CH 43 - MUSCULOSKELETAL TRAUMA

Which client statement identifies a knowledge deficit about cast care?

"I can pull out cast padding to scratch inside the cast." Explanation: Clients should not pull out cast padding to scratch inside the cast because of the hazard of skin breakdown and subsequent potential for infection. Clients are encouraged to elevate the casted extremity above the level of the heart to reduce edema and to exercise or move the joints above and below the cast to promote and maintain flexibility and muscle strength. Applying ice for 10 minutes during the first 24 hours helps to reduce edema.

A nurse is performing an admission assessment on a client admitted with a pelvic fracture. Which statement by the client requires the nurse to seek more information from a legal standpoint?

"Sometimes my husband gets so angry with me." Explanation: Legally, the nurse must further investigate the client's statement concerning her husband's anger. This statement suggests that the client's injury might be caused by domestic abuse. The other statements are common and don't require further investigation, from a legal standpoint, by the nurse.

The nurse is caring for a client on a second course of antibiotics to eliminate osteomyelitis. It is most essential for the nurse to instruct on which aspect of daily care?

A diet high in protein and nutrients Explanation: It is essential for the nurse to instruct on a diet that is high in protein and nutrients to increase healing and strengthen the immune system. This, in addition to the second course of antibiotics, may be sufficient to eliminate the osteomyelitis. Opioids may be needed for pain management but this is not most essential. Bedrest is not common in care and assistive devices are used only in the acute period.

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

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 client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be?

Administering ordered analgesics and monitoring their effects Explanation: An acute exacerbation of rheumatoid arthritis can be very painful, and the nurse should make pain management the priority. Client teaching, skin care, and supplying adaptive devices are important, but these actions don't not take priority over pain management.

A client reports to the emergency department after experiencing pain in the left arm. The client reports that he extended his arms in an attempt to prevent a fall. Which fracture type does the nurse anticipate?

Colles' fracture Explanation: A Colles' fracture occurs in the distal radius. Falling with outstretched arms and hands may increase the risk of this type of fracture. A spiral fracture results from a twisting movement. A greenstick fracture is a bent and incomplete fracture commonly seen in children. A compound fracture results in the bone extending through the skin.

What would be the most important nursing intervention in caring for the client's residual limb during the first 24 hours after amputation of the left leg?

Elevate the residual limb on a pillow. Explanation: Elevating the residual limb on a pillow for the first 24 hours after surgery helps prevent edema and promotes comfort by increasing venous return. Elevating the residual limb for longer than the first 24 hours is contraindicated because of the potential for developing a hip flexion contracture. Keeping the limb flat will be an important intervention after the first 24 hours. Preventing excessive swelling, however, is a priority in the first 24 hours. Adducting the residual limb on a scheduled basis prevents abduction contracture. Traction may be used to prevent or treat a hip flexion contracture—however, not in the first 24 hours.

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

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 is experiencing chronic arthritis and active range of motion is ordered. The nurse understands that the goal is to do which of the following?

Increase muscle strength. Explanation: Active range of motion is to enhance client strength and abilities. The other choices are reflective of passive range of motion and reduction of inflammation, and maintaining circulation is not applicable to this question

A female client is at risk for developing osteoporosis. Which action will reduce the client's risk?

Initiating weight-bearing exercise routines Explanation: Performing weight-bearing exercise increases bone health. A sedentary lifestyle increases the risk of developing osteoporosis. Estrogen is needed to promote calcium absorption. The recommended daily intake of calcium is 1,000 mg, not 300 mg

A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis?

Prevent internal rotation of the affected leg. Explanation: The nurse and other caregivers should prevent internal rotation of the affected leg. However, external rotation and abduction of the hip will help prevent dislocation of a new hip joint. Postoperative total hip replacement clients may be turned onto the unaffected side. The hip may be flexed slightly, but it shouldn't exceed 90 degrees. Maintenance of flexion isn't necessary.

When caring for a client with acute osteomyelitis in the right tibia, which measure is most appropriate to implement when repositioning the client's leg?

Support the leg above and below the affected area when positioning. Explanation: Acute osteomyelitis can be very painful. Therefore, the extremity must be handled carefully and moved slowly. The most appropriate action when moving an extremity with acute osteomyelitis is to ensure that the extremity is carefully supported above and below the affected area. A splint may be useful to decrease discomfort. Holding the leg by the ankle or allowing the client to move the leg is inappropriate because doing so does not provide adequate support to the affected area. Applying warm, moist compresses does not decrease the need to adequately support the affected area.

A nurse is teaching a female client about preventing osteoporosis. Which teaching point is correct?

The recommended daily allowance of calcium may be found in a wide variety of foods. Explanation: Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. Clients usually can get the recommended daily requirement of calcium by eating a varied diet. Osteoporosis doesn't show up on ordinary X-rays until 30% of bone has been lost. Bone densitometry, however, can detect bone loss of 3% or less. This test is sometimes recommended routinely for women older than 35 who are at risk for osteoporosis. Strenuous exercise won't cause fractures. Although supplements are available, they aren't always necessary

A client is taking methotrexate for severe rheumatoid arthritis. The nurse instructs the client that it will be necessary to monitor:

complete blood count (CBC) with differential and platelet count. Explanation: This client should be monitored for blood dyscrasias, evidenced by decreased platelet count and white blood cell count with changes in the CBC differential.

Two days after being placed in a cast for a fractured femur, the client suddenly has chest pain and dyspnea. The client is confused and has an elevated temperature. The nurse should assess the client for:

fat embolism syndrome. Explanation: Clients with fractures of the long bones such as the femur are particularly susceptible to fat embolism syndrome (FES). Signs and symptoms include chest pain, dyspnea, tachycardia, and cyanosis. Changes in mental status are caused by hypoxemia and can be the first symptoms noted in FES. The client can also be restless and febrile and can develop petechiae. Osteomyelitis is infection of the bone; signs and symptoms of osteomyelitis do not include respiratory symptoms. Compartment syndrome causes signs of localized neurovascular impairment, not systemic symptoms. Venous thrombosis occurs in the lower extremities and is caused by venous stasis.

Passive range-of-motion (ROM) exercises for the legs and assisted ROM exercises for the arms are part of the care regimen for a client with a spinal cord injury. Which observation by the nurse would indicate a successful outcome of this treatment?

free, easy movement of the joints Explanation: ROM exercises help preserve joint motion and stimulate circulation. Contractures develop rapidly in clients with spinal cord injuries, and the absence of this complication indicates treatment success. Range of motion will keep the ankle joints freely mobile. Footdrop, however, is prevented by proper positioning of the ankle and foot, which is usually accomplished with high-top sneakers or splints. External rotation of the hips is prevented by using trochanter rolls. Local ischemia over bony prominences is prevented by following a regular turning schedule.

After a laminectomy, the client states, "The doctor said that I can do anything I want to." Which activity that the client intends to do indicates the need for further teaching?

sweeping the front porch Explanation: Sweeping causes a twisting motion, which should be avoided because twisting can cause undue stress on the recently ruptured disc site, muscle spasms, and a potential recurrent disc rupture. Although the client should not bend at the waist, such as when washing dishes at the sink, the client can dry dishes because no bending is necessary. The client can sit in a firm chair that keeps the back anatomically aligned. The client should not twist and pull, so when making the bed, the client should pull the covers up on one side and then walk around to the other side before trying to pull the covers up there

A client has a total hip replacement. Which of the following client statements indicates a need for further teaching before discharge?

"I can't wait to take a tub bath when I get home." Explanation: The client will need to avoid extremes of motion in the hip to avoid dislocation. The hip should not be flexed more than 90 degrees, internally rotated, or legs crossed. It is not possible to safely sit in the bathtub without flexing the hip beyond the recommended 90 degrees. The client can implement the prescribed exercise program at the time of discharge home. The client should take care not to stress the hip for 3 to 6 months after surgery. An elevated toilet seat will be necessary during the recovery from surgery.

Which statement by the client with rheumatoid arthritis would indicate the need for additional teaching to safely receive the maximum benefit of aspirin therapy?

"I try to take aspirin only on days when the pain seems particularly bad." Explanation: Aspirin therapy in rheumatoid arthritis involves continuous ongoing administration to establish and maintain therapeutic blood levels. Aspirin should not be used on an as-needed basis. Aspirin should always be buffered with food. Generic aspirin is acceptable. Clients should be instructed to observe for symptoms of bleeding.

A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct?

"OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." Explanation: OA is a degenerative arthritis, characterized by the loss of cartilage on the articular surfaces of weight-bearing joints with spur development. RA is characterized by inflammation of synovial membranes and surrounding structures. OA may occur in one hip or knee and not the other, whereas RA commonly affects the same joints bilaterally. RA is more common in women; OA affects both sexes equally

On a visit to the family physician, a client is diagnosed with a bunion on the lateral side of the great toe, at the metatarsophalangeal joint. Which statement should the nurse include in the teaching session?

"Some bunions are congenital; others are caused by wearing shoes that are too short or narrow." Explanation: Bunions may be congenital or may be acquired by wearing shoes that are too short or narrow, which increases pressure on the bursa at the metatarsophalangeal joint. Acquired bunions can be prevented. Wearing shoes that are too big may cause other types of foot trauma but not bunions. Gout doesn't cause bunions. Although a client with gout may have pain in the big toe, such pain doesn't result from a bunion.

Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education?

"The client is receiving physical therapy twice per day, so he doesn't need a continuous passive motion device." Explanation: Further staff education is needed when the nurse states that the continuous passive motion device isn't needed because the client receives physical therapy twice per day. The continuous passive motion device should be used in conjunction with physical therapy because the device helps prevent adhesions. Bleeding is a complication associated with the continuous passive motion device; skin integrity should be monitored while the device is in use

A client suspected of having systemic lupus erythematosus (SLE) is being scheduled for testing. She asks which of the tests ordered will determine if she is positive for the disorder. Which statement by the nurse is most accurate?

"The diagnosis won't be based on the findings of a single test but by combining all data found." Explanation: There is no single test available to diagnose SLE. Therefore, the nurse should inform the client that diagnosis is based on combining the findings from the physical assessment and the laboratory tests results. Advising the client to speak with the physician, stating that SLE is a serious systemic disorder, and asking the client to express her feelings about the potential diagnosis don't answer the client's question.

The nurse is caring for a client admitted for pneumonia with a history of hypertension and heart failure. The client has reported at least one fall in the last 3 months. The client may ambulate with assistance, has a saline lock in place, and has demonstrated appropriate use of the call light to request assistance. Using the Morse Fall Scale (see chart), what is this client's total score and risk level?

60, high risk Explanation: Several factors designate this client as a high fall risk based on the Morse Fall Scale: history of falling (25), secondary diagnosis (15), plus IV access (20). The client's total score is 60. There is also concern that the client's gait is at least weak if not impaired due to hospitalization for pneumonia, which may add to the client's fall risk. After evaluating the client's risk, the nurse must develop a plan and take action to maximize the client's safety.

A nurse is caring for a client who had hip pinning surgery 6 hours ago to treat intertrochanteric fracture of the right hip. What assessment finding requires further investigation by the nurse?

Client is anxious and confused Explanation: The client is anxious and confused is the appropriate answer. Postoperative complications of hip fractures include hemorrhage, pulmonary emboli, and fat emboli. Anxiety and confusion may be indicative of hypoxia as a result of any of above these complications and needs further investigation. Capillary refill of 2-3 seconds is an expected finding, edema is present from both the injury and the surgical intervention. 100 milliliters of bright red drainage 6 hours after surgery should be watched, but is not of immediate concern.

Which goal is the priority for a client with a fractured femur who is in traction at this time?

Prevent effects of immobility while in traction. Explanation: The priority for this client is to prevent the effects of prolonged immobility, such as preventing skin breakdown and encouraging the client to take deep breaths, and use active range-of-motion exercises for the joints that are not immobilized. Although not the priority, the nurse also should seek ways to help the client adjust to and cope with the present state of immobility. Emphasis should be placed on what the client can do, such as participating in daily care and exercises to maintain muscle strength. Finding diversional activities is not a priority at this moment. Although the client must adapt to the inactivity, helping the client develop coping skills is the priority at this time.

A client is preparing for discharge from the emergency department after sustaining an ankle sprain. The client is instructed to avoid weight bearing on the affected leg and is given crutches. After instruction, the client demonstrates proper crutch use in the hallway. What additional information is most important to know before discharging the client?

Whether the client needs to navigate stairs routinely at home Explanation: Knowing whether the client must routinely navigate steps at home is most important. If the client must navigate steps, special crutch-walking techniques must be taught to safely navigate the stairs. Although pets, parking on the street, and driving a car with a stick shift can pose problems for the client, these factors aren't important to know before discharging the client with crutches.

To assess the joints, a nurse asks a client to perform various movements. As the client moves his arm away from the midline, the nurse evaluates his ability to perform:

abduction. Explanation: A client performs abduction when moving a body part away from the midline. Protraction refers to drawing out or lengthening of a body part. Retraction, the opposite of protraction, refers to drawing back or shortening of a body part. Adduction, the opposite of abduction, is movement of a body part toward the midline.

When the client who has had a hip replacement is lying on the side, the nurse should place pillows or an abductor splint between the legs to prevent:

adduction of the hip joint. Explanation: After hip replacement surgery, the client should be positioned on the nonoperative side with pillows or an abductor splint between the legs to help prevent adduction of the operative leg. This positioning places the hip in proper alignment. Dislocation of the hip can occur if the leg on the affected side is allowed to adduct.

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. 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

After surgery and insertion of a total hip prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse interprets these findings as indicating:

joint dislocation. Explanation: The joint has dislocated when the client with a total joint prosthesis develops severe sudden pain and an inability to move the extremity. Clinical manifestations of an infection would include inflammation, redness, erythema, and possibly drainage and separation of the wound. Bleeding could be external (e.g., blood visible from the wound or on the dressing) or internal and manifested by signs of shock (e.g., pallor, coolness, hypotension, tachycardia). The seepage of glue into soft tissue would have occurred in the operating room, when the glue is still in the liquid form. The glue dries into the hard, fixed form before the wound is closed.

Which findings best correlate with a diagnosis of osteoarthritis?

joint stiffness that decreases with activity Explanation: A characteristic feature of osteoarthritis (degenerative joint disease) is joint stiffness that decreases with activity and movement. Erythema and edema over the affected joint, anorexia, weight loss, and fever and malaise are associated with rheumatoid arthritis, a more severe and destructive form of arthritis

A client has the leg immobilized in a long leg cast. Which finding indicates the beginning of circulatory impairment?

tingling of toes Explanation: Tingling and numbness of the toes would be the earliest indication of circulatory impairment. Inability to move the toes and cyanosis are later indicators. Cast tightness should be investigated because cast tightness can lead to circulatory impairment; it is not, however, an indicator of impairment.