Musculoskeletal Problems (Practice Mode) - Rnpedia

1. 1. You are initiating a nursing care plan for a patient with osteoporosis. All of these nursing interventions apply to the nursing diagnosis Risk for Falls. Which intervention should you delegate to the nursing assistant?

Identify environmental factors that increase risk for falls.

Monitor gait, balance, and fatigue level with ambulation.

Collaborate with physical therapy to provide patient with walker.

Assist the patient with ambulation to bathroom and in halls.

Assisting with activities of daily living is within the scope of the nursing assistant’s practice. The other three interventions require additional educational preparation and are within the scope of practice of licensed nurses. Focus: Delegation/supervision

Explanation

Assisting with activities of daily living is within the scope of the nursing assistant’s practice. The other three interventions require additional educational preparation and are within the scope of practice of licensed nurses. Focus: Delegation/supervision

2. 8. You are providing nursing care for a patient with carpal tunnel syndrome (CTS) who is preparing for surgery. Which intervention should you delegate to the nursing assistant?

Initiate placement of a splint for immobilization during the day.

Assess the patient’s wrist and hand for discoloration and brittle nails.

Assist the patient with daily self-care measures such as bathing and eating.

Test the patient for painful tingling in the four digits of the hand.

Placing a splint for the first time is appropriate to the scope of practice for physical therapists. Assessing and testing for paresthesia are not within the scope of practice for nursing assistants. Assistance with activities of daily living is within the scope of practice for a nursing assistant. Focus: Delegation/supervision

Explanation

Placing a splint for the first time is appropriate to the scope of practice for physical therapists. Assessing and testing for paresthesia are not within the scope of practice for nursing assistants. Assistance with activities of daily living is within the scope of practice for a nursing assistant. Focus: Delegation/supervision

3. 15.After change-of-shift report, which patient should the nurse assess first?

A 42-year-old patient with carpal tunnel syndrome complaining of pain

A 64-year-old patient with osteoporosis who is waiting for discharge

A 28-year-old patient with fracture complaining that the cast is tight

A 56-year-old patient with left leg amputation complaining of phantom pain

The patient with the tight cast is at risk for circulation impairment and peripheral nerve damage. While all of the other patients’ concerns are important and the nurse will want to see them as soon as possible, none of their concerns is urgent. Focus: Prioritization

Explanation

The patient with the tight cast is at risk for circulation impairment and peripheral nerve damage. While all of the other patients’ concerns are important and the nurse will want to see them as soon as possible, none of their concerns is urgent. Focus: Prioritization

4. 21.During assessment of a patient with fractures of the medial ulna and radius, you find all of the following data. Which assessment finding should you report to the physician immediately?

The patient complains of pressure and pain.

The cast is in place and is dry and intact.

The skin is pink and warm to touch.

The patient can move all fingers and thumb.

Pressure and pain may be due to increased compartment pressure and indicate the serious complication of acute compartment syndrome. This is urgent. If not treated, cyanosis, tingling, numbness, paresis, and severe pain occur. Focus: Prioritization

Explanation

Pressure and pain may be due to increased compartment pressure and indicate the serious complication of acute compartment syndrome. This is urgent. If not treated, cyanosis, tingling, numbness, paresis, and severe pain occur. Focus: Prioritization

5. 10.The patient is scheduled for endoscopic carpal tunnel release surgery in the morning. What key point will you be sure to teach the patient?

Pain and numbness will be experienced for several days to weeks.

Immediately after surgery, the patient will no longer need assistance.

After surgery, the dressing will be large with dots of drainage

After surgery, the pain and paresthesia will no longer be present.

Post-operative pain and numbness occur for a longer period of time with endoscopic carpal tunnel release than with the open procedure. Patients often need assistance post-operatively, even after they are discharged. The dressing from the endoscopic procedure is usually very small and there should not be a lot of drainage. Focus: Prioritization

Explanation

Post-operative pain and numbness occur for a longer period of time with endoscopic carpal tunnel release than with the open procedure. Patients often need assistance post-operatively, even after they are discharged. The dressing from the endoscopic procedure is usually very small and there should not be a lot of drainage. Focus: Prioritization

6. 14.The patient suffered a fractured femur. Which of the following would you tell the nursing assistant to report immediately?

The patient complains of pain.

The patient appears confused.

The patient’s blood pressure is 136/88.

The patient voided using the bedpan.

Fat embolism syndrome is a serious complication that is often the result of fractures of long bones. The earliest manifestation of this is altered mental status caused by low arterial oxygen level. The nurse would want to know about and treat the pain, but it is not life threatening. The nurse would also want to know about the blood pressure and that the patient voided; however, neither of these pieces of information is urgent. Focus:Prioritization, delegation/supervision

Explanation

Fat embolism syndrome is a serious complication that is often the result of fractures of long bones. The earliest manifestation of this is altered mental status caused by low arterial oxygen level. The nurse would want to know about and treat the pain, but it is not life threatening. The nurse would also want to know about the blood pressure and that the patient voided; however, neither of these pieces of information is urgent. Focus:Prioritization, delegation/supervision

7. 9. You deserve the nursing assistant performing all of these interventions for the patient with CTS. Which action requires that you intervene immediately?

Arrange the patient’s lunch tray and cut the meat.

Provide warm water and assist the patient with a bath.

Replace the patient’s splint in hyperextension position.

Remind the patient not to lift very heavy objects.

When a patient with CTS has a splint used for immobilization of the wrist, it is placed either in the neutral position or in slight extension. The other interventions are correct and are within the scope of practice for a nursing assistant. Nursing assistants may remind patients about elements of their care plans such as avoiding heavy lifting. Focus: Delegation/supervision

Explanation

When a patient with CTS has a splint used for immobilization of the wrist, it is placed either in the neutral position or in slight extension. The other interventions are correct and are within the scope of practice for a nursing assistant. Nursing assistants may remind patients about elements of their care plans such as avoiding heavy lifting. Focus: Delegation/supervision

8. 13.During discharge preparations, a patient with osteoporosis makes all of these statements. Which statement indicates to you that the patient needs additional teaching?

“I take my ibuprofen every morning as soon as I get up.”

“My daughter removed all of the throw rugs in my home.”

“My husband helps me every afternoon with range-of-motion exercises.”

“I rest in my recliner chair every day for at least an hour.”

Ibuprofen can cause abdominal discomfort or pain and gastrointestinal ulceration. I such cases, it should be given with meals or milk. Removal of throw rugs helps prevent falls. Range-of-motion exercises and rest are important strategies for coping with osteoporosis. Focus: Prioritization

Explanation

Ibuprofen can cause abdominal discomfort or pain and gastrointestinal ulceration. I such cases, it should be given with meals or milk. Removal of throw rugs helps prevent falls. Range-of-motion exercises and rest are important strategies for coping with osteoporosis. Focus: Prioritization

9. 17.A patient with a fracture of the right ankle has a nursing diagnosis of Impaired Physical Mobility. As charge nurse you observe a new graduate RN perform all of these interventions. For which action should you intervene?

Encourages the patient to go from lying to standing position

Administers pain medication prior to beginning exercises

Explains to the patient and family the purpose of the exercise program

Reminds the patient about correct usage of crutches

Moving from a lying position to a sitting position, then a standing position allows the patient to establish balance prior to standing. Administering pain medication prior to exercising decreases pain with exercise. Explanations about the purpose of the exercise program and proper use of crutches are appropriate interventions with this patient. Focus: Delegation/supervision

Explanation

Moving from a lying position to a sitting position, then a standing position allows the patient to establish balance prior to standing. Administering pain medication prior to exercising decreases pain with exercise. Explanations about the purpose of the exercise program and proper use of crutches are appropriate interventions with this patient. Focus: Delegation/supervision

10. 5. As charge nurse you are making assignments for the day shift. Which patient would you assign to the nurse who has been pulled from the post-anesthesia care unit (PACU) for the day?

A 35-year-old patient with osteomyelitis who needs teaching prior to hyperbaric oxygen therapy

A 62-year-old patient with osteomalacia who is being discharged to a long-term care facility

A 68-year-old patient with osteoporosis and a new orthotic device whose knowledge of use of this device must be assessed.

A 72-year-old patient with Paget’s disease who has just returned from surgery for total knee replacement

The PACU nurse is very familiar with the assessment skills necessary to monitor a newly post-operative patient. The other patients need care from nurses familiar with musculoskeletal-related nursing care, to provide teaching, assessment, and report to the long-term care facility. Focus: Assignment

Explanation

The PACU nurse is very familiar with the assessment skills necessary to monitor a newly post-operative patient. The other patients need care from nurses familiar with musculoskeletal-related nursing care, to provide teaching, assessment, and report to the long-term care facility. Focus: Assignment

11. 20.During morning care, the patient with a below-the-knee amputation asks the nursing assistant about prostheses. How should you instruct the nursing assistant to respond?

“You should get a prosthesis so that you can walk again.”

“Wait and ask your doctor that question next time he comes in.”

“It’s too soon to be worrying about getting a prosthesis.”

“I’ll ask the nurse to come in and discuss this with you.”

The patient is indicating an interest in learning about prostheses. The experienced nurse can initiate discussion and begin educating the patient. Certainly the physician can also discuss prostheses with the patient, but the patient’s wish to learn should receive a quick response. The nurse can then notify the physician about the patient’s request. Focus: Delegation/supervision

Explanation

The patient is indicating an interest in learning about prostheses. The experienced nurse can initiate discussion and begin educating the patient. Certainly the physician can also discuss prostheses with the patient, but the patient’s wish to learn should receive a quick response. The nurse can then notify the physician about the patient’s request. Focus: Delegation/supervision

12. 6. You delegate taking vital signs to an experienced nursing assistant. The patient has been diagnosed with osteomyelitis. Which vital sign do you want the nursing assistant to report immediately?

Temperature 99.90 F

Blood pressure 136/80

Heart rate 96/minute

Respiratory rate 24/minute

An elevated temperature indicates infection and inflammation. This patient needs IV antibiotic therapy. The other vital signs are normal or high normal results. Focus: Delegation/Supervision

Explanation

An elevated temperature indicates infection and inflammation. This patient needs IV antibiotic therapy. The other vital signs are normal or high normal results. Focus: Delegation/Supervision

13. 12.You are preparing the post-operative CTS patient for discharge. Which information is important to provide to this patient?

The surgical procedure is a cure for CTS.

Hand movements will be restricted for 4 – 6 weeks after surgery.

Frequent pain medication dosages will no longer be necessary.

Notify the physician immediately for any pain or discomfort.

Hand movements, including heavy lifting, may be restricted for 4- 6 weeks after surgery. Patients experience discomfort for weeks to months after surgery. The surgery is not always a cure. In some cases, CTS may recur months to years after surgery. Focus: Prioritization

Explanation

Hand movements, including heavy lifting, may be restricted for 4- 6 weeks after surgery. Patients experience discomfort for weeks to months after surgery. The surgery is not always a cure. In some cases, CTS may recur months to years after surgery. Focus: Prioritization

14. 16.A patient with a fractured fibula is receiving skeletal traction and has skeletal pins in place. You instruct the nursing assistant to immediately report which of the following?

The patient wants to change position in bed.

There is a small amount of clear fluid on the pin sites.

The traction weights are resting on the floor.

The patient is complaining of pain and muscle spasm.

When the weights are resting on the floor, they are not exerting pulling force to provide reduction and alignment, or to prevent muscle spasm. The weights should always hang freely. Attending to the weights may reduce the patient’s pain and spasm. With skeletal pins, a small amount of clear fluid drainage is expected. It is important to inspect the traction system after a patient changes position because position changes may alter the traction. Focus: Delegation/supervision, prioritization

Explanation

When the weights are resting on the floor, they are not exerting pulling force to provide reduction and alignment, or to prevent muscle spasm. The weights should always hang freely. Attending to the weights may reduce the patient’s pain and spasm. With skeletal pins, a small amount of clear fluid drainage is expected. It is important to inspect the traction system after a patient changes position because position changes may alter the traction. Focus: Delegation/supervision, prioritization

15. 4. As charge nurse you observe the LPN/LVN providing all of these interventions for the patient with Paget’s disease. Which action requires that you intervene?

Administers 600 mg of ibuprofen to the patient

Encourages the patient to perform PT recommended exercises

Applies ice and gentle massage to the patient’s lower extremities

Reminds the patient to drink milk and eat cottage cheese

Application of heat, not ice, is the appropriate measure to help reduce the patient’s pain. Ibuprofen is useful to manage mild to moderate pain. Exercise prescribed by the PT is non-impact in nature and provides strengthening for the patient. A diet rich in calcium promotes bone health. Focus: Delegation/supervision

Explanation

Application of heat, not ice, is the appropriate measure to help reduce the patient’s pain. Ibuprofen is useful to manage mild to moderate pain. Exercise prescribed by the PT is non-impact in nature and provides strengthening for the patient. A diet rich in calcium promotes bone health. Focus: Delegation/supervision

16. 18.The charge nurse assigns the nursing care of a patient who is 1 day post-operative after a left below-the-knee amputation to an experienced LPN/LVN, what will you describe as the major focus for care today?

To attain pain control for phantom pain.

To monitor for signs of sufficient tissue perfusion.

To assist the patient to ambulate as soon as possible.

To elevate the residual limb when the patient is supine.

Monitoring for sufficient tissue perfusion is the priority at this time. Phantom pain is a concern, but is more common is patients with above-the-knee amputations. Early ambulation is a goal, but at this time, the patient is more likely to be engaged in muscle-strengthening exercises. Elevation of the residual limb on a pillow is controversial because it may promote knee flexion contracture. Focus: Delegation/supervision

Explanation

Monitoring for sufficient tissue perfusion is the priority at this time. Phantom pain is a concern, but is more common is patients with above-the-knee amputations. Early ambulation is a goal, but at this time, the patient is more likely to be engaged in muscle-strengthening exercises. Elevation of the residual limb on a pillow is controversial because it may promote knee flexion contracture. Focus: Delegation/supervision

17. 3. You discover all of these assessment findings when admitting a patient with Paget’s disease. Which finding indicates that the physician should be notified?

The patient has bowing of both legs and the knees are asymmetric.

The base of the patient’s skull is invaginated (platybasia).

The patient is only 5 feet tall and weighs 120 pounds.

The patient’s skull is soft, thick, and larger than normal.

Platybasia (basilar skull invagination) causes brain stem manifestations that threaten life. Patients with Paget’s disease are usually short and often have bowing of the long bones that results in asymmetric knees or elbow deformities. Their skull is typically soft, thick and enlarged. Focus:Prioritization

Explanation

Platybasia (basilar skull invagination) causes brain stem manifestations that threaten life. Patients with Paget’s disease are usually short and often have bowing of the long bones that results in asymmetric knees or elbow deformities. Their skull is typically soft, thick and enlarged. Focus:Prioritization

18. 11.As charge nurse you assign the nursing care of a patient who has just returned form open carpal tunnel release surgery to an experienced LPN/LVN, who will perform under the supervision of an RN. Which of the following instructions will you provide for the LPN/LVN? (Choose all that apply.)

Check the patient’s vital signs every 15 minutes in the first hour.

Check the dressing for drainage and tightness.

Elevate the patient’s hand above the heart.

The patient will no longer need pain medication.

Check the neurovascular status of the fingers every hour.

Post-operatively, patients with OCTR surgery have pain and numbness. Their discomfort may last for weeks to months. All of the other directions are appropriate to the post-operative care for this patient. It is important or monitor for drainage, tightness, and neurovascular changes. Raising the hand/wrist above the heart reduces the swelling form surgery, and this is often done for several days. Focus: Assignment,delegation/supervision

Explanation

Post-operatively, patients with OCTR surgery have pain and numbness. Their discomfort may last for weeks to months. All of the other directions are appropriate to the post-operative care for this patient. It is important or monitor for drainage, tightness, and neurovascular changes. Raising the hand/wrist above the heart reduces the swelling form surgery, and this is often done for several days. Focus: Assignment,delegation/supervision

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19. 2. You are preparing to teach a newly diagnosed patient with osteoporosis about strategies to prevent falls. Which of these points will you be sure to include? (Choose all that apply.)

Wear a hip protector when ambulating.

Remove throw rugs and other obstacles at home.

Exercise will help build your strength.

You should expect a few bumps and bruises when you go home.

When you are tired, you should rest.

The purpose of the teaching is to help the patient prevent falls. The hip protector can prevent hip fractures if the patient falls. Throw rugs and obstacles in the home increase the risk for falls. Patients who are tired are also more likely to fall. Exercise helps to strengthen muscles and improve coordination. Focus: Prioritization

Explanation

The purpose of the teaching is to help the patient prevent falls. The hip protector can prevent hip fractures if the patient falls. Throw rugs and obstacles in the home increase the risk for falls. Patients who are tired are also more likely to fall. Exercise helps to strengthen muscles and improve coordination. Focus: Prioritization

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20. 19.A patient with a right above-the-knee amputation has phantom limb pain (PLP) and asks you why. What is your best response?

“Phantom limb pain is not explained or predicted by any one theory.”

“Phantom limb pain occurs because your body thinks you leg is still present.”

“Phantom limb pain will not interfere with your activities of daily living.”

“Phantom limb pain is not real pain, but is remembered pain.”

There are three theories being researched with regard to PLP. The peripheral nervous system theory implies that sensations remain as a result of severing peripheral nerves during the amputation. The central nervous system theory states that PLP results from a loss of inhibitory signals that are generated through afferent impulses from the amputated limb. The psychological theory helps predict and explain PLP in that stress, anxiety, and depression often trigger or worsen an episode of PLP. Focus: Prioritization

Explanation

There are three theories being researched with regard to PLP. The peripheral nervous system theory implies that sensations remain as a result of severing peripheral nerves during the amputation. The central nervous system theory states that PLP results from a loss of inhibitory signals that are generated through afferent impulses from the amputated limb. The psychological theory helps predict and explain PLP in that stress, anxiety, and depression often trigger or worsen an episode of PLP. Focus: Prioritization

21. 7. You are working with a nursing assistant to provide care for six patients. At the beginning of the shift, you carefully tell the nursing assistant what patient interventions and tasks she will be expected to perform. To be sure that your communication is appropriate you refer to the 4 C’s. List the 4 C’s below.

The 4 Cs of communication help the nurse ensure that the nursing assistant understands what is being said and does not confuse the nurse’s directions; that directions are according to policies, procedures, job descriptions, and the law; and that the nursing assistant has all the information to complete the tasks assigned. Focus: Delegation/supervision

Explanation

The 4 Cs of communication help the nurse ensure that the nursing assistant understands what is being said and does not confuse the nurse’s directions; that directions are according to policies, procedures, job descriptions, and the law; and that the nursing assistant has all the information to complete the tasks assigned. Focus: Delegation/supervision

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