ANSWER AND RATIONALE

MUSCOLOSKELETAL

1. A patient reports all of the following symptoms.

Which of these symptoms would indicate to the
nurse a serious complication of systemic lupus 1. B. Systemic lupus erythematosus ( SLE) is
erythematosus? characterized by alternating periods of remissions
a. Fatigue c. Joint pain and exarcerbations. Normal symptoms of SLE
b. Hematuria d. Oral ulcers include microscopic hematuria, that the patient
would not see. Therefore, if the patient reports
hematuria, it should be considered a serious
2. Which of the following disorders would a nurse complication
expect to identify when assessing a patient who us
experiencing afternoon slumps, carbohydrate 2. B. People with seasonal affective disorder report a
craving and weight gain during the fall and winter craving for, and increased consumption of,
months that disappear in spring and summer? carbohydrates, weight gain, fatigue and irritability
a. Major depressive disorder c. Dysthymic disorder during the winter months. A reversal of these
b. Seasonal affective disorder d. Bipolar symptoms occurs in the spring and summer, with
Disorder elation, increased social activity, decreased appetite
and weight loss occurring

3. A 12-year-old girl has a long leg cast applied to her

left leg. She is being instructed in crutch-walking 3. D. The axilla should not rest on the crutches. Such
with no weight bearing on her left leg. Which of the pressure may cause discomfort and nerve damage.
following observations indicates that the girl needs The weight of the body should be borne by the
further teaching? hands. The girl needs further instruction in this area
a. She is using the three-point gait
b. Her elbows are slightly flexed
c. She places the crutches approximately
six to eight inches (15 to 20 cm) in front of her
with each step
d. She is supporting her weight on the
axillary bars and hand pieces of the crutches

4. Diazepam ( Valium) is prescribed for a patient with

low back pain. The desired therapeutic action of 4. D. Diazepam ( Valium) is prescribed for a
valium in this situation is to patient with low back pain to decrease
a. reduce anxiety levels muscle spasms
b. eliminate pain sensation
c. suppress the inflammatory process
d. lessen muscle spasticity

5. A patient who has a spinal cord transection is in

spinal shock. On assessment, the nurse would expect 5.
the patient to describe which of the following
findings ion the lower extremities?
a. Loss of sensation c. Excessive diaphoresis
b. Complaints of tingling d. Constant tremors
A. A patient with a spinal cord transection
has no movement or feeling below the level
of the injury

6. A six-year-old child has a short arm cast placed on

the right extremity. While assessing the fingers 6. D. Capillary refill greater than two seconds
during immediate period after casting, a nurse would indicates vascular compromise or pressure
report which of the following finding?
from the immobilizing device
a. Mild enema
b. Pain on movement
c. Slight coolness of the cast when touched
d. Capillary refill greater than three
seconds
 Self-care deficit d. Sleep pattern
disturbance
7. Which of the following medications would a nurse
have available when administering an injection of
heparin sodium to a patient? 7. B. Protamine sulfate is the antidote for heparin
a. Naloxone hydrochloride (narcan) toxicity and overdose
b. Protamine sulfate
c. Phytonadione ( aquaMEPHYTON)
d. Phentolamine mesylate ( Regitine)

8. To promote the skin integrity of a patient who is in

Russell’s traction, which of the following measures
should be included in the care plan? 8. C. Massaging the patient’s back and buttocks
a. Having the patient lie on the right side frequently promotes skin integrity and should be
for 20 minutes every two to three hours included in the care of a patient in traction
b. Placing pillows under the patient’s
sacral and scapular areas
c. Massaging the patient’s back and
buttocks frequently
d. Applying an antiseptic solution to the
patient’s bony prominences after bathing

9. The bowel retraining program for a patient who has

had cerebrovascular accident should include which
of the following measures? 9. D. Bowel retraining is established by providing a
a. Checking for impaction daily consistent time for evacuation each day
b. Increasing the intake of milk products
c. Utilizing incontinent pads until control
is achieved
d. Establishing a consistent time for
elimination

10. A patient who has hyperthyroidism is taking

methimazole (Tapazole) and attends the clinic
regularly. To evaluate the effectiveness of Tapazole 10. D. Tapazole is used to decrease iodine use and
therapy, the nurse should consider which of the inhibit the synthesis of thyroid hormones. Therefore,
following questions? metabolic activity will be decreased if the treatment
a. Has the patient’s vision improved? is effective
b. Has the patient’s appetite improved?
c. Has the patient’s need for sleep
decreased?
d. Has the patient’s pulse rate decreased?

11. Prior to surgery for correction of congenital hip

dysplasia in four-month-old infant, which of the
following home care instructions would a nurse 11. A. Multiple diapers can be sued prior to surgery to
include in the teaching plan for the infant’s family? effectively separate the child’s legs and hold the legs
a. “ Apply double diapers when changing in an abducted, externally rotated position
the infant.”
b. “ Perform passive range-of-motion on
the lower extremities.”
c. “ Support the legs in an adducted
position with pillows during sleep.”
d. “ Avoid placing the infant in upright
position.”

12. A 12-year-old child who has been diagnosed with

scoliosis is to be treated with a Milwaukee brace. To
which of the following nursing diagnoses would a 12. A. Alteration in skin integrity is the priority nursing
nurse give priority? diagnosis. Skin excoriation can occur if the leather
a. Skin integrity c. Impaired gas and plastic pads of the brace touch the child’s skin.
exchange The brace can be worn over a tee shirt
 c. Keeping the patient’s stump elevated on
a pillow
d. Encouraging the patient to lie prone in
bed
13. Which of the following guidelines should a nurse
include in the teaching plan for a patient who has 13. A. Nutritional counseling for weight reduction may
Osteoarthritis? be necessary to eliminate excessive strain on the
a. Achieve ideal body weight joints of a patient with osteoarthritis.
b. Increase daily calcium intake to 1500
mg
c. Maintain a high-fiber diet
d. Sleep at least 10 hours each day

14. A six-year-old child who sustained a fracture has a

long leg cast applied to the left leg. Which of the 14. C. This statement indicates a need for further
following statements, if made by a parent, would teaching. The child should have sensation while the
indicate the need for further teaching? cast is in place. Observation such as pain, swelling,
a. “ I will call the clinic if my child discoloration of the exposed portions, lack of
complains of sudden pain on his foot.” pulsation and warmth and the inability to move the
b. “ I will check the skin temperature of my exposed part are reported immediately
child’s toes at least once a day.”
c. “ I should not expect my child to have
sensation in the toes while the cast is on.”
d. “ I should not let my child put anything
inside the cast to relieve itching.”

15. A nurse places a patient in four-point restraints

following orders from a physician. Which of the
following measures should the nurse in the patient’s
care of plan?
a. Socialize with other patients once a shift
b. Check circulation periodically
c. Provide stimulating diversional activities
d. Assess rectal temperature frequently
15. B. Restraints encircle the limbs, placing the patient
at risk for circulation being restricted to the distal
areas of the extremities. Checking the patients
circulation every 15-30 minutes will allow the nurse
to adjust the restraints before injury form decreased
blood flow occurs. The nurse must document the
time of the check and the degree of capillary refill

16. A nurse conducts discharge teaching with a patient

who is in cervical traction with a halo apparatus. 16. A. The long term goal is to have the patient return to
Which of the following statements indicates that the full function in approximately three months
patient needs further instructions?
a. “ I will need to wear the halo for several
months.”
b. “ I should remove the halo when I
shower.”
c. “ I plan to take a walk every day.”
d. “ I will continue my previous diet.”

17. A patient who has had a right hip replacement

should be instructed to carry out which of the 17. B. Because dislocation of a total hip prosthesis is a
following techniques when turning in bed? possible complication of the surgery, the patient’s
a. Bring both knees to the chest before legs are to be kept away from the middle of the
turning body, or abducted. To ensure that abduction is
b. Keep an abductor wedge between the maintained and the prosthesis does not dislocate, the
legs patient is instructed to keep an abduction pillow
c. Maintain flexion of the affected hip between the legs
d. Move the affected leg with the
unaffected foot

18. Which of the following nursing measures is

appropriate when caring for a patient who has 18. D. The patient should be assisted into the prone
undergone a right, above-the-knee amputation? position every three to four hours for 20 to 30-
a. Ambulating the patient in the hallway minute periods, This is necessary to prevent hip
with crutches flexion contractures
b. Placing the patient in a chair during
waking hours
 He will identify his areas of interest
He will engage in occupational therapy

19. If a patient were to develop thrombophlebitis at an 19. B. Thrombophlebitis is the formation of a clot with
intravenous infusion site, which of the following inflammation of a vein. Clinical manifestation s are
early findings should the nurse expect to observe? tenderness, redness and warmth. Edema may oir
a. Pallor and swelling may not occur
b. Erythema and heat
c. Mottling and coolness
d. Leakage of fluid and numbness

20. Which of the following measures should be included 20. B. Patients in traction should be assessed for nerve
in the care plan of a patient whose left leg is in and circulatory disturbances. To check for capillary
traction? filling times, the patient’s nail beds are compressed
a. Checking the feet for the presence of ankle to produce blanching and assessed for return of color
clonus
b. Noting the color of the toenails after applying
temporary pressure
c. Assessing the femoral arteries for equality of
pulses
d. Precussing the knee for a patellar reflex

21. Following a hip replacement, the patient should have 21. A. Following a hip replacement, the patient’s
the affected hip placed in which of these positions? affected hip should be placed in extension, with an
a. Extended, with a wedge between the abduction wedge between his legs
legs
b. Flexed, with the knee supported on
sandbags
c. Elevated, with pillows under the leg
from the knee to the ankle
d. Rotated externally, with a trochanter roll
in place

22. A 15-year old boy has undergone a spinal
instrumentation at the level of T4 to T5 for scoliosis.
Because there is an order to maintain strict bed rest,
a nurse should use which of the following
techniques when repositioning the boy?
a. Assist the patient in pulling himself up
with the overhead trapeze bar
b. Turn the patient’s head to one side, then
have him reach for the rail to turn
c. Place the bed in Trendelenburg position,
then have the boy roll to one side
d. Use an assistant and logroll the patient
to the desired side
22. D. Scoliosis is a complex spinal deformity that
includes curvature of the spine. It can be congenital
but more commonly develops during the growth
spurt of early adolescence. To maintain proper body
alignment after surgery, the patient should avoid
twisting movements that can cause indwelling
instruments to twist the spine. Log-rolling is
preferred when moving the child.

23. A nurse would assess a patient who has undergone a 23. A. Following a lumbar laminectomy, the patient
lumbar laminectomy for which of the following should wear anti-embolism stockings or another
post-surgical complications? anti-embolism device to prevent deep vein
a. Deep vein thrombosis c. Intemittent thrombosis
claudification
b. Urinary frequency d. Flank pain

24. A physician tells a 30-year-old man who had an 24. A. A long-term goal for a 30-year-old man who is
above the knee amputation that he will not be able to unable to return to construction work would be to
return to his construction work. Which of the develop alternate vocational skills
following long-term goals would be an appropriate
expectation of the man?
a. He will develop alternative vocational
skills
b. He will acknowledge his loss
 25. A patient with hypothyroidism is to receive
levothyroxine sodium ( Synthroid), 75 mcg by IV
25. The formula for this calculation is as follows
push. The medication available is labeled 200
,cg/10ml. Which of the following doses is the
Desired amount x volume = dose
correct amount?
Available amount
a. 5.0 ml b. 3.75ml c. 4.75ml d. 2.5 ml

75 mcg x 10 ml = dose

x 750 = dose
200

3.75ml = dose

26. A patient who has vascular insufficiency of the

26. C. Activity intolerance should be addressed as a
lower extremities experiences intermittent
priority. The pain of intermittent claudification is
claudification. To which of the following nursing
alleviated by cessation of activity
diagnoses would a nurse give priority?
a. Ineffective thermoregulation
b. Non-compliance with treatment plan
c. Activity intolerance
d. Alteration in the body image

Opportunities are often disguised as hard

work, so most people fail to recognize
them.
-Ann Landers