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Musculoskeletal Injuries Situation: Mr. Janno Alcasid, overweight, 61 years old, was admitted and diagnosed with osteoarthritis.

1. Mr. Alcasid asks the nurse, "What is osteoarthritis?" Which response from the nurse is correct? a) your bones are inflamed b) your weight bearing joints are inflamed c) you have inflammation in your joints d) there is shortening of your long bones 2. Which of the following guidelines should a nurse include in the teaching plan for a patient who has osteoarthritis? a) achieve ideal body weight b) increase daily calcium intake to 1500 mg c) maintain a high fiber diet d) sleep at least 10 hours each day Situation: Maco, a newly registered nurse, works as a private duty nurse of a 55 year old female Canadian national who has gout. 3. Which of the following nursing diagnoses is a priority for a patient with gout? a) pain b) fatigue c) risk for infection d) risk for peripheral neurovascular dysfunction 4. The nurse would instruct the patient which of the following to minimize complications? a) drinking a minimum of 3000 ml of fluid per day b) eating a minimum of 2500 calories per day c) walking at least three miles per day d) resting at least three hours per day 5. Foods allowed in the diet of gout patient include: a) cheese b) beef c) sardines d) liver

6. The patient is placed on allopurinol (Zyloprim) therapy. To monitor effectiveness of the therapy, the nurse will monitor which the following serum laboratory values? a) uric acid b) fasting blood glucose c) serum calcium d) alkaline phosphatase 7. A patient with rheumatoid arthritis asks the nurse why she is taking Prednisone (Deltasone) the nurse best response would be that it: a) enhance the immune system b) increase bone density c) decrease inflammation d) reduce peripheral edema 8. A patient under steroid therapy should be advised by the nurse to: a) limit carbohydrates in the diet b) take the medication on an empty stomach c) avoid individuals who have infections d) stop the medication when symptoms have subsided

NCLEX Secrets about Musculoskeletal Injuries: ANSWERS AND RATIONALE 1) B - Osteoarthritis, also known as hypertrophic arthritis, osteoarthritis, senescent arthritis and degenerative joint disease is characterized by destruction of the articular cartilage, which becomes opaque, yellow, soft, weak and deteriorated. It is followed by thickening of bone under the cartilage and formation of osteophytes or bone spurs. Unlike RH, osteoarthritis is not a systemic disease and affects only the joint and its surrounding tissue. This disorder commonly occurs in the 50-70 year age group but women are more severely affected. The Signs and Symptoms of Osteoarthritis include: pain - worse with weight bearing, improves with rest may occur with paresthesia joint swelling and enlargement - may be from inflammatory exudates entering joint capsule causing an increase in synovial fluid or from fragments of osteophytes entering synovial cavity

decreased ROM - depends on the amount of destroyed cartilage muscular atrophy - from disuse, joint instability and deformity crepitus - must be present on movement of the joint joint stiffness - worse in the morning and after a period of rest and disuse heberden's nodes - bony protuberances occurring on the dorsal surface of the distal interphalangeal joints of the fingers bouchard's nodes - bony protruberances occurring on the proximal interphalangeal joints of fingers coxaarthrosis - pain in the hip on weight bearing with pain progressing to include the groin and medial knee pain and limited range of motion varus (bowlegs) or valgus (knock kneed)

2) A - the primary cause of arthritis is not yet known but it is often-associated with obesity, aging, trauma, fractures, and infections. Osteoarthritis is a wear and tear disease of the joints. The more pressure it takes the more severe and the faster is the progression of the disease. Thus, one of the important aspects of management if the patient is obese is to lose weight to lessen the pressure on the joints 3) A - Gouty arthritis is a metabolic disorder characterized by accumulation and deposition of uric acid crystals, called tophi, in tissues especially in joints that results in inflammatory response. It is caused by prolonged hyperuricemia due to problems in synthesizing purines or by poor excretion of uric acid by the kidney. This disorder is more common in men, with onset around age 50. The immediate problem of patient suffering from gout is the acute pain experienced on affected joints such as the great toe, feet, ankles, or knees. Other signs and symptoms include: malaise pruritus headache elevated serum uric acid presence of tophi positive monsodium urate crystals in synovial fluid inflammation of affected joint Nursing care during the acute phase when severe joint pain afflicts the patient includes: provide bed rest use bed cradle to support bed sheets and keep pressures of sheets off joint perform range of motion exercise gently carefully align joints so they are slightly flexed

administer medications

4) A - renal urate lithiasis (kidney stones) may result from precipitation of uric acid in the presence of low urinary pH. This can be avoided by allowing the patient liberal fluid intake to promote urinary excretion of uric acid. 5) A - preventive measures for gout: uric acid is formed from metabolism of purine. To prevent further formation and accumulation of uric acid, the patient must be advised to stick on a low purine diet. This means that the patient must avoid: sweet breads, yeast, heart, herring, sardines, anchovies, shellfish, heavy alcohol intake avoidance of excessive weight gain alkaline ash diet to increase the pH of urine to discourage precipitation of uric acid and enhance the action of drugs such as probenicid (Benemid) 6) A - preventive therapy - prevention of future gout attacks is by placing the patient on daily medication that either promote uric acid excretion or prevent uric acid formation. To evaluate the effectiveness of the therapy, serum uric acid level of the patient must be monitored. The medication is effective when uric acid goes down to normal level below 6.9 mg/dl. 7) C - the main effect of corticosteroids is to supress inflammation. However, this same effect is also one of the main setback of corticosteroid therapy suppression of the inflammatory response also decreases the immune response making the patient susceptible to infection. 8) C - Long Term Side Effects of Prednisone Therapy causes GI irritation so it must be taken with food. Patient may need antacid (must not contain sodium) to prevent ulcer. Give once-daily dose in the morning to lessen toxicity. Maybe diluted in juice or semi-solid food such as apple sauce causes sodium and water retention that results in cushinghoid appearance: moon face, buffalo hump, thinning of hair, hypertension and edema. Advise patient on low sodium diet that's high in potassium and protein avoid discontinuing abruptly as it can cause adrenal insufficiency and rebound inflammation. Reduce dosage gradually can cause glaucoma and cataract so monitor patient for visual disturbances and advise to have annual eye exam if on long term therapy increases cholesterol and glucose levels so diabetics must increase insulin dosage

skin tests will be false-negative because it suppresses immune response avoid active immunization while under therapy because patient is immunosuppressed causes hypocalcemia and hypokalemia and increased urine calcium levels, causes osteoporosis so patient needs Vitamin D and calcium supplement will decrease iodine uptake and protein-bound iodine levels in thyroid function test tell patient to report: slow healing, exposure to infection, depression, insomnia, psychotic symptoms, weakness and fatigue, dizziness, joint pain, fever, anorexia and fainting always give by deep IM in gluteal muscle to prevent sterile abscess if given by subcutaneous and rotate injection sites route to prevent tissue atrophy always give the lowest dose to minimize toxicity

Situation: Karen, a 32 year old vendor, is admitted to the hospital with diagnosis of Rheumatoid Arthritis. 9. Which type of exercise should the nurse recommend to Cindy? a) jogging b) swimming c) bicycling d) skating 10. Before discharge, the nurse tells Karen that she should pace her activities. An example of pacing activities would be: a) doing all her household chores in the morning and resting in the afternoon b) taking a nap before going shopping c) hiring a helper to do the housework 11. Which type of medication is most commonly used to treat rheumatoid arthritis? a) glucocorticoids b) non-steroidal ant-inflammatory drugs (NSAIDs) c) antimalarial drugs d) gold salts

12. Which assessment findings should the nurse expect for Karen? a) an asymmetrical pattern of affected joints

b) a positive rheumatoid factor titer c) the presence of Herberden's nodes d) a positive antinuclear antibody titer 13. The nurse discussed to Karen the nature of RA. Which of the following statements by indicate a correct understanding of disease process? a) the nodules under my skin behind my forehead is part of RA b) I have to be careful because my bones have become brittle c) I have been working very hard lifting heavy things while selling in the market d) my disease is a normal aspect of my aging

NCLEX Secrets about Musculoskeletal Injuries: ANSWERS AND RATIONALE 9) B - swimming is an ideal exercise for patient with arthritis because it allows ROM exercise for most of the joints of the body with less danger of injury. 10) B - pacing activities means alternating and balancing rest periods and activity in order to prevent excessive fatigue and over exertion. Rheumatoid arthritis is a chronic autoimmune disease characterized by inflammation and destruction of connective tissue within the joints that leads to eventual depletion of joint cartilage that weakens and cause dislocation of joint. This disease is characterized by periods of remissions and exacerbations. This disorder occurs three times more frequent in women until age 65 when both sexes have the same incidence. The most common joints affected are those of the hands, wrist, feet, ankles, elbows and knees. May also affect the heart, lungs and spleen late in the disease process. 11) B - NSAID's are the first drugs of choice of RA. Its main action is to inhibit the inflammatory action of the mediators of inflammation; arachidonic acid and prostaglandins, etc to stop the disease process. It also provide pain relief. However it does not correct existing damage or bone deformity. below are the drugs used to treat RA. SALICYLATES: - ASA-Aspirin Anti-inflammatory and analgesic

SIDE-EFFECTS take every 4-6 hours to maintain anti-inflammatory effect gastric irritation - take with food or milk toxicity - tinnitus, increase bleeding tendencies - instruct to report dark tarry stool hypersensitivity - rash NSAIAs (nonsteroidal) indomethacin (indocin) ibuprofen (motrin) tolmetin Na (tolectin) naproxen (naprosyn) fenoprofen (nalfon) sulindac (clinoril) diflunisal (dolobid) piroxicam (feldene) diclofenac Na (voltaren) SIDE-EFFECTS GIT irritation - take with food and milk, take with antacids headache and dizziness - discontinue and notify physician drowsiness - avoid driving do not use with salicylates or other anti-inflammatory agents do not crush enteric coated tablets Adrenocorticosteroids Prednisone Suppresses inflammatory reaction by the body SIDE-EFFECTS fluid retention - monitor weight increased susceptibility to infection - avoid exposure to persons with infection GIT irritation - take with food or antacid. Take in the morning if to be taken once a day decreased healing potential osteoporosis hirsutism adrenal crisis if abruptly withdrawn DM - do not stop, increase, decrease without doctor's order Antimalarials Hydroxychloroquine (plaquenil) Chloroquine (aralen)

anti-inflammatory effect Quinacrine (atabrine) SIDE-EFFECTS effect expected after 6-12 months retinal edema that can lead to blindness - have an eye exam every 6 months yellow discoloration of the skin - may be stopped periodically to prevent deepening of skin discoloration Gold Salts: (IM) Gold Sodium Thimalate (myochrysine) Gold thioglucose (solganol) Gold (oral) Aurafin (ridaural) SIDE-EFFECTS effect after 3-6 months renal damage and hepatic damage - urinalysis and CBC before each injection dermatitis, ulcerations in mouth - report dermatitis and metallic taste and lesions in mouth to physician 12) B - Signs and Symptoms: Begins as fatigue, musculoskeletal pain, low grade fever, lack of appetite and weight loss. Criteria for diagnosis of RA: The first four signs must be present for at least six weeks. Four of these signs and symptoms must be present at the same time to establish a diagnosis. stiffness after prolonged period of inactivity. Morning stiffness lasting at least one hour swelling of three or more joints swelling of the wrist, proximal interphalangeal (PIP) or metacarpophalangeal (MCP) joints symmetric joint swelling, same joint on each side of the body excluding the phalangeal joints positive rheumatoid factor rheumatoid nodules - painless and firm nodules found in subcutaneous tissue that develop during periods of exacerbation and most often in the wrist, carpal, knee, elbow and finger joints X-ray - decalcified areas of bone near joint margins Other Signs:

- formation of pannus - fibrous scar tissue at the cartilage that eventually invades and erodes bones - hand deformities ulnar drift boutonniere deformity swan neck deformity - poor mucin precipitate in synovial fluid histological changes of synovium - presence of chronic inflammatory infiltrate 13) A - the bones in rheumatoid arthritis do not become brittle as it is the joints that are affected not the bone. Brittle bone is characterized of osteoporosis. Overuse of joint is associated with osteoarthritis which is a wear and tear disease. Rheumatoid arthritis is not a part of normal aging as it is a disease process and occurs often in young women. Nodules which are firm and nontender may develop in the subcutaneous tissues of patients with RA. 14. The nurse should include which of the following client teachings for prevention of rapid progression of osteoporosis? a) avoid taking skim milk b) avoid taking protein-rich foods c) avoid calcium supplement d) avoid alcohol 15. A client is brought to the emergency room with compound femur fracture. What is the first action the emergency room nurse should do? a) cover the open wound b) check the clients blood pressure c) assess the client's neurologic status d) prepare the client for X-ray 16. A 3-year old in Bryant's traction is with foot foam. You found the child pulling out the foot foam. What is your most appropriate nursing action? a) remove the foot foam and assess the area b) reapply the foot foam at once c) call another nurse to maintain traction as you reapply the foot foam d) tell the child to stop removing the foot foam 17. How do you position a client with left hip fracture in Buck's traction? a) head of bed raised at 45 degree angle b) left calf on pillow from knee to ankle

c) position the left on affected side with pillows between legs d) position the left in the center of the bed with the leg extended 18. A patient had hip surgery. On the second post-op day, the patient is agitated, is tremulous and confused. What should the nurse primarily assess? a) the surgical wound b) alcohol use before surgery c) peripheral circulation d) breathing pattern 19. A nurse is conducting a health screening among females at the mall to assess those who are at risk for developing osteoporosis. Which of the following questions is most appropriate to be asked by the nurse in relation to development of osteoporosis? a) at what age did you have your menstruation? b) did you have any fracture? c) are you taking corticosteroids? d) are you on the diet high in vitamin D? 20. Which of the following will contribute to the development of primary gout? a) beer and wine b) eggs and milk c) vegetables and meat d) butter and fruits

NCLEX Secrets about Musculoskeletal Injuries: ANSWERS AND RATIONALE 14) D - avoiding alcohol and cigarette smoking will prevent rapid progression of osteoporosis. Skim milk is indicated among elderly because it is low in fats. Protein foods are necessary for calcium absorption. Calcium supplements help maintain integrity of the bones. 15) B - compound fracture of the femur may cause severe internal bleeding. Internal bleeding is characterized by hypotension. 16) C

- maintain the traction as the foot foam is reapplied. 17) B - elevate the leg with pillow to relieve pressure from the heel of the foot and to improve the effectiveness of the countertraction. 18) B - the client's sign and symptoms indicate alcohol withdrawal. 19) C - corticosteroids promote calcium loss. This increases the risk for osteoporosis. 20) A - beer and wine are purine-rich beverages. Gout is a metabolic disorder of purine. Other foods rich in purine are: organ meats, legumes, salted anchovies, shellfish, mushroom, sweetbreads, consomme, hearing fish. 21. Which of the following nursing interventions will best help alleviate the discomfort of the patient with rheumatoid arthritis? a) walking a mile each morning b) active range-of-motion exercises of joints c) application of hot or cold packs on the joints d) splinting the joint during waking hours 22. Which of the following instructions should the nurse include when giving health teachings on prevention of crutch palsy? a) assuming a tripod position when using crutches b) bearing the weight on the palms of the hands and elbows c) bearing the weight on the axillae d) placing the crossbar of the crutches so that the elbows are extended 23. Which of the following should be included when giving client teaching to an obese woman, whose height is 5 feet and 2 inches, on prevention of progression of osteoporosis? a) bed rest b) avoid sunlight c) weight-bearing exercises and weight reduction d) limit intake of milk and dairy products 24. The best position for a child with myelomeningocele is a) prone b) supine

c) semi-fowler's d) modified trendelenburg 25. Which of the following complications does the nurse suspect when a client had fracture of the femur and is now experiencing respiratory distress? a) sepsis b) fat embolism c) bleeding d) shock

NCLEX Secrets about Musculoskeletal Injuries ANSWERS AND RATIONALE 21) C - during acute phase of pain, cold application is recommended. Cold numbs nerve endings and therefore, relieves pain. After the acute phase of pain, heat application is done. This thins the synovial fluid and relieves joint stiffness. Heat also improves circulation to the area, improves oxygen supply and will relieve pain. 22) B - during crutch-walking, the weight of the body should be borne by the hands and elbows, not by the axillae to prevent crutch palsy. 23) C - weight-bearing exercises promote calcium absorption in he bones. Weight reduction reduces strain at the cartilage of joints. These measures prevent progression of osteoporosis. 24) A - prone position will prevent trauma to the sac at the lumbosacral area in a child with myelomeningocele. 25) B - fat embolism is a common complication of fracture of the long bones, like fracture of the femur. Yellow marrow is released into the circulation and reaches the pulmonary circulation. Acute respiratory distress syndrome may occur. 26. Which among these clients is at highest risk for developing low back pain?

a) the man working with a drill hammer b) the man delivering mails in the building c) the salesman selling truck tires d) the man washing windows of a building 27. The client had been diagnosed to have fracture of the tibia after a motorcycle accident. Few hours after, he complains of pain distal to the injury, with numbness and tingling sensation. The nurse notes pallor and coolness of the extremity with absent distal pulse. What complication of fracture does the nurse identify in this client? 28. A man with cast will start to walk with crutches. What should the nurse check first? a) lying and sitting blood pressure b) pulse rate c) temperature d) respiratory rate 29. Which of the following is the primary reason for splinting the hands and wrists of client with rheumatoid arthritis? a) to improve the strength of the hands and wrists b) to prevent contractures c) to relieve muscle spasm d) to relieve pain 30. Which of the following factors should concern the nurse most in a client who had undergone total hip replacement? a) the client has a small dog and a cat at home b) the client goes for a walk in the park each morning c) the client showers instead of having tub bath d) the client uses raised toilet seat

NCLEX Secrets about Musculoskeletal Injuries: ANSWERS AND RATIONALE 26) A - dealing with drill hammer puts strain at the back more than the other jobs mentioned.

27) Compartment Syndrome - compression and edema of the content of the compartment (blood vessels, nerves, and muscles) leads to five p's - pain, pallor, pulselessness, paresthesia, paralysis. 28) A - BP should be checked first before starting to ambulate to assess for potential postural hypotension. 29) B - splinting of hands and wrists of the client with rheumatoid arthritis is done primarily to prevent contractures. 30) A - bending and stooping like taking care of a small dog and a cat, may cause dislodgement of the hip prosthesis. 31. The client is diagnosed to have fibromyalgia. Which of the following signs and symptoms is commonly experienced by the client? a) irritability b) headache c) fever d) lethargy 32. The client is being prepared for crutch-walking. Which of the following health teachings should be included? a) flex the arms at 90 degree angle with the crutches b) the axillae should rest on both crutches c) bear weight on the palms of the hands d) going up and down the stairs is not allowed when using crutches 33. The nurse notes that the client on cast has diminished distal pulse. Which of the following is the most appropriate nursing action? a) check the client's vital signs b) get doppler and check for distal pulse c) elevate the affected feet d) notify the physician 34. The client will go electromyography (EMG). Which of the following information should be given when preparing the client for this procedure? a) a contrast medium will be injected into your vein

b) you will be placed in a tunnel-like device c) electrode needles will be inserted into your muscles d) scalp electrodes will be applied and graphical recording of electrical activities of your brain will be done 35. X-rays confirm that a patient has a fractured femur. While the patient is in balanced skeletal traction, which of these measures is important? a) adjusting the weights when moving him up in bed b) supporting his affected leg in plantar flexion c) raising him up in bed whenever he slips down d) maintaining him in semi-fowler's position

NCLEX Secrets about Musculoskeletal Injuries: ANSWERS AND RATIONALE 31) B - fibromyalgia is a chronic syndrome of musculoskeletal tissues characterized by chronic widespread pain. Assessment: painful muscles, fatigue, sleep disturbances, headache, restlessness leg syndrome, depression. 32) C - when using crutches, the client should bear weight on the palms of the hands not on the axillae. This is to prevent crutch palsy. 33) D - diminished distal pulse in an extremity on cast indicates that the cast is too tight. This leads to circulatory impairment. Therefore, the physician should be notified. Bivalving/splitting of the cast will be done by the physician to prevent necrosis and gangrene formation. 34) C - in EMG, electrode needles will be inserted into the muscles. There will be mild discomfort. 35) C - raising the patient with traction, up in bed whenever he slips down maintains efficiency of the traction. 36. A patient was admitted and diagnosed with fibromyalgia. Which of the following is true of the disease? a) the disease is characterized by muscle weakness

b) the signs and symptoms are relieved by steroids c) the disease is related to arthritis d) the disease is characterized by tender points in the different parts of the body and headache 37. The client with cervical spinal cord injury is on halo-vest traction. Which of the following emergency equipment is most important to keep readily available at the bedside? a) small wrench b) suction apparatus c) ambu bag d) tracheostomy tray 38. The client had undergone total hip replacement. Which of the following crutch-walking gaits is most appropriate for the client? a) four-point gait b) two-point gait c) swing-to gait d) three-point gait 39. Which non-pharmacologic intervention should the nurse include in the care plan for a patient who has moderate rheumatoid arthritis? a) massaging inflamed joints b) avoiding range of motion c) selecting clothing that have Velcro fasteners d) using assistive devices at meal times 40. A client with Paget's disease develops osteoporosis due to a) vitamin D deficiency b) inadequate calcium in diet c) bone resorption is rapid d) lack of pressure on the bones

NCLEX Secrets about Musculoskeletal Injuries: ANSWERS AND RATIONALE 36) D - fibromyalgia is characterized by muscle pain and tender points in the different parts of the body and headache. Treatment of choice is non-steroidal

anti-inflammatory drugs. 37) A - the small wrench taped over the vest will be used for untightening the screws of the traction if CPR needs to be done to the client with halo-vest traction. 38) D - three point gait is the most appropriate crutch gait for the client who had undergone total hip replacement. It is a non-weight bearing crutch gait. 39) C - selecting clothing that have Velcro fasteners facilitates task of the client with rheumatoid arthritis. Joints of fingers of the client are the most commonly affected joint. This makes it difficult for the client to perform activities of daily living like dressing and grooming. 40) C - paget's disease is characterized by very rapid bone resorption, followed by very rapid bone regeneration. However, the new bone tissues formed are weak. The client is prone to fracture. 41. A nurse is working with a nursing assistant on an orthopedic unit. The nurse observes the nursing assistant caring for a client after a left total hip replacement. The nurse will intervene if which of the following is observed? a) the nursing assistant stoops by bending at the hips and knees to pick up an object that the client dropped on the floor b) the nursing assistant keeps the client's bed in the low position when administering the bath c) the client is positioned with leg abducted slightly d) the head of the bed is elevated 30 degrees 42. A nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse determines that the client needs additional teaching if the client states: a) aspirin can cause bleeding after surgery b) aspirin can cause my ability to clot blood to abnormal c) I need to discontinue the aspirin 48 hours before the scheduled surgery d) I need to continue to take aspirin until the day of surgery 43. A 4-year old sustains a fall at home and is brought to the emergency room by the mother. After an x-ray examination, the child is determined to have a fractured arm and plaster cast is applied. The nurse provides instructions to the mother regarding care for the child's cast. Which statement by the mother

indicates a need for further instructions? a) the cast may feel warm as the cast dries b) I can use lotion or powder around the cast edges to relieve itching c) a small amount of white shoe polish can touch up a soiled white cast d) if the cast becomes wet, a blow drier set on the cool setting may be used to dry the cast 44. A nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction? a) I will encourage my child to perform prescribed exercises b) I will have my child wear soft fabric clothing under the brace c) I should apply lotion under the brace to prevent skin breakdown d) I should avoid the use of powder because it will cake under the brace 45. A 1-month old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip (DDH). The nurse assesses the infant, knowing that which of the following findings would be noted in this condition? a) limited range of motion in the affected hip b) an apparent lengthened femur on the affected side c) asymmetrical adduction of hte affected hip when the infant is placed supine with the knees and hips flexed d) symmetry of the gluteal skinfolds when the infant is placed prone and the legs are extended against the examining table

ANSWERS AND RATIONALE 41) B - during administration of bath, the nursing assistant should raise the bed to waist level to prevent bending and stooping. This prevents muscle strain and back injury. 42) D - anticoagulants alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. Options A, B, and C are accurate client statements. 43) B - The mother needs to be instructed not to use lotion or powders on the skin around the cast edges or inside the cast. Lotions or powders can become

sticky or caked and cause skin irritation. Options A, C, and D are appropriate instructions. 44) C - The use of lotions or powders under a brace should be avoided because they can become sticky and cake under the brace, causing irritation. Options A, B, and D are appropriate interventions in the care of a child with a brace. 45) A - In DDH, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Asymmetrical abduction of the affected hip, when the child is placed supine with the knees and hips flexed, would be an assessment finding in DDH in infants beyond the newborn period. Other findings include an apparent short femur on the affected side, asymmetry of the gluteal skinfolds, and limited range of motion in the affected extremity. 46. A client is treated in physician's office for a sprained ankle after a fall. Radiographic examination has ruled out a fracture. Before sending the client home, the nurse plans to teach the client to avoid which of the following in the next 24 hours? a) resting the foot b) applying a heating pad c) applying an elastic compression bandage d) elevating the ankle on a pillow while sitting or lying down 47. A nurse is conducting health screening for osteoporosis. Which of the following client is at greatest risk of developing this disorder? a) a 25-year old woman who jogs b) a 36-year old man who has asthma c) a 70-year old man who consumes excess alcohol d) a sedentary 65-year old woman who smokes cigarettes

48. A nurse has given instructions to a client returning home after knee arthroscopy. The nurse determines that the client understands the instructions if the client states that he or she will: a) resume regular exercise the following day b) stay off the leg entirely for the rest of the day c) report fever or site inflammation to the physician d) refrain from eating food for the remainder of the day 49. A client with possible rib fracture has never had a chest radiograph. The nurse would plan to tell the client which of the following items about the

procedure? a) the x-rays stimulate a small amount of pain b) removal of jewelry and any other metal objects is necessary c) the client will be asked to breathe in and out as the x-ray is taken d) the x-ray technologist will stand next to the client during the procedure 50. A nurse is one of several persons who witness a vehicle hit a pedestrian at fairly low speed on a small street. The person is dazed and tries to get up. The leg appears fractured. The nurse would plna to: a) try to reduce the fracture manually b) assist the person to get up and walk to the sidewalk c) leave the person for a few moments to call an ambulance d) stay with the person and encourage the person to remain still

ANSWERS AND RATIONALE 46) B - Soft tissue injuries such as sprains are treated by RICE (rest, ice, compression, and elevation) for the first 24 hours after the injury. Ice is applied intermittently for 20 to 30 minutes at a time. Heat is not used in the first 24 hours because it could increase venous congestion, which would increase edema and pain. 47) D - Risk factors for osteoporosis include female gender, postmenopausal, advanced age, low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids, anticonvulsants, and/or furosemide (Lasix) also increases risk. 48) C - After arthroscopy, the client usually can walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for at least a few days. The client may resume the usual diet. Signs and symptoms of infection should be reported to the physician. 49) B - A radiograph is a photographic image of part of the body on a special film, which is used to diagnose a wide variety of conditions. Radiography itself is painless; any discomfort would arise from repositioning a painful part for filming. The nurse may want to premedicate a client who is at risk for pain. Any radiopaque objects such as jewelry or other metal must be removed. The client is asked to breathe in deeply and then hold the breath while the chest radiograph is

taken. To minimize risk of radiation exposure, the x-ray technologist stands in a separate area protected by a lead wall. The client also wears a lead shield over his or her gonads. 50) D - With a suspected fracture, the client is not moved unless it is dangerous to remain in that spot. The nurse should remain with the client and have someone else call for emergency help. A fracture is not reduced at the scene. Before the client is moved, the site of fracture is immobilized to prevent further injury. 51. A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when the client will be able to walk using the casted leg. The nurse replies that the client will be able to bear weight on the casted leg: a) in 48 hours b) in 24 hours c) in about hours d) within 20 to 30 minutes of application 52. A nurse has given a client with a leg cast instructions on cast care at home. The nurse would evaluate that the client needs further instruction if the client makes which of the following statements? a) I should avoid walking on wet, slippery floors b) I'm not supposed to scratch the skin underneath the cast c) it's okay to wipe dirt off the top of the cast with a damp cloth d) if the cast gets wet, I can dry it with a hair dryer turned to the warmest setting

53. A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction primarily: a) allows bony healing to begin before surgery b) provides rigid immobilization of the fracture site c) lengthens the fractured leg to prevent severing of blood vessels d) provides comfort by reducing muscle spasms and provides fracture immobilization 54. A client returns to the nursing unit following the application of skeletal leg traction. Upon assessment, the nurse notes a small amount of bleeding around the pin insertion sites. The nurse should take which action? a) notify the surgeon b) recheck the site in 1 hour

c) check the client's vital signs d) place a small pressure dressing at the bleeding site 55. A nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which of the following findings? a) inflammation b) serous drainage c) pain at a pin site d) purulent drainage

NCLEX SECRETS ABOUT MUSCULOSKELETAL INJURIES: ANSWERS AND RATIONALE 51) D - A fiberglass cast is made of water-activated polyurethane materials that are dry to the touch within minutes and reach full rigid strength in about 20 minutes. Because of this, the client can bear weight on the cast within 20 to 30 minutes. 52) D - Client instructions should include avoiding walking on wet slippery floors to prevent falls. Surface soil on a cast can be removed with a damp cloth. If the cast gets wet, it can be dried with a hair dryer set to a cool setting to prevent skin breakdown. If the skin under the cast itches, cool air from a hair dryer may be used to relieve it. The client should never scratch under a cast because of the risk of skin breakdown and ulcer formation. 53) D - Bucks extension traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps immobilize the fracture. Traction does not lengthen the leg for the purpose of preventing blood vessel severance. Traction also does not allow for bony healing to begin. 54) D - Following pin insertion for skeletal traction, a small amount of bleeding is expected. This can be controlled with small pressure dressings; however, bleeding that continues for more than 24 hours should be brought to the surgeon's attention. It is not necessary to notify the surgeon immediately. Rechecking the site in 1 hour delays necessary intervention. Although vital signs may be checked in the immediate post-operative period, this action is unrelated to the small amount of bleeding.

55) B - A small amount of serous oozing is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported to the physician. 56. A client with a fractured right ankle has a short leg cast applied in the emergency department. During discharge teaching, the nurse provides which information to the client to prevent complications? a) trim the rough edges of the cast after it is dry b) weigh-bearing on the right leg is allowed once the cast feels dry c) expect burning and tingling sensations under the cast for 3 to 4 days d) keep the right ankle elevated above the heart level with pillows for 24 hours 57. An older adult female client with a fractured left tibia has a long leg cast and is using crutches to ambulate. In caring for the client, the nurse assesses for which sign or symptom that indicates a complication associated with crutch walking? a) left leg discomfort b) weak biceps brachii c) triceps muscle spasms d) forearm muscle weakness 58. A nurse is caring for a client with Buck's traction and is monitoring the client for complications of the traction. Which assessment finding indicates a complication? a) weak pedal pulses b) drainage at the pin sites c) complaints of discomfort d) warm toes with brisk capillary refill 59. A client has fallen and sustained a leg injury. Which question would the nurse ask the cleint to help determine if the injury caused a fracture? a) is the pain a dull ache? b) is the pain sharp and continuous? c) does the discomfort feel like a cramp? d) does the pain feel like the muscle was stretched? 60. The nurse is assessing the casted extremity of a client for signs of infection. Which of the following findings is indicative of infection? a) dependent edema b) diminished distal pulse c) coolness and pallor of the skin

d) presence of a "hot spot" on the cast

NCLEX RN Questions: Answers and Rationale 56) D - Leg elevation is important to increase venous return and decrease edema, which can cause compartment syndrome, a major complication of fractures and casting. Weight-bearing on a fractured extremity is prescribed by the physician during follow-up examination, after radiographs are obtained. Additionally, a walking heel or cast shoe may be added to the cast if the client is allowed to bear weight and walk on the affected leg. Although the client may feel heat after the cast is applied, burning and/or tingling sensations indicate nerve damage or ischemia and are not expected. These complaints should be reported immediately. Option 1 is incorrect. The client and/or family may be taught how to "petal" the cast to prevent skin irritation and breakdown, but rough edges, if trimmed, can fall into the cast and cause a break in skin integrity. 57) D - Forearm muscle weakness is a sign of radial nerve injury caused by crutch pressure on the axillae. When a client lacks upper body strength, especially in the flexor and extensor muscles of the arms, he or she frequently allows weight to rest on the axillae and on the crutch pads instead of using the arms for support while ambulating with crutches. Leg discomfort is expected as a result of the injury. Triceps muscle spasms may occur as a result of increased muscle use but is not a complication of crutch walking. Weak biceps brachii is a common physical assessment finding in older adults and is not a complication of crutch walking. 58) A - Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage or prefabricated boot used to secure this type of traction. 59) B - Fracture pain is generally described as sharp, continuous, and increasing in frequency. Bone pain is often described as a dull, deep ache. Strains result from trauma to a muscle body or to the attachment of a tendon from overstretching or overextension. Muscle injury is often described as an aching or cramping pain, or soreness. 60) D

- Signs and symptoms of infection under a casted area include a musty odor or purulent drainage from the cast or the presence of "hot spots," which are areas on the cast that are warmer than others. The physician should be notified if any of these occur. 61. A nurse is performing pin site care on a client in skeletal traction. Which finding would the nurse expect to note when assessing the pin sites? a) loose pin sites b) clear drainage from the pin sites c) purulent drainage from the pin sites d) redness and swelling around the pin sites 62. A nurse is caring for a client who has been placed in Buck's extension traction while awaiting surgical repair of a fractured femur. The nurse prepares to perform a complete neurovascular assessment of the affected extremity and plans to assess: a) vital signs and bilateral lung sounds b) warmth of the skin and the temperature in the affected extremity c) pain level and for the presence of edema in the affected extremity d) color, sensation, movement, capillary refill, and pulse of the affected extremity 63. A client in the emergency department has a cast applied. The client arrives at the nursing unit, and the nurse prepares to transfer the client into the bed by: a) placing ice on top of the cast b) supporting the cast with the fingertips only c) asking the client to support the cast during transfer d) using the palms of the hands and soft pillows to support the cast 64. A nurse is caring for a client who has been placed in Buck's extension traction. The nurse provides for countertraction to reduce shear and friction by: a) using a footboard b) providing an overhead trapeze c) slightly elevating the foot of the bed d) slightly elevating the head of the bed 65. The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. The nurse's response is based on the understanding that: a) A bone fragment has injured the nerve supply in the area b) an injured artery causes impaired arterial perfusion through the compartment c) bleeding and swelling cause increased pressure in an area that cannot expand d) the fascia expands with injury, causing pressure on underlying nerves and


NCLEX RN: Answers and Rationale 61) B - A small amount of clear drainage ("weeping") may be expected after cleaning and removing crusting around the pin sites. Redness and swelling around the pin sites and purulent drainage may be indicative of an infection. Pins should not be loose, and, if this is noted, the physician should be notified. 62) D - A complete neurovascular assessment of an extremity includes color, sensation, movement, capillary refill, and pulse of the affected extremity. 63) D - The palms or the flat surface of the extended fingers should be used when moving a wet cast to prevent indentations. Pillows are used to support the curves of the cast to prevent cracking or flattening of the cast from the weight of the body. Half-full bags of ice may be placed next to the cast to prevent swelling, but this action would be performed after the client is placed in bed. Asking the client to support the cast during transfer is inappropriate. 64) C - The part of the bed under an area in traction is usually elevated to aid in countertraction. For the client in Buck's extension traction (which is applied to a leg), the foot of the bed is elevated. An overhead trapeze or footboard is not used to provide countertraction. Option C provides a force that opposes the traction force effectively without harming the client. 65) C - Compartment syndrome is caused by bleeding and swelling within a compartment, which is lined by fascia that does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms.