Ch 42: Management of Patients with MSK trauma PrepU

A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction?

A: Apply ice packs for the first 24 - 48 hours, then apply heat packs The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing. Applying ice for only 12 to 18 hours may not keep swelling from recurring. Applying heat for the first 24 to 48 hours would worsen, not ease, swelling. Applying ice 48 hours after the injury would be less effective because swelling already has occurred by that time.

A client with a recent left above-the-knee amputation states, "I can feel pain in my left toes." Which is the best response by the nurse?

Correct response: "Describe the pain and rate it on the pain scale." Explanation: The nurse should recognize phantom pain as real and complete a pain assessment as if the limb were attached. The client's pain should be address and treated appropriately. By telling the client that the toes have been amputated or the pain is really from the nerves in the upper leg, the nurse is negating the client's pain. Opioid pain medication can be effective with phantom pain.

Two days after surgery to amputate the left lower leg, a client reports pain in the missing extremity. Which action by the nurse is most appropriate?

Correct response: Administer medication, as ordered, for the reported discomfort. Explanation: The sensation of pain and discomfort in an amputated extremity is known as phantom pain. Phantom pain is a normal occurrence after an amputation. It should be treated with medication. The nurse doesn't need to contact the health care provider at this time. Consultation with the psychologist isn't indicated, and the nurse shouldn't take this action without consulting the health care provider.

Which type of fracture involves a break through only part of the cross-section of the bone?

Correct response: Incomplete Explanation: An incomplete fracture involves a break through only part of the cross-section of the bone. A comminuted fracture is one that produces several bone fragments. An open fracture is one in which the skin or mucous membrane wound extends to the fractured bone. An oblique fracture runs across the bone at a diagonal angle of 45 to 60 degrees.

A client has had surgical repair of a hip injury after joint manipulation was unsuccessful. After surgery, the nurse implements measures to prevent complications. Which complications is the nurse seeking to prevent? Select all that apply.

Correct response: skin breakdown wound infection pneumonia Explanation: After surgery, the nurse implements measures to prevent skin breakdown, wound infection, pneumonia, constipation, urinary retention, muscle atrophy, and contractures.

A client who has sustained a fracture reports an increase in pain and decreased function of the affected extremity. What will the nurse suspect?

Correct response: Avascular necrosis Explanation: Avascular necrosis refers to the death of the bone from insufficient blood supply, typically manifested by complaints of increased pain and decreased function. Fever or redness, purulent drainage, and swelling of the site would suggest infection. Respiratory distress would suggest a pulmonary embolism. Changes in vital signs, level of consciousness, and signs and symptoms of fluid loss would suggest hypovolemic shock.

An important nursing assessment, post fracture, is to evaluate neurovascular status. Therefore, the nurse should check for:

Correct response: Capillary refill. Explanation: Assessment for neurovascular impairment includes checking for weak pulses or delayed capillary refill (normal is <2 seconds).

An x-ray demonstrates a fracture in which a bone has splintered into several pieces. Which type of fracture is this?

Correct response: Comminuted Explanation: A comminuted fracture may require open reduction and internal fixation. A compound fracture is one in which damage also involves the skin or mucous membranes. A depressed fracture is one in which fragments are driven inward. An impacted fracture is one in which a bone fragment is driven into another bone fragment.

Two days after application of a cast to treat a fractured femur, the client reports severe, deep, and constant pain in the leg. What will the nurse suspect?

Correct response: Compartment syndrome. Explanation: Compartment syndrome refers to the compression of nerves, blood vessels, and muscle within a closed space. This leads to tissue death from lack of oxygenation.

Which of the following type of fracture is associated with osteoporosis?

Correct response: Compression Explanation: Compression fractures are caused by compression of vertebrae and are associated frequently with osteoporosis. Stress fractures occur with repeated bone trauma from athletic activities, most frequently involving the tibia and metatarsals. An oblique fracture runs across the bone at a diagonal angle of 45 to 60 degrees. A simple fracture (closed fracture) is one that does not cause a break in the skin.

A client with a traumatic amputation of the right lower leg is refusing to look at the leg. Which action by the nurse is most appropriate?

Correct response: Provide feedback on the client's strengths and available resources. Explanation: The nurse should encourage the client to look at, and assist with, care of the residual limb. Providing feedback on the client's strengths and resources may allow the client to start to adapt to the body image and lifestyle change. The nurse should also allow time for the client to discuss their feelings related to the amputation. Requesting a referral to occupational therapy and encouraging the client to perform ROM exercises are appropriate but do not address the emotional aspect of losing an extremity.

A client comes to the emergency department complaining of localized pain and swelling of his lower leg. Ecchymotic areas are noted. History reveals that the client got hit in the leg with a baseball bat. Which of the following would the nurse suspect as most likely?

Correct response: Contusion Explanation: The client's description of blunt trauma by a baseball bat and localized pain in conjunction with swelling and ecchymosis would most likely suggest a contusion. A fracture would be manifested by pain, loss of function, deformity, swelling, and spasm. A sprain would be manifested by pain and swelling; ecchymosis may appear later. A strain is characterized by inflammation, local tenderness, and muscle spasms.

Which of the following would lead a nurse to suspect that a client has a rotator cuff tear?

Correct response: Difficulty lying on affected side Explanation: Clients with a rotator cuff tear experience pain with movement and limited mobility of the shoulder and arm. They especially have difficulty with activities that involve stretching their arm above their head. Many clients find that the pain is worse at night and that they are unable to sleep on the affected side.

Which of the following disorders results in widespread hemorrhage andmicrothrombosis with ischemia?

Correct response: Disseminated intravascular coagulation (DIC) Explanation: DIC is a systemic disorder that results in widespread hemorrhage and microthrombosis with ischemia. AVN of the bone occurs when the bone loses its blood supply and dies. CRPS is a painful sympathetic nervous system problem. FES occurs when the fat globules released when the bone is fractured occludes the small blood vessels that supply the lungs, brain, kidneys, and other organs.

A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan?

Correct response: Elevating the stump for the first 24 hours Explanation: Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility. Heat application would be inappropriate because it promotes vasodilation, which may cause hemorrhage and increase pain. The initial pressure dressing usually remains in place for 48 to 72 hours after surgery.

A client with a fracture develops compartment syndrome that requires surgical intervention. What treatment will the nurse would most likely prepare the client for?

Correct response: Fasciotomy Explanation: Surgical treatment of compartment syndrome is achieved with a fasciotomy, a surgical incision of the fascia and separation of the muscle to relieve pressure and restore tissue perfusion. Bone graft, joint replacement or amputation may be done for a client who experiences avascular necrosis.

A patient sustained an open fracture of the femur 24 hours ago. While assessing the patient, the nurse observes the patient is having difficulty breathing, and oxygen saturation decreases to 88% from a previous 99%. What does the nurse understand is likely occurring with this patient?

Correct response: Fat emboli Explanation: After fracture of long bones or pelvic bones, or crush injuries, fat emboli frequently form. Fat embolism syndrome (FES) occurs when fat emboli cause morbid clinical manifestations. The classic triad of clinical manifestations of FES include hypoxemia, neurologic compromise, and a petechial rash (NAON, 2007), although not all signs and symptoms manifest at the same time (Tzioupis & Giannoudis, 2011). The typical first manifestations are pulmonary and include hypoxia and tachypnea.

The client with a fractured left humerus reports dyspnea and chest pain. Pulse oximetry is 88%. Temperature is 100.2 degrees Fahrenheit (38.5 degrees Centigrade); heart rate is 110 beats per minute; respiratory rate is 32 breaths per minute. The nurse suspects the client is experiencing:

Correct response: Fat embolism syndrome Explanation: The clinical manifestations described in the scenario are characteristic of fat embolism syndrome.

Radiographic evaluation of a client's fracture reveals that a bone fragment has been driven into another bone fragment. The nurse identifies this as which type of fracture?

Correct response: Impacted Explanation: An impacted fracture is one in which a bone fragment is driven into another bone fragment. A comminuted fracture is one in which the bone has splintered into several fragments. A compression fracture is one in which bone has been compressed. A greenstick fracture is one in which one side of the bon is broken and the other side is bent.

A client experienced an open fracture to the left femur during a horse-riding accident. For which complication is this client at highest risk?

Correct response: Infection Explanation: This client is at the highest risk for infection because of the open fracture that was obtained while horseback riding. Infection that enters the body and affects the bone can lead to osteomyelitis. The treatment may involve long-term antibiotics and may even result in death. The client is still at risk for malunion, but this risk is slight because the bone can be visualized (either through the wound or surgical intervention) and returned to anatomical position. The other options are possible consequences of this type of injury but do not represent the most serious complication.

A client undergoes open reduction with internal fixation to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan?

Correct response: Keeping a pillow between the client's legs at all times Explanation: After open reduction with internal fixation, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period, because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After open reduction with internal fixation, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.

A client with metastatic bone cancer sustained a left hip fracture without injury. What type of fracture does the nurse understand occurs without trauma or fall?

Correct response: Pathologic fracture Explanation: A pathologic fracture is a fracture that occurs through an area of diseased bone and can occur without trauma or a fall. An impacted fracture is a fracture in which a bone fragment is driven into another bone fragment. A transverse fracture is a fracture straight across the bone. A compound fracture is a fracture in which damage also involves the skin or mucous membranes.

Which nursing intervention is essential in caring for a client with compartment syndrome?

Correct response: Removing all external sources of pressure, such as clothing and jewelry Explanation: Nursing measures should include removing all clothing, jewelry, and external forms of pressure (such as dressings or casts) to prevent constriction and additional tissue compromise. The extremity should be maintained at heart level (further elevation may increase circulatory compromise, whereas a dependent position may increase edema). A compression wrap, which increases tissue pressure, could further damage the affected extremity. There is no indication that diagnostic studies would require I.V. access in the affected extremity.

Which of the following musculoskeletal injuries is manifested by acromioclavicular joint pain?

Correct response: Rotator cuff tears Explanation: Key assessment findings related to rotator cuff tears include acromioclavicular joint pain, limited range of motion, and muscle weakness. Epicondylitis (tennis elbow) is manifested by pain that usually radiates down the extensor surface of the forearm and generally is relieved with rest and avoidance of the aggravating activity. Heterotopic ossification is the abnormal formation of bone, near bones or in muscle, in response to soft tissue trauma after blunt trauma, fracture, or total joint replacement. Acute compartment syndrome involves a sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive intervention does not occur.

After surgery to treat a hip fracture, a client returns from the postanesthesia care unit to the medical-surgical unit. Postoperatively, how should the nurse position the client?

Correct response: With the leg on the affected side abducted Explanation: The nurse must keep the leg on the affected side abducted at all times after hip surgery to prevent accidental dislodgment of the affected hip joint. Placing a pillow or an A-frame between the legs helps maintain abduction and reminds the client not to cross the legs. The nurse should avoid acutely flexing the client's affected hip (for example, by elevating the head of the bed excessively), adducting the leg on the affected side (such as by moving it toward the midline), or externally rotating the affected hip (such as by removing support along the outer side of the leg) because these positions may cause dislocation of the injured hip joint.

A fracture is considered pathologic when it

Correct response: occurs through an area of diseased bone. Explanation: Pathologic fractures can occur without the trauma of a fall. An avulsion fracture results in a fragment of bone being pulled away by a ligament or tendon and its attachment. A greenstick fracture presents as one side of the bone being broken and the other side being bent. A compound fracture involves damage to the skin or mucous membranes.