Ch 43 NCLEX
Which factor may contribute to compartment syndrome? a) Hemorrhage b) Disuse syndrome c) Venous thromboemboli d) Macular lesion
a) Hemorrhage Explanation: The normal pressure of a compartment can be altered in cases of fracture by the force of the injury itself or by development of edema or hemorrhage at the site of the injury. Venous thromboemboli are some of the other early complications of fracture, but they are not related to compartment syndrome. Macular lesion is caused by the accumulation of blood under the skin, as occurs with trauma such as bone fracture. Disuse syndrome mostly occurs in hip fracture.
When is it advisable for the nurse to apply heat to a sprain or a contusion? a) Do not apply at all b) After 2 days c) Immediately d) Only after a week
b) After 2 days Explanation: It is advisable to apply heat on a sprain or a contusion 2 days after a sprain or a contusion has occurred. This is because after 2 days, swelling is not likely to increase and as a result heat application reduces pain and relieves local edema by improving circulation. Delaying the application of heat prolongs the pain and increases the risk of local edema.
The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects which complication? a) Hypovolemic shock b) Fat embolism syndrome c) Compartment syndrome d) Reflex sympathetic dystrophy syndrome
b) Fat embolism syndrome Explanation: Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion. With compartment syndrome, the patient complains of deep, throbbing, unrelenting pain. With hypovolemic shock, the patient would have decreased BP and increased pulse rate. Clinical manifestations of reflex sympathetic dystrophy syndrome include severe, burning pain, local edema, hyperesthesia, muscle spasms, and vasomotor skin changes.
Which patient(s) is most likely to have compartment syndrome after sustaining a fracture? Select all that apply. a) The patient who sustained a clavicle fracture b) The patient with a plaster cast applied immediately after injury c) The patient with hemorrhage in the site of injury d) The patient with elevated pressure level within the muscles e) The patient using ice for pain control in the extremity
b) The patient with a plaster cast applied immediately after injury, c) The patient with hemorrhage in the site of injury, d) The patient with elevated pressure level within the muscles Explanation: Compartment syndrome occurs when the normal pressure of a compartment is altered in cases of fracture by the force of the injury itself, by development of edema, or by hemorrhaging at the site of the injury, which increases the contents of the compartment, or from outside pressure caused by constriction from a dressing or cast. A patient with elevated muscle pressure is at risk for compartment syndrome. The application of a plaster cast immediately after the injury places the patient at risk for compartment syndrome because the cast will not allow for edema and therefore will compress the tissue. Clavicle fractures are not a risk factor for compartment syndrome due to the location of the fracture. Ice will assist in decreasing the edema and may help prevent compartment syndrome.
Colles' fracture occurs in which of the following areas? a) Distal radius b) Humeral shaft c) Clavicle d) Elbow
a) Distal radius Explanation: A Colles' fracture is a fracture of the distal radius (wrist). It is usually the result of a fall on an open, dorsiflexed hand.
A patient complains of pain in the right knee, stating, "My knee got twisted when I was going down the stairs." The patient was diagnosed with an injury to the ligaments and tendons of the right knee. Which terminology, documented by the nurse, best reflects the injury? a) Dislocation b) Subluxation c) Strain d) Sprain
c) Strain Explanation: A sprain is an injury to the ligaments and tendons surrounding a joint, usually caused by a wrenching or twisting motion. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation or dislocation of joint surfaces. Strain refers to a muscle pull or tear.
In a patient with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which of the following complications do the assessments help the nurse to monitor in the patient? a) Compartment syndrome b) Fat embolism syndrome c) Disseminated intravascular coagulation d) Carpal tunnel syndrome
a) Compartment syndrome Explanation: The nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable in a patient with a dislocation to assess for compartment syndrome. It is a complication associated with dislocation. A patient with a dislocation does not experience an increased risk of complications such as disseminated intravascular coagulation, carpal tunnel syndrome, or fat embolism syndrome.
An x-ray demonstrates a fracture in which a bone has splintered into several pieces. Which type of fracture is this? a) Compound b) Depressed c) Comminuted d) Impacted
c) 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.
Which of the following terms refers to failure of fragments of a fractured bone to heal together? a) Dislocation b) Malunion c) Nonunion d) Subluxation
c) Nonunion Explanation: When nonunion occurs, the patient complains of persistent discomfort and movement at the fracture site. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation or dislocation of joint surfaces. Malunion refers to growth of the fragments of a fractured bone in a faulty position, forming an imperfect union.
What assessment findings of the leg are consistent with a fracture of the femoral neck? a) Abducted and externally rotated b) Shortened, adducted, and externally rotated c) Adducted and internally rotated d) Shortened, abducted, and internally rotated
b) Shortened, adducted, and externally rotated Explanation: With fractures of the femoral neck, the leg is shortened, adducted, and externally rotated.
A patient with a recent left above-the-knee amputation states, "I can feel pain in my left toes." Which of the following is the best response by the nurse? a) "Your left toes have been amputated." b) "The pain is really from the nerves in the upper leg." c) "Describe the pain and rate it on the pain scale." d) "Pain medication usually does not help this type of pain."
c) "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 patient's pain should be address and treated appropriately. By telling the patient that the toes have been amputated or the pain is really from the nerves in the upper leg, the nurse is negating the patient's pain. Opioid pain medication can be effective with phantom pain.
Which of the following terms refers to a fracture in which one side of a bone is broken and the other side is bent? a) Spiral b) Oblique c) Greenstick d) Avulsion
c) Greenstick Explanation: A greenstick fracture is a fracture in which one side of a bone is broken and the other side is bent. A spiral fracture is a fracture twisting around the shaft of the bone. An avulsion is the pulling away of a fragment of bone by a ligament or tendon and its attachment. An oblique fracture is a fracture occurring at an angle across the bone.
Which of the following refers to a blunt force injury to soft tissue? a) Strain b) Dislocation c) Fracture d) Contusion
d) Contusion Explanation: A contusion is blunt force injury to the soft tissue. A dislocation is a separation of joint surfaces. A strain is a musculotendinous injury. A fracture is a break in the continuity of the bone.
Which nursing intervention is appropriate for a patient with a closed reduction extremity fracture? a) Administering prescribed enema to prevent constipation b) Encouraging participation in ADLs c) Promoting intake of omega-3 fatty acids d) Using frequent dependent positioning to prevent edema
b) Encouraging participation in ADLs Explanation: General nursing measures for a patient with a fracture reduction include administering analgesics, providing comfort measures, encouraging participation with ADLs, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing the patient for self-care. Omega-3 fatty acids have no implications on the diet of a patient with a fracture reduction. Dependent positioning may increase edema since the extremity is below the level of the heart. While some pain medications may contribute to constipation, this intervention would be reserved for a patient experiencing constipation and not as a preventative measure.
Pulselessness, a very late sign of compartment syndrome, may signify which of the following? a) Diminished arterial perfusion b) Lack of distal tissue perfusion c) Venous congestion d) Nerve involvement
b) Lack of distal tissue perfusion Explanation: Pulselessness is a very late sign that may signify lack of distal tissue perfusion. The other answers do not apply.
A patient is transported to the ED for a femur fracture following a motor vehicle crash. What action by the nurse is the highest priority? a) Assess vital signs and level of consciousness. b) Assess the diameter of the thigh every 15 minutes. c) Assess pedal pulses. d) Administer pain medication per orders.
a) Assess vital signs and level of consciousness. Explanation: Femur fractures can lead to hypovolemic shock due to blood loss in the tissue. By assessing the vital signs and level of consciousness, the nurse can assess for shock. Assessing the pedal pulses and measuring the diameter of the thigh are appropriate interventions for someone with a femur fracture, but assessing for hypovolemic shock would be a priority. Pain medication should be safely administered per orders to help control pain. Many pain medications lower BP. If the patient is in shock, BP may be too low to administer the pain medication safely.
A 75-year-old patient had surgery for a left hip fracture yesterday. When completing the plan of care, the nurse should include assessment for which of the following complications? Select all that apply. a) Skin breakdown b) Necrosis of the humerus c) Sepsis d) Pneumonia e) Delirium
a) Skin breakdown, c) Sepsis, d) Pneumonia, e) Delirium Explanation: Complications in patients with hip fractures are often related to the age of the patient. During the first 24 to 48 hours following surgery for hip fracture, atelectasis or pneumonia from the anesthesia can develop. Thromboemboli are possible, as is sepsis. Elderly patients are also at risk for delirium in hospital settings because of the stress of the trauma, unfamiliar surroundings, sleep deprivation, and medications. An elderly patient with decreased mobility is at risk for skin breakdown. Necrosis is a potential complication of the surgery, but the complication would be with the femur, not the humerus.
The ED nurse teaches patients with sports injuries to remember the acronym RICE. This acronym stands for which of the following combinations of treatment? a) Rotation, ice, compression, and examination b) Rest, ice, compression, elevation c) Rest, ice, circulation, and examination d) Rotation, immersion, compression, and elevation
b) Rest, ice, compression, elevation Explanation: RICE is used for the treatment of contusions, sprains, and strains. While circulation problems must be examined, the RICE treatment does not refer to circulation and examination. Rotation of a joint is contraindicated when injury is suspected, and immersion of the area may be anatomically difficult. Examination, while indicated, does not provide treatment.
A patient who has extremity right wrist fracture complains of severe burning pain, frequent changes in the skin from hot and dry to cold and feeling clammy shiny skin that is growing more hair in the injured extremity. The nurse should anticipate providing care for what complication? a) Reaction to an internal fixation device b) Heterotrophic ossification c) Avascular necrosis of bone d) Complex regional pain syndrome (CRPS)
d) Complex regional pain syndrome (CRPS) Explanation: The symptoms reported by the patient are consistent with CRPS. Avascular necrosis is manifested by pain and limited movement. Pain and decreased function are the prime indicators of reaction to an internal fixation device. Heterotrophic ossification causes muscular pain and limited muscular contraction and movement.
A patient suffered an open fracture to the left femur during a horseback riding accident. For which of the following complications is this patient at highest risk? a) Infection b) Malunion c) Complex regional pain syndrome d) Depression
a) Infection Explanation: This patient 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 fatality. The patient is still at risk for malunion, but this is a slight risk 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 patient who was in a motor vehicle crash is diagnosed with a stable T7 spinal fracture with no neurologic deficits. Which of the following nursing interventions should the nurse implement? a) Maintain NPO status (nothing by mouth) for surgical repair. b) Maintain bed rest with head of bed at 20 degrees. c) Sit patient upright in a padded chair for meals. d) Withhold opioid pain medication to prevent ileus.
b) Maintain bed rest with head of bed at 20 degrees. Explanation: The patient should maintain limited bed rest with the head of the bed lower than 30 degrees. If the patient's pain is not controlled with a lower form of pain medication, then an opioid may be used to treat the pain. The nurse should monitor for an ileus. Stable spinal fractures are treated conservatively and not with surgical repair. The patient should avoid sitting until the pain eases.
A patient asks the nurse why his residual limb cannot be elevated on a pillow. What is the best response by the nurse? a) "Elevating the leg might lead to a flexion contracture." b) "You need to turn yourself side to side. If your leg is on a pillow, you would not be able to do that." c) "I am sorry. We ran out of pillows. I can elevate it on a few blankets." d) "Elevating the extremity may increase your chances of compartment syndrome."
a) "Elevating the leg might lead to a flexion contracture." Explanation: Elevating the residual limb on a pillow may lead to a flexion contracture; this could jeopardize the patient's ability to use a prosthesis. The patient does need to turn to both sides, but might still be able to do it with his extremity elevated. Elevating the extremity would not increase the risk for compartment syndrome. The limb should not be elevated on pillows or blankets.
Which of the following is a factor that inhibits fracture healing? a) Increased vitamin D and calcium in the diet b) History of diabetes c) Immobilization of the fracture d) Patient age of 35
b) History of diabetes Explanation: Factors that inhibit fracture healing include diabetes, smoking, local malignancy, bone loss, extensive local trauma, age greater than 40, and infection. Factors that enhance fracture healing include proper nutrition, vitamin D and calcium, exercise, maximum bone fragment contact, proper alignment, and immobilization of the fracture.
A patient with a traumatic amputation of the right lower leg is refusing to look at the leg. Which of the following actions by the nurse is most appropriate? a) Encourage the patient to perform range-of-motion (ROM) exercises to the right leg. b) Provide feedback on the patient's strengths and available resources. c) Provide wound care without discussing the amputation. d) Request a referral to occupational therapy.
b) Provide feedback on the patient's strengths and available resources. Explanation: The nurse should encourage the patient to look at, and assist with, care of the residual limb. Providing feedback on the patient's strengths and resources may allow the patient to start to adapt to the body image and lifestyle change. The nurse should also allow time for the patient to discuss his or her feelings related to the amputation. Requesting a referral to occupational therapy and encouraging the patient to perform ROM exercises are appropriate, but do not address the emotional aspect of losing an extremity.
A patient with a right below-the-knee amputation is being transferred from the postanesthesia care unit to a medical-surgical unit. What is the highest priority nursing intervention by the receiving nurse? a) Delegate the gathering of enough pillows for proper positioning and comfort. b) Document the receiving report from the transferring nurse. c) Ensure that a large tourniquet is in the room. d) Review the physician orders for type and frequency of ordered pain medication.
c) Ensure that a large tourniquet is in the room. Explanation: The patient with an amputation is at risk for hemorrhage. A tourniquet should be placed in plain sight for use if the patient hemorrhages. Documenting the receiving report is important, but is not the highest priority. The nurse may delegate to unlicensed assistive personnel (UAP) the job of gathering more pillows for positioning, but this is not the highest priority. The nurse will need to review the physician's orders for pain medication but, again, this is not the highest priority because any patient is hemorrhaging by the patient needs to be addressed first.