I am outside.”
b. “I will try to keep exercising even if I am tired.”
c. “I should take birth control pills to keep from getting pregnant.”
d. “I should not take aspirin or nonsteroidal anti-inflammatory drugs.”

Back 89

ANS: A
Severe skin reactions can occur in patients with SLE who are exposed to the sum. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal anti-inflammatory drugs are used to treat the musculoskeletal manifestations of SLE.

Front 90

A patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, “I hate the way I look! I never go anywhere except here to the health clinic.” An appropriate nursing diagnosis for the patient is
a. activity intolerance related to fatigue and inactivity.
b. impaired social interaction related to lack of social skills.
c. impaired skin integrity related to itching and skin sloughing.
d. social isolation related to embarrassment about the effects of SLE.

Back 90

ANS: D
The patient’s statement about not going anywhere because of hating the way he or she looks supports the diagnosis of social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this as a diagnosis. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.

Front 91

To determine whether a patient with joint swelling and pain has systemic lupus erythematosus, which test will be most useful for the nurse to review?
a. Rheumatoid factor (RF)
b. Antinuclear antibody (ANA)
c. Anti-Smith antibody (Anti-Sm)
d. Lupus erythematosus (LE) cell prep

Back 91

ANS: C
The anti-Sm is antibody found almost exclusively in SLE. The other blood tests also are used in screening but are not as specific to SLE.

Front 92

When caring for a patient with gout and a red and painful left great toe, which nursing action will be included in the plan of care?
a. Gently palpate the toe to assess swelling.
b. Use pillows to keep the left foot elevated.
c. Use a footboard to hold bedding away from the toe.
d. Teach patient to avoid use of acetaminophen (Tylenol).

Back 92

ANS: C
Since any touch on the area of inflammation may increase pain, bedding should be held away from the toe and touching the toe will be avoided. Elevation of the foot will not reduce the pain, which is caused by the urate crystals. Acetaminophen can be used for pain relief.

Front 93

The health care provider has prescribed the following collaborative interventions for a 49-year-old who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question?
a. Draw anti-DNA blood titer.
b. Administer varicella vaccine.
c. Use naproxen (Aleve) 200 mg BID.
d. Take famotidine (Pepcid) 20 mg daily.

Back 93

ANS: B
Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient.

Front 94

A patient has systemic sclerosis manifested by CREST (calcinosis, Raynaud’s phenomenon, esophageal dysfunction, sclerodactyly, telangiectasia) syndrome. Which action will the nurse include in the plan of care?
a. Avoid use of capsaicin cream on hands.
b. Keep patient’s room warm and draft free.
c. Obtain capillary blood glucose before meals.
d. Assist to bathroom every 2 hours while awake.

Back 94

ANS: B
Keeping the room warm will decrease the incidence of Raynaud’s phenomenon, one aspect of the CREST syndrome. Capsaicin cream may be used to improve circulation and decrease pain. There is no need to obtain blood glucose levels or to assist the patient to the bathroom every 2 hours

Front 95

After teaching a patient diagnosed with progressive systemic sclerosis about health maintenance activities, the nurse determines that additional instruction is needed when the patient says,
a. “I should lie down for an hour after meals.”
b. “Paraffin baths can be used to help my hands.”
c. “Lotions will help if I rub them in for a long time.”
d. “I should perform range-of-motion exercises daily.”

Back 95

ANS: A
Because of the esophageal scarring, patients should sit up for 2 hours after eating. The other patient statements are correct and indicate that the teaching has been effective.

Front 96

A patient with rheumatoid arthritis refuses to take the prescribed methotrexate (Rheumatrex), telling the nurse “That drug has too many side effects. My arthritis isn’t that bad yet.” The most appropriate response by the nurse is
a. “You have the right to refuse to take the methotrexate.”
b. “Methotrexate is less expensive than some of the newer drugs.”
c. “It is important to start methotrexate early to decrease the extent of joint damage.”
d. “Methotrexate is effective and has fewer side effects than some of the other drugs.”

Back 96

ANS: C
Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible.

Front 97

A patient with an exacerbation of rheumatoid arthritis (RA) is taking prednisone (Deltasone) 40 mg daily. Which of these assessment data obtained by the nurse indicate that the patient is experiencing a side effect of the medication?
a. The patient’s blood glucose is 165 mg/dL.
b. The patient has no improvement in symptoms.
c. The patient has experienced a recent 5-pound weight loss.
d. The patient’s erythrocyte sedimentation rate (ESR) has increased.

Back 97

ANS: A
Hyperglycemia is a side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR and no improvement in symptoms would indicate that the prednisone was not effective but would not be side effects of the medication.

Front 98

A patient with an acute attack of gout in the left great toe has a new prescription for probenecid (Benemid). Which information about the patient’s home routine indicates a need for teaching regarding gout management?
a. The patient sleeps about 8 to 10 hours every night.
b. The patient usually eats beef once or twice a week.
c. The patient generally drinks about 3 quarts of juice and water daily.
d. The patient takes one aspirin a day prophylactically to prevent angina.

Back 98

ANS: D
Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid. The patient’s sleep pattern will not affect gout management. Drinking 3 quarts of water and eating beef only once or twice a week are appropriate for the patient with gout

Front 99

The home health nurse is doing a follow-up visit to a patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates that more patient teaching is needed?
a. The patient requires a 2-hour midday nap.
b. The patient has been taking 16 aspirins daily.
c. The patient sits on a stool when preparing meals.
d. The patient sleeps with two pillows under the head.

Back 99

ANS: D
The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping. The other information is appropriate for a patient with RA and indicates that teaching has been effective.

Front 100

When the nurse is reviewing laboratory results for a patient with systemic lupus erythematosus (SLE), which result is most important to communicate to the health care provider?
a. Decreased C-reactive protein (CRP)
b. Elevated blood urea nitrogen (BUN)
c. Positive antinuclear antibodies (ANA)
d. Positive lupus erythematosus cell prep

Back 100

ANS: B
The elevated BUN and creatinine levels indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus (LE) cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows an improvement in the inflammatory process.

Front 101

The nurse obtains this information when assessing a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis. Which symptom is most important to report to the health care provider?
a. Abdominal cramping
b. Complaint of blurry vision
c. Phalangeal joint tenderness
d. Blood pressure 170/84 mm Hg

Back 101

ANS: B
Plaquenil can cause retinopathy; the medication should be stopped. The other findings are not related to the medication, although they also will be reported.

Front 102

After obtaining the health history from a 28-year-old woman who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis, which information about the patient is most important for the nurse to report to the health care provider?
a. The patient had a history of infectious mononucleosis as a teenager.
b. The patient is trying to have a baby before her disease becomes more severe.
c. The patient has a family history of age-related macular degeneration of the retina.
d. The patient has been using large doses of vitamins and health foods to treat the RA.

Back 102

ANS: B
Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy.

Front 103

When the nurse is reviewing laboratory data for a patient who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis, which information is most important to communicate to the health care provider?
a. The blood glucose is 75 mg/dL.
b. The rheumatoid factor is positive.
c. The white blood cell (WBC) count is 1500/L.
d. The erythrocyte sedimentation rate is elevated.

Back 103

ANS: C
Bone marrow suppression is a possible side effect of methotrexate, and the patient’s low WBC count places the patient at high risk for infection. The elevated erythrocyte sedimentation rate and positive rheumatoid factor are expected in rheumatoid arthritis. The blood glucose is normal.

Front 104

A patient who had arthroscopic surgery of the left knee 5 days ago is admitted with a red, swollen, and hot knee. Which assessment finding by the nurse should be reported to the health care provider immediately?
a. The blood pressure is 88/46 mm Hg.
b. The white blood cell count is 14,200/µL.
c. The patient is taking ibuprofen (Motrin).
d. The patient says the knee is very painful.

Back 104

ANS: A
The low blood pressure suggests that the patient may be developing septicemia as a complication of septic arthritis. Immediate blood cultures and initiation of antibiotic therapy are indicated. The other information is typical of septic arthritis and also should be reported to the health care provider, but it does not indicate any immediately life-threatening problems.

Front 105

A patient hospitalized with polymyositis has joint pain, an erythematosus facial rash with eyelid edema, and a weak, hoarse voice. The priority nursing diagnosis for the patient is
a. acute pain related to inflammation.
b. risk for aspiration related to dysphagia.
c. risk for impaired skin integrity related to scratching.
d. disturbed visual perception related to eyelid swelling.

Back 105

ANS: B
The patient’s vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a high risk for aspiration. The other nursing diagnoses also are appropriate but are not as high a priority as the maintenance of the patient’s airway.

Front 106

A patient with dermatomyositis is receiving long-term prednisone (Deltasone) therapy. Which assessment finding by the nurse is most important to report to the health care provider?
a. The blood glucose is 112 mg/dL.
b. The patient has painful hematuria.
c. The patient has an increased appetite.
d. Acne is noted on the back and face.

Back 106

ANS: B
Corticosteroid use is associated with increased risk for infection, so the nurse should report the urinary tract symptoms immediately to the health care provider. The increase in blood glucose, increased appetite, and acne also are adverse effects of corticosteroid use, but do not need diagnosis and treatment as rapidly as the probable urinary tract infection.

Front 107

Which of these patients seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce risk for osteoarthritis (OA)?
a. A 56-year-old man who is a member of a construction crew
b. A 24-year-old man who participates in a summer softball team
c. A 49-year-old woman who works on an automotive assembly line
d. A 36-year-old woman who is newly diagnosed with diabetes mellitus

Back 107

ANS: C
OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces risk for OA. Diabetes is not a risk factor for OA. Working on a construction crew would involve nonrepetitive work and thus would not be as risky.

Front 108

During assessment of the patient with fibromyalgia syndrome (FMS), the nurse would expect the patient to report (select all that apply)?
a. sleep disturbances.
b. multiple tender points.
c. cardiac palpitations and dizziness.
d. multijoint pain with inflammation and swelling.
e. widespread bilateral, burning musculoskeletal pain.

Back 108

ANS: A, B, C, E
These symptoms are commonly described by patients with FMS. Cardiac involvement and joint inflammation are not typical of FMS.