Exam 13: Mobility

A client hospitalized with an open reduction and internal fixation of a fractured femur reports right calf pain.The nurse notes that the right calf is 3.5 cm larger than the left calf with generalized posterior erythema.The right calf is tender to touch.Dorsalis pedis pulse is 3/4+ bilaterally.Which is the priority action by the nurse?

During a health screening,the nurse analyzes that which client is at the highest risk for back problems? Select all that apply.

An older adult client with bilateral osteoarthritis of the knees tells the nurse,"I know I need to lose weight but exercising makes my knees ache." What instruction should the nurse provide to this client?

A middle-aged client states to the nurse,"I have noticed a slight tremor of my left hand when at rest.I think I might have Parkinson disease because my mother had it and passed away because of respiratory failure." Which response by the nurse is the most appropriate?

The nurse is planning care for a client with osteoarthritis.Which diagnosis would have the highest priority?

A client who is hospitalized after a left hip fracture is scheduled for surgery late this afternoon.After receiving report,the nurse evaluates the Buck traction applied by a new physical therapist.Which finding indicates that the traction is correctly applied?

The nurse is planning care for a client with multiple sclerosis.Which intervention would address the nursing diagnosis of Fatigue?

The nurse in the emergency department is preparing to administer methylprednisolone to a client with a spinal cord injury.Which effect will this medication have on the client?

The school nurse is conducting a screening on back safety for school-age clients who are in the 6th grade.The nurse brings a scale and weighs all the children and their backpacks behind a screen for privacy.One client weighs 40 kg and the backpack weighs 8 kg.Which intervention is appropriate for this client?

A client with multiple sclerosis is prescribed diazepam (Valium).What assessment finding indicates that the medication is effective for the client?

The nurse is planning care for client who weighs70 kg client and is post-op day 1 after spinal fusion surgery.Which is an appropriate outcome for this client?

A client with osteoarthritis tells the nurse about having difficulty walking to the bathroom first thing in the morning.Which nursing action would assist this client?

A client with Parkinson disease (PD)states to the nurse,"It is 1950 and I am late for work." What action should the nurse take at this time?

The nurse is presenting a talk for the monthly Nursing Case Study education group.Which client would be a good choice for a case study on multiple sclerosis (MS)?

The nurse is evaluating the care of a client with Parkinson disease (PD).Which finding indicates an improvement in nutritional status?

A client who sustained a cervical neck injury 2 days ago is demonstrating an irregular respiratory pattern with the rate of 8-10 breaths per minute.Based on this data,which is the priority nursing diagnosis?

On the first postoperative day after spinal fusion,the nurse assesses a client and finds temperature 39.2°C,blood pressure 100/50 mmHg,heart rate 118 bpm,and respirations 23 breathes per min.Drainage at the incision site is clear and tests positive for glucose.Which assessment parameter indicates the highest risk for surgical wound infection?

A school nurse is treating a school-age client who has fallen down a flight of stairs.The client is breathing but unconsciousness.After calling the ambulance,which is the priority action by the nurse?

A client with Parkinson disease (PD)ambulates with a shuffling gait and leans slightly forward.When seated,the client conducts a conversation,reads,and is able to self-feed without assistance.Which diagnosis is a priority for this client?

During a home care visit,an older adult client begins to cry softly when asked about coping with back pain.The client states,"My back hurts bad all the time and I am so confused about all these tests and scared that the doctor wants me to have surgery" Which is the priority intervention by the nurse?