ch 62 traumatic musculoskeletal injuries
A patient has suffered a femoral shaft fracture in an industrial accident. What is an immediate nursing concern for this patient?
Hypovolemic shock Explanation: Frequently, the patient develops shock, because the loss of 1,000 mL of blood into the tissues is common with fractures of the femoral shaft
A patient who has undergone a lower limb amputation is preparing to be discharged home. What outcome is necessary prior to discharge?
Patient can demonstrate safe use of assistive devices. Explanation: A patient should be able to use assistive devices appropriately and safely prior to discharge. Scar formation will not be complete at the time of hospital discharge. It is anticipated that the patient will require some assistance with ADLs postdischarge. Pain should be well managed, but may or may not be wholly absent.
(see full question) A nurse is assigned to support a patient while a cast is being applied to treat a greenstick fracture. The nurse documents that this fracture is classified as what type of fracture?
Incomplete Explanation: A greenstick fracture involves a break through only part of the cross-section of the bone.
Pulselessness is a very late sign of compartment syndrome and may signify which of the following?
Lack of distal tissue perfusion Explanation: Pulselessness is a very late sign that may signify lack of distal tissue perfusion.
A nurse is caring for a patient who has suffered an unstable thoracolumbar fracture. Which of the following is the priority during nursing care?
Maintaining spinal alignment Explanation: Patients with an unstable fracture must have their spine in alignment at all times in order to prevent neurologic damage. This is a greater threat, and higher priority, than promoting function and preventing infection, even though these are both valid considerations. Increased ICP is not a high risk.
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
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 classic indicator of edema and alveolar hemorrhage associated with FES is:
Hyperventilation. Explanation: Occlusion of the small vessels in the alveoli leads to a PaO2 of less than 80 mm Hg with an early respiratory alkalosis. The patient experiences hyperventilation in an attempt to get oxygen into the lungs
A nurse in a busy emergency department provides care for many patients who present with contusions, strains, or sprains. Treatment modalities that are common to all of these musculoskeletal injuries include which of the following? Select all that apply.
• Applying ice • Compression dressings • Resting the affected extremity • Elevating the injured limb Correct Explanation: Treatment of contusions, strains, and sprains consists of resting and elevating the affected part, applying cold, and using a compression bandage. Massage and corticosteroids are not used to treat these injuries.
A client is hospitalized for open reduction of a fractured femur. During the postoperative assessment, the nurse notes that the client is restless and she observes petechiae on the client's chest. Which nursing action is indicated first
Administer oxygen. Explanation: The client is demonstrating clinical manifestations consistent with a fatty embolus. Administering oxygen is the top priority. Elevating the extremity won't alter the client's condition. Notifying the nursing supervisor may be indicated by facility policy after other immediate actions have been taken. The nurse should contact the physician after administering oxygen.
A nurse is caring for a patient who has had an amputation. What interventions can the nurse provide to foster a positive self-image? (Select all that apply.)
• Encouraging the patient to care for the residual limb • Allowing the expression of grief • Introducing the patient to local amputee support groups. Explanation: The nurse creates an accepting and supportive atmosphere in which the patient and family are encouraged to express and share their feelings and work through the grief process. The support from family and friends promotes the patient's acceptance of the loss. The nurse helps the patient deal with immediate needs and become oriented to realistic rehabilitation goals and future independent functioning. Mental health and support group referrals may be appropriate (McFarland et al., 2010). Amputation affects the patient's ability to provide adequate self-care. The patient is encouraged to be an active participant in self-care.
Which type of fracture produces several bone fragments?
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. An incomplete fracture involves a break through only part of the cross-section of the bone
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?
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 nurse admits a patient who has a fracture of the nose that has resulted in a skin tear and involvement of the mucous membranes of the nasal passages. The orthopedic nurse is aware that this description likely indicates which type of fracture?
Compound Explanation: A compound fracture involves damage to the skin or mucous membranes and is also called an open fracture. A compression fracture involves compression of bone and is seen in vertebral fractures. An impacted fracture occurs when a bone fragment is driven into another bone fragment. A transverse fracture occurs straight across the bone shaft.
Colles' fracture occurs in which of the following areas?
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.
The primary nursing intervention that will control swelling while treating a musculoskeletal injury is:
Elevate the affected area. Explanation: Elevation is used to control swelling. It is facilitated by cold, immobilization, and compression.
A patient asks the nurse why his residual limb cannot be elevated on a pillow. What is the best response by the nurse?
"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.
The nurse is monitoring a patient who sustained an open fracture of the left hip. What type of shock should the nurse be aware can occur with this type of injury?
Hypovolemic Explanation: Hypovolemic shock resulting from hemorrhage is more frequently noted in trauma patients with pelvic fractures and in patients with a displaced or open femoral fracture in which the femoral artery is torn by bone fragments.
A high school student who was injured in a football game presents with knee pain with internal rotation of the foot. Which of the following is an inappropriate nursing intervention?
Assist the client to "walk" off the pain. Explanation: The client has a torn lateral meniscus. Priority interventions include rest, ice, compression, and elevation of the affected extremity and the administration of NSAIDs for pain
An older adult patient has fallen in her home and is brought to the emergency department by ambulance with a suspected fractured hip. X-rays confirm a fracture of the left femoral neck. When planning assessments during the patient's presurgical care, the nurse should be aware of the patient's heightened risk of what complication?
Avascular necrosis Explanation: Fractures of the neck of the femur may damage the vascular system that supplies blood to the head and the neck of the femur, and the bone may become ischemic. For this reason, AVN is common in patients with femoral neck fractures. Infections are not immediate complications and phantom pain applies to patients with amputations, not hip fractures.
Which type of fracture is one in which the skin or mucous membranes extends to the fractured bone?
Compound Explanation: A compound fracture is one in which the skin or mucous membrane wound extends to the fractured bone. A complete fracture involves a creak across the entire cross-section of the bone and is frequently displaced. An incomplete fracture involves a break through only part of the cross-section of the bone. A simple fracture is one that does not cause a break in the skin.
Which of the following surgical procedures may need to be done when removing a cast or bandage does not restore circulation to the extremity?
Fasciotomy Explanation: If pressure is not relieved by removing the bandage or cast and circulation is not restored, a fasciotomy may be necessary to relive the pressure within the muscle compartment. Hemiarthroplasty is the replacement of the femoral head with a prosthesis. An ORIF is done to reduce a fracture. A bone graft wound not be used to restore circulation.
A nurse is preparing to discharge an emergency department patient who has been fitted with a sling to support her arm after a clavicle fracture. What should the nurse instruct the patient to do?
Use the arm for light activities within the range of motion. Explanation: A patient with a clavicle fracture may use a sling to support the arm and relieve the pain. The patient may be permitted to use the arm for light activities within the range of comfort. The patient should not elevate the arm above the shoulder level until the ends of the bones have united, but the nurse should encourage the patient to exercise the elbow, wrist, and fingers.
Sarah Butler, age 26 years, has been participating in a tennis tournament. She is being seen in the clinic for elbow discomfort. The physician has given her a diagnosis of tendinitis, epicondylitis, or tennis elbow. What symptoms and signs did she have? Choose all that are correct.
• Pain radiating down the dorsal surface of the forearm • Weak grasp Explanation: Tennis elbow is characterized by pain radiating down the dorsal surface of the forearm and weak grasp. Carpal tunnel syndrome is characterized by pain or burning in one or both hands and pain more prominent at night.
Which of the following terms refers to failure of fragments of a fractured bone to heal together?
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.
Which nursing diagnosis takes highest priority for a client with a compound fracture?
Risk for infection related to effects of trauma Explanation: A compound fracture involves an opening in the skin at the fracture site. Because the skin is the body's first line of defense against infection, any skin opening places the client at risk for infection. Imbalanced nutrition: Less than body requirements is rarely associated with fractures. Although Impaired physical mobility and Activity intolerance may be associated with any fracture, these nursing diagnoses don't take precedence because they aren't as life-threatening as infection.
A 19-year-old patient presents to the emergency room with an injury to her left ankle that occurred during a high school basketball game. She complains of limited motion and pain on walking, which increased over the last 2 hours. The nurse knows that her diagnosis is most likely which of the following?
Second-degree sprain Explanation: A sprain is the result of an injury to ligaments that is caused by a twisting motion. A second-degree sprain is an incomplete tear of the ligament that results in painful weight bearing. A third-degree sprain involves a complete ligament tear with loss of weight-bearing function.
Ms. Bixley has been gardening all season and has come to the clinic with a complaint of shoulder pain. The physician assesses the shoulder and decided that she probably has a rotator cuff tear. What are the possible treatment options for treating this condition? Select all that apply.
• Arthroscopic surgery • NSAIDs • Modify activities and rest the joint Correct Explanation: NSAIDs, modifying activities and resting the joint, arthroscopic surgery, and open acromioplasty with tendon repair are all options. Traction is not an option.
Special elements of care to be incorporated into the care of a client in traction include which of the following? Select all that apply. a) The client requires simple and direct explanations about the traction and its purpose. b) The nurse points out activities that are allowed or contraindicated. c) All of the answers are true. d) When traction is discontinued, the nurse prepares the client for further treatment, such as casting, and for the appearance of the affected are—skin and muscles.
All of the answers are true. Correct Explanation: The client requires simple and direct explanations about the traction and its purpose. The nurse points out activities that are allowed or contraindicated. When traction is discontinued, the nurse prepares the client for further treatment, such as casting, and for the appearance of the affected area—skin and muscles.
A 78-year-old client is in the emergency department following involvement in a motor vehicle collision. Radiographs indicate a fractured humerus; the client is awaiting the casting of her upper extremity and admission to the orthopedic unit. Other than her bone, what other physical structures could be affected by this injury? a) Nerves b) All options are correct. c) Muscles d) Blood vessels
All options are correct. Correct Explanation: A fractured bone or other injury can potentially cause dysfunction to the surrounding muscle and injury to the blood vessels and nerves.
(see full question) A patient has returned to the postsurgical unit from the PACU after an above-the-knee amputation of the right leg. Results of the nurse's initial postsurgical assessment were unremarkable but the patient has called out. The nurse enters the room and observes copious quantities of blood at the surgical site. What should be the nurse's initial action?
Apply a tourniquet. Explanation: The nurse should apply a tourniquet in the event of postsurgical hemorrhage. Elevating the limb and applying sterile gauze are likely insufficient to stop the hemorrhage. The nurse should attempt to control the immediate bleeding before contacting the surgeon
A patient was climbing a ladder, slipped on a rung, and fell on the right side of the chest. X-ray studies reveal three rib fractures, and the patient is complaining of pain with inspiration. What is the anticipated treatment for this patient?
Coughing and deep breathing with pillow splinting Explanation: Because these fractures cause pain with respiratory effort, the patient tends to decrease respiratory excursions and refrains from coughing. As a result, tracheobronchial secretions are not mobilized, aeration of the lung is diminished, and a predisposition to atelectasis and pneumonia results. To help the patient cough and take deep breaths and use an incentive spirometer (see Chapter 21), the nurse may splint the chest with his or her hands, or may educate the patient on using a pillow to temporarily splint the affected site.
A patient has sustained a long bone fracture and the nurse is preparing the patient's care plan. Which of the following should the nurse include in the care plan?
Monitor temperature and pulses of the affected extremity. Explanation: The nurse should include monitoring for sufficient blood supply by assessing the color, temperature, and pulses of the affected extremity. Weight-bearing exercises are encouraged, but passive ROM exercises have the potential to cause pain and inhibit healing. Corticosteroids, vitamin D, and calcium are not normally administered.
A young patient is being treated for a femoral fracture suffered in a snowboarding accident. The nurse's most recent assessment reveals that the patient is uncharacteristically confused. What diagnostic test should be performed on this patient?
Arterial blood gases Explanation: Subtle personality changes, restlessness, irritability, or confusion in a patient who has sustained a fracture are indications for immediate arterial blood gas studies due to the possibility of fat embolism syndrome. This assessment finding does not indicate an immediate need for electrolyte levels, an ECG, or abdominal ultrasound.
A nurse is caring for a patient who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. Which of the following measures will best achieve these goals?
Encouraging the patient to turn from side to side and to assume a prone position Explanation: The nurse encourages the patient to turn from side to side and to assume a prone position, if possible, to stretch the flexor muscles and to prevent flexion contracture of the hip. Postoperative ROM exercises are started early, because contracture deformities develop rapidly. ROM exercises include hip and knee exercises for patients with BKAs. The nurse also discourages sitting for prolonged periods of time.
A patient with a simple arm fracture is receiving discharge education from the nurse. What would the nurse instruct the patient to do?
Engage in exercises that strengthen the unaffected muscles. Explanation: The nurse will encourage the patient to engage in exercises that strengthen the unaffected muscles. Comfort measures may include appropriate use of analgesics and elevation of the affected extremity to the heart level. Topical anesthetics are not typically used.
A nurse suspects that a client with a recent fracture has compartment syndrome. Assessment findings may include:
inability to perform active movement and pain with passive movement. Correct Explanation: With compartment syndrome, the client can't perform active movement, and pain occurs with passive movement. A body-wide decrease in bone mass is seen in osteoporosis. A growth in and around the bone tissue may indicate a bone tumor.
When joint manipulation is unsuccessful for a client, he is taken to surgery for surgical repair of his hip injury. He is brought to the ICU where you practice nursing for postoperative recovery. After surgery, the nurse implements measures to prevent complications. Select all of the following which are complications that the nurse seeks to prevent.
• Pneumonia • Skin breakdown • Wound infection Correct Explanation: After surgery, the nurse implements measures to prevent skin breakdown, wound infection, pneumonia, constipation, urinary retention, muscle atrophy, and contractures.
A patient sustains an open fracture of the left arm after an accident at the roller skating rink. What does emergency management of this fracture involve? (Select all that apply.)
• Splinting the injured limb • Immobilizing the affected site • Covering the area with a clean dressing if the fracture is open Correct Explanation: Immediately after injury, if a fracture is suspected, the body part must be immobilized before the patient is moved. Adequate splinting is essential. Joints proximal and distal to the fracture also must be immobilized to prevent movement of fracture fragments. In an upper extremity injury, the arm may be bandaged to the chest, or an injured forearm may be placed in a sling. The neurovascular status distal to the injury should be assessed both before and after splinting to determine the adequacy of peripheral tissue perfusion and nerve function. With an open fracture, the wound is covered with a sterile dressing to prevent contamination of deeper tissues.
The nurse is caring for a patient with a pelvic fracture. What nursing assessment for a pelvic fracture should be included? (Select all that apply.)
• Testing the stool for occult blood • Palpating peripheral pulses in both lower extremities • Checking the urine for hematuria Correct Explanation: In pelvic fracture, the nurse should palpate the peripheral pulses, especially the dorsalis pedis pulses of both lower extremities; absence of a pulse may indicate a tear in the iliac artery or one of its branches. To assess for urinary tract injury, the patient's urine is analyzed for blood.
Which of the following are associated with compartment syndrome? Select all that apply.
• Trauma from accidents • Surgery • Casts • Tight bandages • Crushing injuries Explanation: Risk factors for compartment syndrome include trauma from accidents, surgery, casts, tight bandages, and crushing injuries. In addition, it may be caused by any condition that increases the risk of bleeding or edema in a confined space including patients with soft tissue injury, without fractures, who are on anticoagulants or have bleeding dyscrasias.