278 Chapter 44 Care of the Patient with a Musculoskeletal Disorder (1362) and's 23. A nurse is checking on an older neig

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278 Chapter 44 Care Of The Patient With A Musculoskeletal Disorder 1362 And S 23 A Nurse Is Checking On An Older Neig 1 (70.67 KiB) Viewed 38 times

278 Chapter 44 Care of the Patient with a Musculoskeletal Disorder (1362) and's 23. A nurse is checking on an older neighbor who 19. The patient had a hip arthroplasty and re- just fell down. The man cheerfully tells the turned from the postanesthesia care unitsev nurse, "just tripped on the carpet and took eral hours ago. The patient is now restless and of injury which assessment is the nurse most a spill. No harm done!" Based on mechanism anxious. What is the nurse's first action? (1367) 1. Decrease andiety by reassuring the patient likely to perform if the neighbor will allow it? that everything is going as expected. 2 Initiate vital signs every 15 minutes, com- 1. Head-to-toe to detect occult injury pare to baseline, and monitor trends. 2 Palpation and range of motion for Wrist 3. Look at the urinary output and compare injury the total to baseline. 3. Mental status examination for head injury 4. Call the patient's family and invite them to Environmental assessment for other haz. spend time at the bedside. 20. A fiberglass cast has been applied to the fore- 24. The patient was in a car accident and reports arm of a 6-year-old child to treat and stabilize a pain over the pelvic region with difficulty rais- greenstick fracture. Which teaching point is the most important to emphasize with the child? ecchymosis over the pelvic region. Which labo ing legs in a supine position. The nurse notes (1366) 1. Instructing the child to keep the cast dry ratory test is the primary concern in the imme 2. Teaching the child to report pain to the par diate phase of care? (1365) ents 1. Hemoglobin and hematocrit 3. Showing the child how to test capillary re- 2. Blood type and Rh 3. Urinalysis 4. Reminding the child to wiggle the fingers 4. Stool for occult blood 21. The nurse is supervising a nursing student in 25. The patient with a cast on the lower extremity caring for a patient who had internal fixation reports pain at 7/10. What should the nurse do for a hip fracture. The nurse would intervene if first? (1357) the student performed which action? (1358) 1. Reposition the leg so that elevation is 1. Assessed the amount of drainage in the maintained Jackson-Pratt drain 2. Administer pain medication as prescribed. 2. Encouraged coughing and the use of the 3. Report potential compartment syndrome incentive spirometer 3. Removed the antiembolism stocking to to RN 4. Perform the 7 Ps of orthopedic assessment. sess the skin 4. Placed the patient in high Fowler's posi- 26. The nurse hears in report that the patient has tion prior to eating Volkmann's contracture of the dominant upper 22. The nurse is providing care for a patient who extremity. Which intervention would the nurse has just had a hip replacement. Which com- plan to use? (1367) ment from the patient indicates the need for i. Frequently assess using the 7 Ps of ortho- further education? (1356) pedic assessment 1. "I need to be on bedrest for the first 72 2. Assess the patient's abilities to perform ac- hours." 2. "I need to obtain a seat riser for my toilet at 3. "I should never sit with my legs crossed. alignment. months. tivities of daily living. 3. Teach the patient to report pain, loss of sensation, or swelling 4. Instruct the UAP on proper position and home." 4. "I'll have limitations in hip position for 2-3