Med Surg: Chapter 42

A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan? Applying heat to the stump as the client desires Elevating the stump for the first 24 hours Removing the pressure dressing after the first 8 hours Maintaining the client on complete bed rest

Elevating the stump for the first 24 hours

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? Administer medication, as ordered, for the reported discomfort. Contact the health care provider. Do nothing because it isn't possible to have pain in a missing limb. Initiate a consult with a psychologist.

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 physician at this time. Consultation with the psychologist isn't indicated, and the nurse shouldn't take this action without consulting the physician.

A 14-year-old client is treated in the emergency room for an acute knee sprain sustained during a soccer game. The nurse reviews discharge instructions with the client's parent. The nurse instructs the parent that the acute inflammatory stage will last how long? At least 7 days 24 to 48 hours 4 to 5 days 3 to 4 days

24 to 48 hours. Rest and ice applications during the first 24 to 48 hours produce vasoconstriction while decreasing bleeding and edema. After this time, the acute inflammatory stage decreases. Refer to Box 42-1 in the text.

After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis? Volkmann's ischemic contracture Infection Compartment syndrome Fat embolism

Fat embolism

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? Encourage the client to perform range-of-motion (ROM) exercises to the right leg. Request a referral to occupational therapy. Provide feedback on the client's strengths and available resources. Provide wound care without discussing the amputation.

Provide feedback on the client's strengths and available resources.

Which of the following are associated with compartment syndrome? Select all that apply. Casts Crushing injuries Trauma from accidents Tight bandages Surgery

Trauma from accidents Surgery Casts Tight bandages Crushing injuries pg. 1165

Which may occur if a client experiences compartment syndrome in an upper extremity? Whiplash injury Volkmann's contracture Callus Subluxation

Volkmann's contracture

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? With the leg on the affected side adducted With the affected hip rotated externally With the affected hip flexed acutely With the leg on the affected side abducted

With the leg on the affected side abducted

An adult is swinging a small child by the arms, and the child screams and grabs his left arm. It is determined in the emergency department that the radial head is partially dislocated. What is this partially dislocated radial head documented as? Volkmann's contracture Compartment syndrome Subluxation Sprain

Subluxation Explanation: A partial dislocation is referred to as a subluxation. A Volkmann's contracture is a claw like deformity that results from compartment syndrome or obstructed arterial blood flow to the forearm and hand. Compartment syndrome is a condition in which a structure such as a tendon or nerve is constricted in a confined space and affects nerve innervation, leading to subsequent palsy. A sprain is injury to the ligaments surrounding the joint.

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? "Describe the pain and rate it on the pain scale." "Pain medication usually does not help this type of pain." "The pain is really from the nerves in the upper leg." "Your left toes have been amputated."

"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.

A client undergoes a total hip replacement. Which statement made by the client indicates to the nurse that the client requires further teaching? "I need to remember not to cross my legs. It's such a habit." "I'll need to keep several pillows between my legs at night." "The occupational therapist is showing me how to use a sock puller to help me get dressed." "I don't know if I'll be able to get off that low toilet seat at home by myself."

"I don't know if I'll be able to get off that low toilet seat at home by myself."

A patient sustains a fracture of the arm. When does the nurse anticipate pendulum exercise should begin? In 2 to 3 weeks, when callus ossification prevents easy movements of bony fragments In about 4 to 5 weeks, after new bone is well established As soon as tolerated, after a reasonable period of immobilization In 2 to 3 months, after normal activities are resumed SUBMIT ANSWER

As soon as tolerated, after a reasonable period of immobilization

The nurse is caring for a client who was involved in an automobile accident and sustained multiple trauma. The client has a Volkmann's contracture to the right hand. What objective data does the nurse document related to this finding? Dislocation of the fingers Extension of the fingers of the right hand Nodules on the knuckles of the third and fourth finger Claw-like deformity of the right hand without ability to extend fingers

Clawlike deformity of the right hand without ability to extend fingers pg. 1170

Which of the following is a term used to describe a soft tissue injury produced by a blunt force? Contusion Hematoma Strain Sprain

Contusion

Which of the following would lead a nurse to suspect that a client has a rotator cuff tear? Ability to stretch arm over the head Minimal pain with movement Pain worse in the morning Difficulty lying on affected side

Difficulty lying on affected side

Which of the following would lead a nurse to suspect that a client has a rotator cuff tear? Minimal pain with movement Increased ability to stretch arm over the head Difficulty lying on affected side Pain worse in the morning

Difficulty lying on affected side

A client 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? Ensure that a large tourniquet is in the room. Delegate the gathering of enough pillows for proper positioning and comfort. Document the receiving report from the transferring nurse. Review the physician's orders for type and frequency of pain medication.

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.

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

Fasciotomy 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.

Which factor inhibits fracture healing? History of diabetes Increased vitamin D and calcium in the diet Immobilization of the fracture Age of 35 years

History of diabetes

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? Greenstick Comminuted Impacted Compression

Impacted

Which factor inhibits fracture healing? Vitamin D Local malignancy Exercise Maximum bone fragment contact

Local malignancy

A client who was in a motor vehicle crash is diagnosed with a stable T7 spinal fracture with no neurologic deficits. Which nursing intervention should the nurse implement? Maintain NPO (nothing by mouth) status for surgical repair. Sit the client upright in a padded chair for meals. Withhold opioid pain medication to prevent ileus. Maintain bed rest with the head of the bed at 20 degrees.

Maintain bed rest with heads of bed at 20 degrees.

Which nursing diagnosis takes highest priority for a client with a compound fracture? Impaired physical mobility related to trauma Risk for infection related to effects of trauma Activity intolerance related to weight-bearing limitations Imbalanced nutrition: Less than body requirements related to immobility

Risk for infection related to effects of trauma

Which of the following musculoskeletal injuries is manifested by acromioclavicular joint pain? Rotator cuff tears Epicondylitis Heterotopic ossification Acute compartment syndrome

Rotator cuff tears

A client comes to the emergency department and reports localized pain and swelling in the lower leg. Ecchymotic areas are noted. History reveals that the client got hit in the leg with a baseball bat. What will the nurse most likely suspect? Strain Sprain Contusion Fracture

contusion

A fracture is considered pathologic when it presents as one side of the bone being broken and the other side being bent. involves damage to the skin or mucous membranes. results in a fragment of bone being pulled away by a ligament or tendon and its attachment. occurs through an area of diseased bone.

occurs through an area of diseased bone.

Which term refers to an injury to ligaments and other soft tissues surrounding a joint? Strain Sprain Subluxation Dislocation

sprain A sprain is 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.

A client has been diagnosed with a muscle strain. What does the physician mean with the term "strain"? stretched or pulled beyond its capacity injury resulting from a blow or blunt trauma subluxation of a joint injuries to ligaments surrounding a joint

stretched or pulled beyond its capacity

A client has been diagnosed with a rotator cuff tear. What are the options for treating this condition? Select all that apply. traction NSAIDs arthroscopic surgery activity modification and joint rest

• Arthroscopic surgery • NSAIDs • Modify activities and rest the joint Explanation: NSAIDs, modifying activities and resting the joint, arthroscopic surgery, and open acromioplasty with tendon repair are all options. Traction is not an option.

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. skin breakdown diarrhea wound infection pneumonia

- skin breakdown- wound infection- pneumonia pg. 1175

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? Turning the client from side to side every 2 hours Performing passive range-of-motion (ROM) exercises on the client's legs once each shift Maintaining the client in semi-Fowler's position Keeping a pillow between the client's legs at all times

Keeping a pillow between the client's legs at all times

A client who has fallen and injured a hip cannot place weight on the leg and is in significant pain. After radiographs indicate intact but malpositioned bones, what would the physician diagnose? fracture sprain dislocation strain

dislocation In joint dislocation, radiographic films show intact yet malpositioned bones. Arthrography or arthroscopy may reveal damage to other structures in the joint capsule. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. Sprains are injuries to the ligaments surrounding a joint. A fracture is a break in the continuity of a bone.

A bone graft may be used for which of the following reasons? Select all that apply. Joint stabilization Stimulation of bone healing Reduction of a fracture Improvement of motion Defect filling

• Joint stabilization • Defect filling • Stimulation of bone healing Explanation: A bone graft is used for joint stabilization, defect filling, or stimulation of bone healing. Tendon transfer is used for improving motion. Either closed or open reduction may be used to reduce a fracture.

Which general nursing measure is used for a client with a fracture reduction? Encourage participation in ADLs Assist with intake of immune-enhancing tube feeding formulas Examine the abdomen for enlarged liver or spleen Promote intake of omega-3 fatty acids

Encourage participation in ADLs General nursing measures for a client with a fracture reduction include administering analgesics, providing comfort measures, encouraging participation in ADLs, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing the client for self-care. Omega-3 fatty acids have no implications on the diet of a client with a fracture reduction. The nurse does not need to examine the abdomen for enlarged liver or spleen because fracture reduction treatment does not affect these organs. It is unlikely that a client with a fracture reduction will be prescribed immune-enhancing tube feeding formulas.

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? "Apply ice packs for the first 12 to 18 hours." "Apply heat packs for the first 24 hours, then apply ice packs for the next 48 hours." "Apply heat packs for the first 24 to 48 hours." "Apply ice packs for the first 24 to 48 hours, then apply heat packs."

"Apply ice packs for the first 24 to 48 hours, then apply heat packs." Rationale: 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.

Which nursing intervention is appropriate for a client with a closed-reduction extremity fracture? Promote intake of omega-3 fatty acids Encourage participation in ADLs Use frequent dependent positioning to prevent edema Administer prescribed enema to prevent constipation

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.

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: Delayed union Complex regional pain syndrome Compartment syndrome Fat embolism syndrome

Fat embolism syndrome Rationale: The clinical manifestations described in the scenario are characteristics of fat embolism syndrome.

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.) Allowing the expression of grief Encouraging the patient to care for the residual limb Encourage the patient to have family and friends view the residual limb to decrease self-consciousness. Encouraging family and friends to refrain from visiting temporarily because this may increase the patient's embarrassment. Introducing the patient to local amputee support groups.

• 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.