Chap 43 Assessment of Digestive, GI & Metabolic Func
Amputation of an extremity affects the patient's ability to provide adequate self-care. The patient is encouraged to be an active participant in self-care. The patient and the nurse need to maintain positive attitudes and to minimize fatigue and frustration during the learning process. Balanced nutrition and the patient's learning style are important variables in the rehabilitation process but the patient's attitude is among the most salient variables. The patient's presurgical level of function may or may not affect participation in rehabilitation. 35. The nurse is providing care for a patient who has had a below-the-knee amputation. The nurse enters the patient's room and finds him resting in bed with his residual limb supported on pillow. What is the nurse's most appropriate action? A) Inform the surgeon of this finding. B) Explain the risks of flexion contracture to the patient. C) Transfer the patient to a sitting position. D) Encourage the patient to perform active ROM exercises with the residual limb.
B
If a dislocation or subluxation is not reduced immediately, avascular necrosis (AVN) may develop. Bone remodeling does not take place because a fracture has not occurred. Realignment does not become more difficult with time and pain would subside with time, not become worse. 23. The surgical nurse is admitting a patient from postanesthetic recovery following the patient's below-the-knee amputation. The nurse recognizes the patient's high risk for postoperative hemorrhage and should keep which of the following at the bedside? A) A tourniquet B) A syringe preloaded with vitamin K C) A unit of packed red blood cells, placed on ice D) A dose of protamine sulfate
A
Older adults are generally vulnerable to falls and have a high incidence of hip fracture. Weak quadriceps muscles, medication effects, vision loss, and slowed reflexes are among the factors that contribute to the incidence of falls. Decreased hearing is not noted to contribute to the incidence of falls. 40. A patient was fitted with an arm cast after fracturing her humerus. Twelve hours after the application of the cast, the patient tells the nurse that her arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action? A) Prepare the patient for opening or bivalving of the cast. B) Obtain an order for a different analgesic. C) Encourage the patient to wiggle and move the fingers. D) Petal the edges of the patient's cast.
A
Open fractures are graded according to the following criteria. Grade I is a clean wound less than 1 cm long. Grade II is a larger wound without extensive soft-tissue damage. Grade III is highly contaminated, has extensive soft-tissue damage, and is the most severe. There is no grade IV fracture. 27. A 25-year-old man is involved in a motorcycle accident and injures his arm. The physician diagnoses the man with an intra-articular fracture and splints the injury. The nurse implements the teaching plan developed for this patient. What sequela of intra-articular fractures should the nurse describe regarding this patient? A) Post-traumatic arthritis B) Fat embolism syndrome (FES) C) Osteomyelitis D) Compartment syndrome
A
Opioid analgesics may be effective in relieving phantom pain. Heat, immobility, and elevation are not noted to relieve this form of pain. 11. 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? A) Encouraging the patient to turn from side to side and to assume a prone position B) Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation C) Minimizing movement of the flexor muscles of the hip D) Encouraging the patient to sit in a chair for at least 8 hours a day
A
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. 8. The patient scheduled for a Syme amputation is concerned about the ability to eventually stand on the amputated extremity. How should the nurse best respond to the patient's concern? A) You will eventually be able to withstand full weight-bearing after the amputation. B) You will have minimal weight-bearing on this extremity but you'll be taught how to use an assistive device. C) You likely will not be able to use this extremity but you will receive teaching on use of a wheelchair. D) You will be fitted for a prosthesis which may or may not allow you to walk.
A
The most serious complication of a supracondylar fracture of the humerus is Volkmann's ischemic contracture, which results from antecubital swelling or damage to the brachial artery. This complication is specific to humeral fractures. 14. An emergency department nurse is assessing a 17-year-old soccer player who presented with a knee injury. The patient's description of the injury indicates that his knee was struck medially while his foot was on the ground. The nurse knows that the patient likely has experienced what injury? A) Lateral collateral ligament injury B) Medial collateral ligament injury C) Anterior cruciate ligament injury D) Posterior cruciate ligament injury
A
The multidisciplinary rehabilitation team helps the patient achieve the highest possible level of function and participation in life activities. The team is not primarily motivated by efficiency, the need for holistic care, or the need to foster the patient's body image, despite the fact that each of these are valid goals. 34. A rehabilitation nurse is working with a patient who has had a below-the-knee amputation. The nurse knows the importance of the patient's active participation in self-care. In order to determine the patient's ability to be an active participant in self-care, the nurse should prioritize assessment of what variable? A) The patient's attitude B) The patient's learning style C) The patient's nutritional status D) The patient's presurgical level of function
A
The residual limb should not be placed on a pillow, because a flexion contracture of the hip may result. There is no acute need to contact the patient's surgeon. Encouraging exercise or transferring the patient does not address the risk of flexion contracture. 36. 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? A) Apply a tourniquet. B) Elevate the residual limb. C) Apply sterile gauze. D) Call the surgeon.
A
Treatment of a sprain consists of resting and elevating the affected part, applying cold, and using a compression bandage. After the acute inflammatory stage (usually 24 to 48 hours after injury), heat may be applied intermittently. Rotation exercises would likely be painful. 5. A nurse is writing a care plan for a patient admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a patient with an open fracture of the radius? A) Risk for Infection B) Risk for Ineffective Role Performance C) Risk for Perioperative Positioning Injury D) Risk for Powerlessness
A
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. 38. A patient who has undergone a lower limb amputation is preparing to be discharged home. What outcome is necessary prior to discharge? A) Patient can demonstrate safe use of assistive devices. B) Patient has a healed, nontender, nonadherent scar. C) Patient can perform activities of daily living independently. D) Patientis free of pain.
A
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. 39. An older adult patient experienced a fall and required treatment for a fractured hip on the orthopedic unit. Which of the following are contributory factors to the incidence of falls and fractured hips among the older adult population? Select all that apply. A) Loss of visual acuity B) Adverse medication effects C) Slowed reflexes D) Hearing loss E) Muscle weakness
A, B, C, E
Placing a pillow between the patient's legs when turning prevents adduction and supports the patient's legs. Administering analgesics addresses pain but does not directly protect bone remodeling and promote healing. Rotation of the affected leg can cause dislocation and must be avoided. Prone positioning does not need to be maintained at all times. 20. A nurse is planning the care of an older adult patient who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures, the nurse should encourage which of the following? Select all that apply. A) Regular bone density testing B) A high-calcium diet C) Use of falls prevention precautions D) Use of corticosteroids as ordered E) Weight-bearing exercise
A, B, C, E
1. 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? A) Compression B) Compound C) Impacted D) Transverse
B
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. 2. 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? A) Administer vitamin D and calcium supplements as ordered. B) Monitor temperature and pulses of the affected extremity. C) Perform passive range of motion exercises as tolerated. D) Administer corticosteroids as ordered.
B
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. 13. The orthopedic nurse should assess for signs and symptoms of Volkmann's contracture if a patient has fractured which of the following bones? A) Femur B) Humerus C) Radial head D) Clavicle
B
Deep vein thrombosis (DVT) is among the most common complications related to a hip fracture. To prevent DVT, the nurse encourages intake of fluids and ankle and foot exercises. The patient should not be told to endure pain; a proactive approach to pain control should be adopted. While respiratory complications commonly include atelectasis and pneumonia, the use of deep-breathing exercises, changes in position at least every 2 hours, and the use of incentive spirometry help prevent the respiratory complications more than using supplementary oxygen. Bed rest may be indicated in the short term, but is not normally required for 14 days. 7. A nurse is caring for a patient who has suffered an unstable thoracolumbar fracture. Which of the following is the priority during nursing care? A) Preventing infection B) Maintaining spinal alignment C) Maximizing function D) Preventing increased intracranial pressure
B
Immediate postoperative bleeding may develop slowly or may take the form of massive hemorrhage resulting from a loosened suture. A large tourniquet should be in plain sight at the patient's bedside so that, if severe bleeding occurs, it can be applied to the residual limb to control the hemorrhage. PRBCs cannot be kept at the bedside. Vitamin K and protamine sulfate are antidotes to warfarin and heparin, but are not administered to treat active postsurgical bleeding. 24. An elite high school football player has been diagnosed with a shoulder dislocation. The patient has been treated and is eager to resume his role on his team, stating that he is not experiencing pain. What should the nurse emphasize during health education? A) The need to take analgesia regardless of the short-term absence of pain B) The importance of adhering to the prescribed treatment and rehabilitation regimen C) The fact that he has a permanently increased risk of future shoulder dislocations D) The importance of monitoring for intracapsular bleeding once he resumes playing
B
Inadequate fracture immobilization can delay or prevent union. A short-term vitamin D deficiency would not likely prevent bone union. VTE is a serious complication but would not be a cause of nonunion. Similarly, bleeding would not likely delay union. 31. 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? A) Osteomyelitis B) Avascular necrosis C) Phantom pain D) Septicemia
B
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. 19. Which of the following is the most appropriate nursing intervention to facilitate healing in a patient who has suffered a hip fracture? A) Administer analgesics as required. B) Place a pillow between the patient's legs when turning. C) Maintain prone positioning at all times. D) Encourage internal and external rotation of the affected leg.
B
Syme amputation (modified ankle disarticulation amputation) is performed most frequently for extensive foot trauma and produces a painless, durable extremity end that can withstand full weight-bearing. Therefore, each of the other teaching statements is incorrect. 9. A patient with a simple arm fracture is receiving discharge education from the nurse. What would the nurse instruct the patient to do? A) Elevate the affected extremity to shoulder level when at rest. B) Engage in exercises that strengthen the unaffected muscles. C) Apply topical anesthetics to accessible skin surfaces as needed. D) Avoid using analgesics so that further damage is not masked.
B
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. 3. A nurse's assessment of a patient's knee reveals edema, tenderness, muscle spasms, and ecchymosis. The patient states that 2 days ago he ran 10 miles and now it really hurts to stand up. The nurse should plan care based on the belief that the patient has experienced what? A) A first-degree strain B) A second-degree strain C) A first-degree sprain D) A second-degree sprain
B
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. 37. 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. A) Massage B) Applying ice C) Compression dressings D) Resting the affected extremity E) Corticosteroids F) Elevating the injured limb
B, C, D, F
An x-ray should be obtained to rule out bone injury, because an avulsion fracture (in which a bone fragment is pulled away from the bone by a tendon) may be associated with a third-degree strain. Nerve damage, compartment syndrome, and greenstick fractures are not associated with third-degree strains. 26. A 20 year-old is brought in by ambulance to the emergency department after being involved in a motorcycle accident. The patient has an open fracture of his tibia. The wound is highly contaminated and there is extensive soft-tissue damage. How would this patient's fracture likely be graded? A) Grade I B) Grade II C) Grade III D) Grade IV
C
Early complications include shock, fat embolism, compartment syndrome, and venous thromboemboli (deep vein thrombosis [DVT], pulmonary embolism [PE]). Infection and CRPS are later complications of fractures. 30. A patient has come to the orthopedic clinic for a follow-up appointment 6 weeks after fracturing his ankle. Diagnostic imaging reveals that bone union is not taking place. What factor may have contributed to this complication? A) Inadequate vitamin D intake B) Bleeding at the injury site C) Inadequate immobilization D) Venous thromboembolism (VTE)
C
Fat embolism syndrome occurs most frequently in young adults and elderly patients who experience fractures of the proximal femur (i.e., hip fracture). Presenting features of fat embolism syndrome include hypoxia, tachypnea, tachycardia, and pyrexia. The respiratory distress response includes tachypnea, dyspnea, wheezes, precordial chest pain, cough, large amounts of thick, white sputum, and tachycardia. Avascular necrosis (AVN) occurs when the bone loses its blood supply and dies. This does not cause coughing. Complex regional pain syndrome does not have cardiopulmonary involvement. 18. 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? A) Electrolyte assessment B) Electrocardiogram C) Arterial blood gases D) Abdominal ultrasound
C
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. 32. A patient is being treated for a fractured hip and the nurse is aware of the need to implement interventions to prevent muscle wasting and other complications of immobility. What intervention best addresses the patient's need for exercise? A) Performing gentle leg lifts with both legs B) Performing massage to stimulate circulation C) Encouraging frequent use of the overbed trapeze D) Encouraging the patient to log roll side to side once per hour
C
Greenstick fractures are an incomplete fracture that results in the bone being broken on one side, while the other side is bent. This is not characteristic of an impacted, compound, or compression fracture. 17. A nurse is performing a shift assessment on an elderly patient who is recovering after surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the patient is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this patient is likely demonstrating symptoms of what complication? A) Avascular necrosis of bone B) Compartment syndrome C) Fat embolism syndrome D) Complex regional pain syndrome
C
Intra-articular fractures often lead to post-traumatic arthritis. Research does not indicate a correlation between intra-articular fractures and FES, osteomyelitis, or compartment syndrome. 28. A nurse is planning the care of a patient with osteomyelitis that resulted from a diabetic foot ulcer. The patient requires a transmetatarsal amputation. When planning the patient's postoperative care, which of the following nursing diagnoses should the nurse most likely include in the plan of care? A) Ineffective Thermoregulation B) Risk-Prone Health Behavior C) Disturbed Body Image D) Deficient Diversion Activity
C
Patients who have experienced sports-related injuries are often highly motivated to return to their previous level of activity. Adherence to restriction of activities and gradual resumption of activities needs to be reinforced. Appropriate analgesia use must be encouraged, but analgesia does not necessarily have to be taken in the absence of pain. If healing is complete, the patient does not likely have a greatly increased risk of reinjury. Dislocations rarely cause bleeding after the healing process. 25. A patient has presented to the emergency department with an injury to the wrist. The patient is diagnosed with a third-degree strain. Why would the physician order an x-ray of the wrist? A) Nerve damage is associated with third-degree strains. B) Compartment syndrome is associated with third-degree strains. C) Avulsion fractures are associated with third-degree strains. D) Greenstick fractures are associated with third-degree strains.
C
Amputations present a serious threat to any patient's body image. None of the other listed diagnoses is specifically associated with amputation. 29. A patient is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The patient has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this patient? Select all that apply. A) Systemic infection B) Complex regional pain syndrome C) Deep vein thrombosis D) Compartment syndrome E) Fat embolism
C, D, E
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. 10. Six weeks after an above-the-knee amputation (AKA), a patient returns to the outpatient office for a routine postoperative checkup. During the nurse's assessment, the patient reports symptoms of phantom pain. What should the nurse tell the patient to do to reduce the discomfort of the phantom pain? A) Apply intermittent hot compresses to the area of the amputation. B) Avoid activity until the pain subsides. C) Take opioid analgesics as ordered. D) Elevate the level of the amputation site.
C
The patient has a significant risk for osteomyelitis and tetanus due to the fact that the fracture is open. Powerlessness and ineffective role performance are psychosocial diagnoses that may or may not apply, and which would be superseded by immediate physiologic threats such as infection. Surgical positioning injury is not plausible, since surgery is not likely indicated. 6. A nurse is caring for a patient who has suffered a hip fracture and who will require an extended hospital stay. The nurse should ensure that the patient does which of the following in order to prevent common complications associated with a hip fracture? A) Avoid requesting analgesia unless pain becomes unbearable. B) Use supplementary oxygen when transferring or mobilizing. C) Increase fluid intake and perform prescribed foot exercises. D) Remain on bed rest for 14 days or until instructed by the orthopedic surgeon.
C
When the knee is struck medially, damage may occur to the lateral collateral ligament. If the knee is struck laterally, damage may occur to the medial collateral ligament. The ACL and PCL are not typically injured in this way. 15. A school nurse is assessing a student who was kicked in the shin during a soccer game. The area of the injury has become swollen and discolored. The triage nurse recognizes that the patient has likely sustained what? A) Sprain B) Strain C) Contusion D) Dislocation
C
A contusion is a soft-tissue injury that results in bleeding into soft tissues, creating a hematoma and ecchymosis. A sprain is an injury to ligaments caused by wrenching or twisting. A strain is a muscle pull from overuse, overstretching, or excessive stress. A dislocation is a condition in which the articular surfaces of the bones forming a joint are no longer in anatomic contact. Because the injury is not at the site of a joint, the patient has not experienced a sprain, strain, or dislocation. 16. Radiographs of a boy's upper arm show that the humerus appears to be fractured on one side and slightly bent on the other. This diagnostic result suggests what type of fracture? A) Impacted B) Compound C) Compression D) Greenstick
D
A second-degree strain involves tearing of muscle fibers and is manifested by notable loss of load-bearing strength with accompanying edema, tenderness, muscle spasm, and ecchymosis. A first-degree strain reflects tearing of a few muscle fibers and is accompanied by minor edema, tenderness, and mild muscle spasm, without noticeable loss of function. However, this patient states a loss of function. A sprain normally involves twisting, which is inconsistent with the patient's overuse injury. 4. A nurse is preparing to discharge a patient from the emergency department after receiving treatment for an ankle sprain. While providing discharge education, the nurse should encourage which of the following? A) Apply heat for the first 24 to 48 hours after the injury. B) Maintain the ankle in a dependent position. C) Exercise hourly by performing rotation exercises of the ankle. D) Keep an elastic compression bandage on the ankle.
D
Health promotion measures after an older adult's hip fracture include weight-bearing exercise, promotion of a healthy diet, falls prevention, and bone density testing. Corticosteroids have the potential to reduce bone density and increase the risk for fractures. 21. A patient is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing him the nurse notes that his right leg is shorter than his left leg; his right hip is noticeably deformed and he is in acute pain. Imaging does not reveal a fracture. Which of the following is the most plausible explanation for this patient's signs and symptoms? A) Subluxated right hip B) Right hip contusion C) Hip strain D) Traumatic hip dislocation
D
Signs and symptoms of a traumatic dislocation include acute pain, change in positioning of the joint, shortening of the extremity, deformity, and decreased mobility. A subluxation would cause moderate deformity, or possibly no deformity. A contusion or strain would not cause obvious deformities. 22. An emergency department patient is diagnosed with a hip dislocation. The patient's family is relieved that the patient has not suffered a hip fracture, but the nurse explains that this is still considered to be a medical emergency. What is the rationale for the nurse's statement? A) The longer the joint is displaced, the more difficult it is to get it back in place. B) The patient's pain will increase until the joint is realigned. C) Dislocation can become permanent if the process of bone remodeling begins. D) Avascular necrosis may develop at the site of the dislocation if it is not promptly resolved.
D
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. 12. 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? A) Elevate the arm above the shoulder 3 to 4 times daily. B) Avoid moving the elbow, wrist, and fingers until bone remodeling is complete. C) Engage in active range of motion using the affected arm. D) Use the arm for light activities within the range of motion.
D
The patient is encouraged to exercise as much as possible by means of the overbed trapeze. This device helps strengthen the arms and shoulders in preparation for protected ambulation. Independent logrolling may result in injury due to the location of the fracture. Leg lifts would be contraindicated for the same reason. Massage by the nurse is not a substitute for exercise. 33. A patient who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team? A) Maximize the efficiency of care B) Ensure that the patient's health care is holistic C) Facilitate the patient's adjustment to a new body image D) Promote the patient's highest possible level of function
D
