NCLEX Quiz-Musculoskeletal Disorder

Answer & Rationale:

Option 2 is Correct

Rationale: In addition to the presence of clinical manifestations, gout is diagnosed by the presence of persistent hyperuricemia, with a uric acid level higher than 8 mg/dL; a normal value ranges from 2.5 to 8 mg/dL. Options 1, 3, and 4 indicate normal laboratory values. Additionally, the presence of uric acid in an aspirated sample of synovial fluid confirms the diagnosis.

Answer & Rationale:

Option 1 is Correct

Rationale: The nursing assessment conducted after spinal surgery is similar to that done after other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101.6 F should be reported.

Answer & Rationale:

Option 2 is Correct

Rationale: Low back pain that radiates into one leg (sciatica) is consistent with herniated lumbar disk. The nurse assesses the client to see whether the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, and coughing, or by lifting the leg straight up while supine (straight leg-raising test).

Answer & Rationale:

Option 3 is Correct

Rationale: If the client with an amputation has a cast or elastic compression bandage that slips off, the nurse must wrap the stump immediately with another elastic compression bandage. Otherwise, excessive edema will form rapidly, which could cause a significant delay in rehabilitation. If the client had a cast that slipped off, the nurse would have to call the physician so that a new one could be applied. Elevation on one pillow is not going to impede the development of edema greatly once compression is released. Ice would be of limited value in controlling edema from this cause. If the physician

Answer & Rationale:

Option 4 is Correct

Rationale: Clients with diabetes mellitus are more prone to wound infection and delayed wound healing because of the disease. Postoperative stump edema and hemorrhage are complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long as it is dry and intact.

Answer & Rationale:

Option 2 is Correct

Rationale: An altered mental state is an early indication of fat emboli; therefore, clear mentation is a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be higher than 95%.

Answer & Rationale:

Option 2 is Correct

Rationale: Crutch tips should remain dry. Water could cause the client to slip by decreasing the surface friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The client should use only crutches measured for the client. The tips should be inspected for wear, and spare crutches and tips should be available if needed.

Answer & Rationale:

Option 3 is Correct

Rationale: Signs and symptoms of infection under a casted area include odor or purulent drainage from the cast or the presence of “hot spots,” which are areas of the cast that are warmer than others. The physician should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished arterial pulse, and edema.

Answer & Rationale:

Option 4 is Correct

Rationale: 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 increase the risk.