Lewis- Ch 63: Musculoskeletal Questions

10. The x-ray shows that the patient's fracture is at the remodeling stage. What characteristics of the fracture healing process are happening at this stage (select all that apply)? a. Radiologic union b. Absorption of excess cells c. Return to preinjury strength and shape d. Semisolid blood clot at the ends of fragments e. Deposition and absorption of bone in response to stress f. Unorganized network of bone woven around fracture parts

10. a, b, c, e. When the remodeling stage of healing occurs, radiologic union is present. Excess callus is reabsorbed, trabecular bone is laid, and the bone returns to its preinjury structure strength and shape. The osteoblasts and osteoclasts function normally in response to stress. The fracture hematoma stage is when the hematoma at the ends of the fragments becomes a semisolid blood clot. There is an unorganized network of bone composed of cartilage, osteoblasts, calcium, and phosphorus woven around fracture parts in the callus formation stage.

11. A patient is brought to the emergency department with an injured lower left leg following a fall while rock climbing. The nurse identifies the presence of a fracture based on what cardinal sign of fracture? a. Muscle spasms b. Obvious deformity c. Edema and swelling d. Pain and tenderness

11. b. Deformity is the cardinal sign of fracture but may not be apparent in all fractures. Other supporting signs include edema and swelling, localized pain and tenderness, muscle spasm, ecchymosis, loss of function, crepitation, and an inability to bear weight.

12. A patient with a fractured femur experiences the complication of malunion. The nurse recognizes that what happens with this complication? a. The fracture heals in an unsatisfactory position. b. The fracture fails to heal properly despite treatment. c. Fracture healing progresses more slowly than expected. d. Loss of bone substances occurs as a result of immobilization.

12. a. A malunion occurs when the bone heals in the expected time but in an unsatisfactory position, possibly resulting in deformity or dysfunction. Nonunion occurs when the fracture fails to heal properly despite treatment and delayed union is healing of the fracture at a slower rate than expected. In posttraumatic osteoporosis, the loss of bone substances occurs as a result of immobilization.

13. What is a disadvantage of open reduction and internal fixation of a fracture compared to closed reduction? a. Infection b. Skin irritation c. Nerve impairment d. Complications of immobility

13. a. Open reduction uses a surgical incision to correct bone alignment but infection is the main disadvantage, as well as anesthesia complications or the effect of preexisting medical conditions. Skin irritation and nerve impairment is most likely with skin traction. Prolonged immobility is possible with skeletal traction.

14. A young patient with a fractured femur has a hip spica cast applied. While the cast is drying, what should the nurse do? a. Elevate the legs above the level of the heart for 24 hours. b. Turn the patient to both sides and prone to supine every 2 hours. c. Cover the cast with a light blanket to avoid chilling from evaporation. d. Assess the patient frequently for abdominal pain, nausea, and vomiting.

14. d. Complaints of abdominal pain or pressure, nausea, and vomiting are signs of cast syndrome that occur when hip spica casts or body jacket braces are applied too tightly, causing compression of the superior mesenteric artery against the duodenum. The cast may need to be split or removed and the health care provider should be notified. Elevation is not indicated for a spica cast and the patient with a spica cast should not be placed in the prone position during the initial drying stage because the cast is so large and heavy it may break. A cast should never be covered with a blanket because heat builds up in the cast and may increase edema.

15. A patient is admitted with an open fracture of the tibia following a bicycle accident. During assessment of the patient, what specifically should the nurse question the patient about? a. Any previous injuries to the leg b. The status of tetanus immunization c. The use of antibiotics in the last month d. Whether the injury was exposed to dirt or gravel

15. b. Infection is the greatest risk with an open fracture and all open fractures are considered contaminated. Tetanus prevention is always indicated if the patient has not been immunized or does not have current boosters. Prophylactic antibiotics are often used in management of open fractures but recent antibiotic therapy is not relevant, nor is previous injury to the site.

Priority Decision: A patient has fallen in the bathroom of the hospital room and reports pain in the upper right arm and elbow. Before splinting the injury, the nurse knows that the priority management of a possible fracture should include which action? a. Elevation of the arm b. Application of ice to the site c. Notification of the health care provider d. Neurovascular checks below the site of the injur

16. d. Pulses, sensation, and motor function distal to the injury should be checked before and after splinting to assess for nerve or vascular damage and documented to avoid doubts about whether a problem discovered later was missed during the original examination or was caused by the treatment. Elevation of the limb and application of ice should be instituted after the extremity is splinted.

17. To assess for neurologic status in a patient with a fractured humerus, what should the nurse ask the patient to do? a. Evert, invert, dorsiflex, and plantar flex the foot. b. Abduct, adduct, and oppose the fingers and pronate and supinate the hand. c. Assess the location, quality, and intensity of pain below the site of the injury. d. Assess the color, temperature, capillary refill, peripheral pulses, and presence of edema in the extremity.

17. b. Neurologic assessment includes evaluation of motor and sensory function and, in the upper extremity, includes abduction and adduction of the fingers, opposition of the fingers, and supination and pronation of the hands. It also includes sensory perception in the fingers. Evaluation of the feet would occur in lower extremity injuries. Assessment of color, temperature, capillary refill, peripheral pulses, and edema evaluates vascular status.

18. A patient is discharged from the outpatient clinic following application of a synthetic fiberglass long arm cast for a fractured ulna. Before discharge, the nurse instructs the patient to do what? a. Never get the cast wet. b. Move the shoulder and fingers frequently. c. Place tape petals around the edges of the cast when it is dry. d. Use a sling to support the arm at waist level for the first 48 hours.

18. b. A patient with any type of cast should exercise the joints above and below the cast frequently and moving the fingers frequently will improve circulation and help to prevent edema. Unlike plaster casts, thermoplastic resin or fiberglass casts are relatively waterproof and, if they become wet, can be dried with a hair dryer on low setting. Tape petals are used on plaster casts to protect the edges from breaking and crumbling but are not necessary for synthetic casts. After the cast is applied, the extremity should be elevated at about the level of the heart to promote venous return and ice may be used to prevent edema.

19. A patient with a fractured tibia accompanied by extensive soft tissue damage initially has a splint applied and held in place with an elastic bandage. What early sign should alert the nurse that the patient is developing compartment syndrome? a. Paralysis of the toes b. Absence of peripheral pulses c. Distal pain unrelieved by opioid analgesics d. Skin over the injury site is blanched when the bandage is removed

19. c. Pain that is distal to the injury and is unrelieved by opioid analgesics is the earliest sign of compartment syndrome. Paralysis and absence of peripheral pulses will eventually occur if it is not treated but these are late signs that often appear after permanent damage has occurred. The overlying skin may appear normal because the surface vessels are not occluded.

2. The nurse teaches individuals that one of the best ways to prevent musculoskeletal injuries during physical exercise is by doing what? a. Increase muscle strength with daily isometric exercise. b. Avoid exercising on concrete or hard pavement surfaces. c. Perform stretching and warm-up exercises before exercise. d. Wrap susceptible joints with elastic bandages or adhesive tape before exercise.

2. c. Warm-up exercises "prelengthen" potentially strained tissues by avoiding the quick stretch often encountered in sports and also increase the temperature of muscle, resulting in increased speed of cell metabolism, increased speed of nerve impulses, and improved oxygenation of muscle fibers. Stretching is also thought to improve kinesthetic awareness, lessening the chance of uncoordinated movement. Muscle strength is not a key factor in soft tissue injuries and taping or wrapping joints may actually predispose a person to injury by weakening the joint, unless a previous injury is being treated.

20. What surgical treatment will the nurse prepare the patient for in the presence of compartment syndrome? a. Fasciotomy b. Amputation c. Internal fixation d. Release of tendons

20. a. Soft tissue edema in the area of the injury may cause an increase of pressure within the closed spaces of the tissue compartments formed by the nonelastic fascia, creating compartment syndrome. If symptoms occur, it may be necessary to incise the fascia surgically, a procedure known as a fasciotomy. Amputation is usually necessary only if the limb becomes septic because of untreated compartment syndrome.

21. Which type of fracture occurred when there is radial nerve and brachial artery damage and the fracture is reduced with a hanging arm cast? a. Fractured tibia b. Colles' fracture c. Fractured humerus d. Femoral shaft fracture

21. c. The fractured humerus may cause radial nerve and brachial artery damage and it may be reduced nonsurgically with a hanging arm cast. A fractured tibia and femoral shaft are in the leg. The Colles' fracture is in the wrist and manifests with pronounced swelling and obvious deformity of the wrist; it is treated with closed manipulation and immobilization.

22. The woman with osteoporosis slipped on the ice and now her wrist hurts. If there is a fracture, what type of fracture is expected? a. Dislocation b. Open fracture c. Colles' fracture d. Incomplete fracture

22. c. A Colles' fracture most often occurs in patients over 50 years of age with osteoporosis and frequently when the patient attempts to break a fall with an outstretched arm and hand. Dislocation is the complete separation of articular surfaces of the joint caused by a ligament injury. Open fracture is when there is communication with the external environment. A fracture is incomplete if only part of the bone shaft is fractured and the bone is still in one piece.

24. In a patient with a stable vertebral fracture, what should the nurse teach the patient to do? a. Remain on bed rest until the pain is gone. b. Logroll to keep the spine straight when turning. c. How to use bone cement to correct the problem. d. Take as much analgesic as needed to relieve the pain.

24. b. The spine should be kept straight by turning the shoulders and hips together (logrolling). This keeps the spine in good alignment until union has been accomplished. Bed rest may be required for a short time but not until the pain is gone. Analgesics should be taken only as ordered. If they do not relieve the pain, the health care provider should be notified. Bone cement is used by the surgeon to stabilize vertebral compression fractures.

When is a fat embolism most likely to occur? a. 24 to 48 hours following a fractured tibia b. 36 to 72 hours following a skull fracture c. 4 to 5 days following a fractured femur d. 5 to 6 days following a pelvic fracture

25. a. Initial manifestations of fat embolism usually occur 24 to 48 hours after injury and are associated with fractures of long bones and multiple fractures related to pelvic injuries, including fractures of the femur, tibia, ribs, and pelvis.

26. The nurse suspects a fat embolism rather than a pulmonary embolism from a venous thrombosis when the patient with a fracture develops what? a. Tachycardia and dyspnea b. A sudden onset of chest pain c. Petechiae around the neck and upper chest d. Electrocardiographic (ECG) changes and decreased PaO2

26. c. Patients with fractures are at risk for both fat embolism and pulmonary embolism from venous thromboembolism but there is a difference in the time of occurrence, with fat embolism occurring shortly after the injury and thrombotic embolism occurring several days after immobilization. They both may cause pulmonary symptoms of chest pain, tachypnea, dyspnea, apprehension, tachycardia, and cyanosis. However, fat embolism may cause petechiae located around the neck, anterior chest wall, axilla, buccal membrane of the mouth, and conjunctiva of the eye, which differentiates it from thrombotic embolism.

27. Which kind of hip fracture is usually repaired with a hip prosthesis? a. Intracapsular b. Extracapsular c. Subtrochanteric d. Intertrochanteric

27. a. A hip prosthesis is usually used for intracapsular fractures. The other options are all extracapsular fractures.

28. An older adult woman is admitted to the emergency department after falling at home. The nurse cautions her not to put weight on the leg after finding what in the patient assessment? a. Inability to move the toes and ankle b. Edema of the thigh extending to the knee c. Internal rotation of the leg with groin pain d. Shortening and external rotation of the leg

28. d. The classic signs of a hip fracture are shortening of the leg and external rotation accompanied by severe pain at the fracture site and additional injury could be caused by weight bearing on the extremity. The patient may not be able to move the hip or the knee but movement in the ankle and toes is not affected.

29. A patient with an extracapsular hip fracture is admitted to the orthopedic unit and placed in Buck's traction. The nurse explains to the patient that the purpose of the traction is to do what? a. Pull bone fragments back into alignment b. Immobilize the leg until healing is complete c. Reduce pain and muscle spasms before surgery d. Prevent damage to the blood vessels at the fracture site

29. c. Although surgical repair is the preferred method of managing intracapsular and extracapsular hip fractures, initially patients frequently may be treated with skin traction, such as Buck's traction or Russell's traction, to immobilize the limb temporarily and to relieve the painful muscle spasms before surgery is performed. Prolonged traction would be required to reduce the fracture or immobilize it for healing, creating a very high risk for complications of immobility.

3. The patient asks, "What does the doctor mean when he says that I have an avulsion fracture in my leg? I thought I had a sprain!" What is the best response by the nurse? a. "It is a fracture with more than two fragments." b. "It means that a ligament pulled a bone fragment loose." c. "The line of the fracture is twisted along the shaft of the bone." d. "The line of the fracture is at right angles to the longitudinal axis of the bone."

3. b. An avulsion fracture occurs when a ligament pulls a bone fragment loose, with pain similar to a sprain. A fracture with two or more fragments is a comminuted fracture. It is a spiral fracture when it is twisted around a bone shaft. It is a transverse fracture when the line of fracture is at right angles to the longitudinal axis.

30. A patient with a fractured right hip has an anterior open reduction and internal fixation of the fracture. What should the nurse plan to do postoperatively? a. Get the patient up to the chair on the first postoperative day. b. Position the patient only on the back and the unoperative side. c. Keep the leg abductor pillow on the patient even when bathing. d. Ambulate the patient with partial weight bearing by discharge.

30. a. Because the fracture site is internally fixed with pins or plates, the fracture site is stable and the patient is moved from the bed to the chair on the first postoperative day. Ambulation begins on the first or second postoperative day without weight bearing on the affected leg. Weight bearing on the affected extremity is usually restricted for 6 to 12 weeks until adequate healing is evident on x-ray. The patient may be positioned on the operative side following internal fixation and abductor pillows are used for patients who have total hip replacements.

31. What should the nurse include in discharge instructions for the patient following a hip prosthesis with a posterior approach? a. Restrict walking for 2 to 3 months. b. Take a bath rather than a shower to prevent falling. c. Keep the leg internally rotated while sitting and standing. d. Have a family member put on the patient's shoes and socks.

31. d. Patients with hip prostheses with a posterior approach must avoid extreme flexion, adduction, or internal rotation for at least 6 weeks to prevent dislocation of the prosthesis. Gradual weight bearing on the limb is allowed and ambulation should be encouraged. The leg should be not be externally rotated.

32. When preparing a patient for discharge following fixation of a mandibular fracture, the nurse determines that teaching has been successful when the patient says what? a. "I can keep my mouth moist by sucking on hard candy." b. "I should cut the wires with scissors if I begin to vomit." c. "I may use a bulk-forming laxative if my liquid diet causes constipation." d. "I should use a moist swab to clean my mouth every time I eat something."

32. c. The low-bulk, high-carbohydrate liquid diet and intake of air through a straw required during mandibular fixation often lead to constipation and flatus, which may be relieved with bulk-forming laxatives, prune juice, or ambulation. Wires or rubber bands should be cut only in the case of cardiac or respiratory arrest and patients should be taught to clear their mouth of vomitus or secretions. The mouth should be thoroughly cleaned with water, saline, or alkaline mouthwashes or using a Water Pik as necessary to remove food debris. Hard candy should not be held in the mouth.

33. Priority Decision: Twenty-four hours after a below-the-knee amputation, a patient uses the call system to tell the nurse that his dressing (a compression bandage) has fallen off. What is the first action that the nurse should take? a. Apply ice to the site. b. Cover the incision with dry gauze. c. Reapply the compression dressing. d. Elevate the extremity on a couple of pillows.

33. c. The compression dressing or bandage supports the soft tissues, reduces edema, hastens healing, minimizes pain, and promotes residual limb shrinkage. If the dressing is left off, edema will form quickly and may delay rehabilitation. Elevation and ice will not be as effective at preventing the edema that will form. Dressing the incision with dry gauze will not provide the benefits of a compression dressing.

A patient complains of pain in the foot of a leg that was recently amputated. What should the nurse recognize about this pain? a. It is caused by swelling at the incision. b. It should be treated with ordered analgesics. c. It will become worse with the use of a prosthesis. d. It can be managed with diversion because it is psychologic.

34. b. Phantom sensation or phantom pain may occur following amputation, especially if pain was present in the affected limb preoperatively. The pain is a real sensation to the patient and will first be treated with analgesics and other pain interventions (i.e., tricyclic antidepressants, antiseizure drugs, transcutaneous electrical nerve stimulation [TENS], mirror therapy, acupuncture). As recovery and ambulation progress, phantom limb sensation usually subsides.

35. Priority Decision: An immediate prosthetic fitting during surgery is used for a patient with a traumatic below-theknee amputation. During the immediate postoperative period, what is a priority nursing intervention? a. Monitor the patient's vital signs. b. Assess the incision for hemorrhage. c. Elevate the residual limb on pillows. d. Have the patient flex and extend the knee every hour.

35. a. Because the device covers the residual limb, the surgical site cannot be directly seen and postoperative hemorrhage is not apparent on dressings, requiring vigilant assessment of vital signs for signs of bleeding. Elevation of the residual limb with an immediate prosthetic fitting is not necessary because the device itself prevents edema formation. Exercises to the leg are not performed in the immediate postoperative period to avoid disruption of ligatures and the suture line.

36. Why does a nurse position a patient with an above-the-knee amputation with a delayed prosthetic fitting prone several times a day? a. To prevent flexion contractures b. To assess the posterior skin flap c. To reduce edema in the residual limb d. To relieve pressure on the incision site

36. a. Flexion contractures, especially of the hip, may be debilitating and delay rehabilitation of the patient with a leg amputation. To prevent hip flexion, the patient should avoid sitting in a chair with the hips flexed or having pillows under the surgical extremity for prolonged periods and the patient should lie on the abdomen for 30 minutes three to four times a day to extend the hip.

37. A patient who had a below-the-knee amputation is to be fitted with a temporary prosthesis. It is most important for the nurse to teach the patient to do what? a. Inspect the residual limb daily for irritation. b. Apply an elastic shrinker before applying the prosthesis. c. Perform range-of-motion (ROM) exercises to the affected leg four times a day. d. Apply alcohol to the residual limb every morning and evening to toughen the skin.

37. a. Skin breakdown on the residual limb can prevent the use of a prosthesis so the limb should be inspected every day for signs of irritation or pressure areas. No substances except water and mild soap should be used on the residual limb and range-of-motion (ROM) exercises are not necessary when the patient is using a prosthesis. A residual limb shrinker is an elastic stocking that is used to mold the limb in preparation for prosthesis use but a cotton residual limb sock is worn with the prosthesis.

38. Which joint surgery is used to arthroscopically remove degenerative tissue in joints? a. Osteotomy b. Arthrodesis c. Debridement d. Synovectomy

38. c. Debridement removes degenerative tissue from joints. Osteotomy corrects bone deformity by removal of a wedge or slice of bone. Arthrodesis surgically fuses a joint to relieve pain. Synovectomy removes tissue involved in joint destruction from rheumatoid arthritis (RA).

39. When the nursing student asks the RN what an arthroplasty is, what is the best description the RN can give the student? a. Surgical fusion of a joint to relieve pain b. Correction of bone deformity by removal of a wedge or slice of bone c. Reconstruction or replacement of a joint to relieve pain and correct deformity d. Used in rheumatoid arthritis to remove the tissue involved in joint destruction

39. c. An arthroplasty is reconstruction or replacement of a joint to relieve pain and correct deformity, especially with osteoarthritis, RA, avascular necrosis, congenital deformities, or dislocations. Arthrodesis is the surgical fusion of a joint to relieve pain. An osteotomy removes a wedge of bone to correct a bone deformity. Synovectomy is used in RA to remove the tissue involved in joint destruction.

4. The patient with osteoporosis had a spontaneous hip fracture. How should the nurse document this before the x-ray results return? a. Open fracture b. Oblique fracture c. Pathologic fracture d. Greenstick fracture

4. c. A pathologic fracture is a spontaneous fracture at the site of bone disease, such as osteoporosis. An open fracture is when there is communication with the external environment. The oblique fracture has a slanted fracture line. A greenstick fracture is splintered on one side and the other side is bent.

40. A 65-year-old patient has undergone a right total hip arthroplasty with a cemented prosthesis for treatment of severe osteoarthritis of the hip. What is included in the activity the nurse anticipates for the patient on the patient's first or second postoperative day? a. Transfer from the bed to the chair twice a day only b. Turning from the back to the unaffected side q2hr only c. Crutch walking with non-weight bearing on the operative leg d. Ambulation and weight bearing on the right leg with a walker

40. d. Physical therapy is initiated on the first postoperative day with ambulation and weight bearing using a walker for a patient with a cemented prosthesis and non-weight bearing on the operative side for an uncemented prosthesis. In addition, the patient sits in the chair at least twice a day and is turned to both sides and back with the operative leg supported.

41. When positioning the patient after a total hip arthroplasty with a posterior approach, it is important that the nurse maintain the affected extremity in what position? a. Adduction and flexion b. Abduction and extension c. Abduction and internal rotation d. Adduction and external rotation

41. b. Following a total hip arthroplasty with a posterior approach, during hospitalization an abduction pillow is placed between the legs to maintain abduction and the leg is extended. Extremes of internal rotation, adduction, and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively to prevent dislocation of the prosthesis.

42. Following a knee arthroplasty, a patient has a continuous passive motion machine for the affected joint. The nurse explains to the patient that this device is used for what purpose? a. To relieve edema and pain at the incision site b. To promote early joint mobility and increase knee flexion c. To prevent venous stasis and the formation of a deep venous thrombosis d. To improve arterial circulation to the affected extremity to promote healing

42. b. Continuous passive motion machines are frequently used following knee surgery to promote earlier joint mobility. Because joint dislocation is not a problem with knee replacements, early exercise with straight leg raises and gentle ROM is also encouraged postoperatively.

Priority Decision: A patient with severe ulnar deviation of the hands undergoes an arthroplasty with reconstruction and replacement of finger joints. Postoperatively, what is it most important for the nurse to do? a. Position the fingers lower than the elbow. b. Perform neurovascular assessments of the fingers q2-4hr. c. Encourage the patient to gently flex, extend, abduct, and adduct the fingers q4hr. d. Remind the patient that function of the hands is more important than their cosmetic appearance.

43. b. Neurovascular checks of the fingers following surgery of the hands are essential to detect compromised vascular and neurologic function caused by trauma or edema. Postoperatively, the hands are elevated with a bulky dressing in place and when the dressing is removed, a guided splinting program is started. Exercises are performed three to four times a day when the splints are removed and the patient is discharged. Before surgery, it must be made clear to the patient that the goal of the surgery is to restore function related to grasp, pinch, stability, and strength and the hands will not necessarily have good cosmetic appearance.

44. Priority Decision: Following change-of-shift handoff, which patient should the nurse assess first? a. A 58-year-old male experiencing phantom pain and requesting analgesic b. A 72-year-old male being transferred to a skilled nursing unit following repair of a hip fracture c. A 25-year-old female in left leg skeletal traction asking for the weights to be lifted for a few minutes d. A 68-year-old male with a new lower leg cast complaining that the cast is too tight and he cannot feel his toes

44. d. The patient with a tight cast may be at risk for neurovascular compromise (impaired circulation and peripheral nerve damage) and should be assessed first. The other patients should be seen as soon as possible. Providing analgesia for the patient with phantom pain would be the next priority. The patient in skeletal traction needs explanation of the purpose and functioning of the traction. She may need analgesia or muscle relaxants to help tolerate the traction.

The patient works on a computer 8 hours each day. What kind of repetitive strain injury would be expected in this patient? a. Meniscus injury b. Rotator cuff injury c. Radial-ulnar fracture d. Carpal tunnel syndrome

5. d. Carpal tunnel syndrome would be expected related to the continuous wrist movements. Injuries of the menisci, which are fibrocartilage in the knee, are common with athletes. Radial-ulnar fractures are seen with great force such as a car accident or a fall. Rotator cuff injuries occur with sudden adduction forces applied to the cuff while the arm is held in abduction. They are commonly seen with repetitive overhead motions.

6. The athlete comes to the clinic with bursitis. What does the nurse know happens to the tissue to cause pain when bursitis occurs? a. Tearing of a ligament b. Stretching of muscle and fascia sheath c. Inflammation of synovial membrane sac at friction sites d. Incomplete separation of articular surfaces of joint caused by ligament injury

6. c. Bursitis is inflammation of synovial membrane sac at friction sites. Tearing of a ligament is a sprain. Stretching of muscle and fascia sheath is a strain. Incomplete separation of articular surfaces of joints caused by ligament injury is subluxation.

7. Application of RICE (rest, ice, compression, and elevation) is indicated for initial management of which type of injury? a. Muscle spasms b. Sprains and strains c. Repetitive strain injury d. Dislocations and subluxations

7. b. Application of cold, compression, and elevation are indicated to prevent edema resulting from sprain and some strain injuries. Muscle spasms are usually treated with heat applications and massage and repetitive strain injuries require cessation of the precipitating activity and physical therapy. Dislocations or subluxations require immediate reduction and immobilization to prevent vascular impairment and bone cell death.

What should be included in the management during the first 48 hours after an acute soft tissue injury of the ankle (select all that apply)? a. Use of elastic wrap b. Initial immobilization and rest c. Elevation of ankle above the heart d. Alternating the use of heat and cold e. Administration of antiinflammatory drugs

8. a, b, c, e. Consider the principle of RICE. Rest: movement should be restricted. Ice: cold should be used to promote vasoconstriction and to reduce edema. C: compression helps to decrease swelling. E: elevate the extremity above the level of the heart. Mild nonsteroidal antiinflammatory drugs (NSAIDs) may be needed to manage pain. Warm, moist compresses may be used after 48 hours for 20 to 30 minutes at a time to reduce swelling and provide comfort.

9. The patient had a fracture. At 3 weeks to 6 months there is clinical union, and this is the first stage of healing that is sufficient to prevent movement of the fracture site when the bones are gently stressed. How is this stage of fracture healing documented? a. Ossification b. Remodeling c. Consolidation d. Callus formation

9. a. Ossification is the stage of fracture healing when there is clinical union and enough strength to prevent movement at the fracture site. Remodeling is the normal function of the bone. Consolidation is when the distance between bone fragments eventually closes and radiologic union first occurs. The callus formation stage appears by the end of the second week of injury when minerals and new bone matrix are deposited in the osteoid that is produced in the granulation tissue stage.

15. A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which information will the nurse teach? a. "You will need to check and clean the pin insertion sites daily." b. "The external fixator can be removed for your bath or shower." c. "You will need to remain on bed rest until bone healing is complete." d. "Prophylactic antibiotics are used until the external fixator is removed."

ANS: A Pin insertion sites should be cleaned daily to decrease the risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given when an external fixator is used.

3. The occupational health nurse will teach the patient whose job involves many hours of typing about the need to a. obtain a keyboard pad to support the wrist. b. do stretching exercises before starting work. c. wrap the wrists with compression bandages every morning. d. avoid using nonsteroidal antiinflammatory drugs (NSAIDs) for pain.

ANS: A Repetitive strain injuries caused by prolonged times working at a keyboard can be prevented by the use of a pad that will keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to use to decrease swelling.

30. Which nursing action for a patient who has had right hip replacement surgery can the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Reposition the patient every 1 to 2 hours. b. Assess for skin irritation on the patient's back. c. Teach the patient quadriceps-setting exercises. d. Determine the patient's pain level and tolerance.

ANS: A Repositioning of orthopedic patients is within the scope of practice of UAP (after they have been trained and evaluated in this skill). The other actions should be done by licensed nursing staff members.

12. A 32-year-old patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next? a. Notify the health care provider. b. Assess the incision for redness. c. Reposition the left leg on pillows. d. Check the patient's blood pressure.

ANS: A The patient's clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.

8. Which nursing intervention will be included in the plan of care after a patient with a right femur fracture has a hip spica cast applied? a. Avoid placing the patient in prone position. b. Ask the patient about abdominal discomfort. c. Discuss remaining on bed rest for several weeks. d. Use the cast support bar to reposition the patient.

ANS: B Assessment of bowel sounds, abdominal pain, and nausea and vomiting will detect the development of cast syndrome. To avoid breakage, the support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical therapy personnel and may be turned to the prone position.

6. The nurse will instruct the patient with a fractured left radius that the cast will need to remain in place a. for several months. b. for at least 3 weeks. c. until swelling of the wrist has resolved. d. until x-rays show complete bony union.

ANS: B Bone healing starts immediately after the injury, but since ossification does not begin until 3 weeks postinjury, the cast will need to be worn for at least 3 weeks. Complete union may take up to a year. Resolution of swelling does not indicate bone healing.

14. Which action will the nurse take in order to evaluate the effectiveness of Buck's traction for a 62-year-old patient who has an intracapsular fracture of the right femur? a. Check peripheral pulses. b. Ask about hip pain level. c. Assess for hip contractures. d. Monitor for hip dislocation.

ANS: B Buck's traction keeps the leg immobilized and reduces painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Buck's traction.

42. Which information obtained by the nurse about a 29-year-old patient with a lumbar vertebral compression fracture is most important to report to the health care provider? a. Patient refuses to be turned due to back pain. b. Patient has been incontinent of urine and stool. c. Patient reports lumbar area tenderness to palpation. d. Patient frequently uses oral corticosteroids to treat asthma.

ANS: B Changes in bowel or bladder function indicate possible spinal cord compression and should be reported immediately because surgical intervention may be needed. The other findings are also pertinent but are consistent with the patient's diagnosis and do not require immediate intervention

29. A young man arrives in the emergency department with ankle swelling and severe pain after twisting his ankle playing basketball. Which of these prescribed collaborative interventions will the nurse implement first? a. Take the patient to have x-rays. b. Wrap the ankle and apply an ice pack. c. Administer naproxen (Naprosyn) 500 mg PO. d. Give acetaminophen with codeine (Tylenol #3).

ANS: B Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.

26. A patient is being discharged 4 days after hip replacement surgery using the posterior approach. Which patient action requires immediate intervention by the nurse? a. The patient uses crutches with a swing-to gait. b. The patient leans over to pull shoes and socks on. c. The patient sits straight up on the edge of the bed. d. The patient bends over the sink while brushing teeth.

ANS: B Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient.

11. A patient who is to have no weight bearing on the left leg is learning to walk using crutches. Which observation by the nurse indicates that the patient can safely ambulate independently? a. The patient moves the right crutch with the right leg and then the left crutch with the left leg. b. The patient advances the left leg and both crutches together and then advances the right leg. c. The patient uses the bedside chair to assist in balance as needed when ambulating in the room. d. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.

ANS: B Patients are usually taught to move the crutches and the injured leg forward at the same time and then to move the unaffected leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid nerve damage. If the 2- or 4-point gaits are to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg.

19. The day after a having a right below-the-knee amputation, a patient complains of pain in the right foot. Which action is best for the nurse to take? a. Explain the reasons for the phantom limb pain. b. Administer prescribed analgesics to relieve the pain. c. Loosen the compression bandage to decrease incisional pressure. d. Inform the patient that this phantom pain will diminish over time.

ANS: B Phantom limb sensation is treated like any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. The compression bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it still requires treatment now.

5. A 22-year-old tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included? a. "You will not be able to serve a tennis ball again." b. "You will work with a physical therapist tomorrow." c. "The doctor will use the drop-arm test to determine the success of surgery." d. "Leave the shoulder immobilizer on for the first 4 days to minimize pain."

ANS: B Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent "frozen shoulder." A shoulder immobilizer is used immediately after the surgery, but leaving the arm immobilized for several days would lead to loss of range of motion (ROM). The drop-arm test is used to test for rotator cuff injury, but not after surgery. The patient may be able to return to pitching after rehabilitation.

39. When assessing for Tinel's sign in a patient with possible right-sided carpal tunnel syndrome, the nurse will ask the patient about a. weakness in the right little finger. b. tingling in the right thumb and fingers. c. burning in the right elbow and forearm. d. tremor when gripping with the right hand.

ANS: B Testing for Tinel's sign will cause tingling in the thumb and first three fingers of the affected hand in patients who have carpal tunnel syndrome. The median nerve does not innervate the right little finger or elbow and forearm. Tremor is not associated with carpal tunnel syndrome.

13. A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing assessment finding is important to report to the health care provider? a. The patient states that the pelvis feels unstable. b. Abdomen is distended and bowel sounds are absent. c. There are ecchymoses across the abdomen and hips. d. The patient complains of pelvic pain with palpation.

ANS: B The abdominal distention and absent bowel sounds may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal bruising would be expected with this type of injury.

17. When doing discharge teaching for a 19-year-old patient who has had a repair of a fractured mandible, the nurse will include information about a. administration of nasogastric tube feedings. b. how and when to cut the immobilizing wires. c. the importance of high-fiber foods in the diet. d. the use of sterile technique for dressing changes.

ANS: B The jaw will be wired for stabilization, and the patient should know what emergency situations require that the wires be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high-fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge, the patient will swallow liquid through a straw.

16. A patient who has had an open reduction and internal fixation (ORIF) of a hip fracture tells the nurse that he is ready to get out of bed for the first time. Which action should the nurse take? a. Use a mechanical lift to transfer the patient from the bed to the chair. b. Check the postoperative orders for the patient's weight-bearing status. c. Avoid administration of pain medications before getting the patient up. d. Delegate the transfer of the patient to nursing assistive personnel (NAP).

ANS: B The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given because the movement is likely to be painful for the patient. The registered nurse (RN) should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish this skill.

37. A patient undergoes a left above-the-knee amputation with an immediate prosthetic fitting. When the patient arrives on the orthopedic unit after surgery, the nurse should a. place the patient in a prone position. b. check the surgical site for hemorrhage. c. remove the prosthesis and wrap the site. d. keep the residual leg elevated on a pillow.

ANS: B The nurse should monitor for hemorrhage after the surgery. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg will not be elevated on a pillow. The patient is placed in a prone position after amputation to prevent hip flexion, but this would not be done during the immediate postoperative period.

. Which statement by a 62-year-old patient who has had an above-the-knee amputation indicates that the nurse's discharge teaching has been effective? a. "I should elevate my residual limb on a pillow 2 or 3 times a day." b. "I should lay flat on my abdomen for 30 minutes 3 or 4 times a day." c. "I should change the limb sock when it becomes soiled or each week." d. "I should use lotion on the stump to prevent skin drying and cracking."

ANS: B The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage flexion contracture.

38. Before assisting a patient with ambulation 2 days after a total hip replacement, which action is most important for the nurse to take? a. Observe the status of the incisional drain device. b. Administer the ordered oral opioid pain medication. c. Instruct the patient about the benefits of ambulation. d. Change the hip dressing and document the wound appearance.

ANS: B The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.

27. After being hospitalized for 3 days with a right femur fracture, a 32-year-old patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? a. Stay with the patient and offer reassurance. b. Administer the prescribed PRN oxygen at 4 L/min. c. Check the patient's legs for swelling or tenderness. d. Notify the health care provider about the symptoms.

ANS: B The patient's clinical manifestations and history are consistent with a pulmonary embolus, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for fat embolus or venous thromboembolism (VTE) are obtained.

45. When caring for a patient who is using Buck's traction after a hip fracture, which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Monitor the skin under the traction boot for redness. b. Ensure that the weight for the traction is off the floor. c. Check for intact sensation and movement in the affected leg. d. Offer reassurance that hip and leg pain are normal after hip fracture.

ANS: B UAP can be responsible for maintaining the integrity of the traction once it has been established. Assessment of skin integrity and circulation should be done by the registered nurse (RN). UAP should notify the RN if the patient experiences hip and leg pain because pain and effectiveness of pain relief measures should be assessed by the RN.

9. A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should a. keep the left arm in dependent position. b. avoid handling the cast using fingertips. c. place gauze around the cast edge to pad any roughness. d. cover the cast with a small blanket to absorb the dampness.

ANS: B Until a plaster cast has dried, using the palms rather than the fingertips to handle the cast helps prevent creating protrusions inside the cast that could place pressure on the skin. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying.

40. Which action will the urgent care nurse take when caring for a patient who has a possible knee meniscus injury? a. Encourage bed rest for 24 to 48 hours. b. Avoid palpation or movement of the knee. c. Apply a knee immobilizer to the affected leg. d. Administer intravenous narcotics for pain relief.

ANS: C A knee immobilizer may be used for several days after a meniscus injury to stabilize the knee and minimize pain. Patients are encouraged to ambulate with crutches. The knee is assessed by flexing, internally rotating, and extending the knee (McMurray's test). The pain associated with a meniscus injury will not typically require IV opioid administration; nonsteroidal antiinflammatory drugs (NSAIDs) are usually recommended for pain relief.

28. A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding is most important for the nurse to communicate to the health care provider? a. There is bruising at the shoulder area. b. The patient reports arm and shoulder pain. c. The right arm appears shorter than the left. d. There is decreased shoulder range of motion.

ANS: C A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion also should be reported, but these do not indicate that emergent treatment is needed to preserve function.

1. When teaching seniors at a community recreation center, which information will the nurse include about ways to prevent fractures? a. Tack down scatter rugs in the home. b. Most falls happen outside the home. c. Buy shoes that provide good support and are comfortable to wear. d. Range-of-motion exercises should be taught by a physical therapist.

ANS: C Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range of motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries.

4. Which discharge instruction will the emergency department nurse include for a patient with a sprained ankle? a. Keep the ankle loosely wrapped with gauze. b. Apply a heating pad to reduce muscle spasms. c. Use pillows to elevate the ankle above the heart. d. Gently move the ankle through the range of motion.

ANS: C Elevation of the leg will reduce the amount of swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to 48 hours, cold packs are used to reduce swelling. The ankle should be rested and kept immobile to prevent further swelling or injury.

10. Which statement by the patient indicates a good understanding of the nurse's teaching about a new short-arm plaster cast? a. "I can get the cast wet as long as I dry it right away with a hair dryer." b. "I should avoid moving my fingers and elbow until the cast is removed." c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." d. "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast."

ANS: C Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.

24. When giving home care instructions to a patient who has comminuted forearm fractures and a long-arm cast on the left arm, which information should the nurse include? a. Keep the left shoulder elevated on a pillow or cushion. b. Keep the hand immobile to prevent soft tissue swelling. c. Call the health care provider for increased swelling or numbness of the hand. d. Avoid nonsteroidal antiinflammatory drugs (NSAIDs) for 24 hours after the injury.

ANS: C Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat pain after a fracture.

43. When a patient arrives in the emergency department with a facial fracture, which action will the nurse take first? a. Assess for nasal bleeding and pain. b. Apply ice to the face to reduce swelling. c. Use a cervical collar to stabilize the spine. d. Check the patient's alertness and orientation.

ANS: C Patients who have facial fractures are at risk for cervical spine injury and should be treated as if they have a cervical spine injury until this is ruled out. The other actions are also necessary, but the most important action is to prevent cervical spine injury.

36. A 42-year-old patient is admitted to the emergency department with a left femur fracture. Which information obtained by the nurse is most important to report to the health care provider? a. Ecchymosis of the left thigh b. Complaints of severe thigh pain c. Slow capillary refill of the left foot d. Outward pointing toes on the left foot

ANS: C Prolonged capillary refill may indicate complications such as arterial damage or compartment syndrome. The other findings are typical with a left femur fracture

25. A patient who slipped and fell in the shower at home has a proximal humerus fracture immobilized with a left-sided long-arm cast and a sling. Which nursing intervention will be included in the plan of care? a. Use surgical net dressing to hang the arm from an IV pole. b. Immobilize the fingers of the left hand with gauze dressings. c. Assess the left axilla and change absorbent dressings as needed. d. Assist the patient in passive range of motion (ROM) for the right arm.

ANS: C The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side.

1. A patient who arrives at the emergency department experiencing severe left knee pain is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for a. a knee immobilizer. b. gentle knee flexion. c. monitored anesthesia care. d. physical activity restrictions.

ANS: C The first goal of collaborative management is realignment of the knee to its original anatomic position, which will require anesthesia or monitored anesthesia care (MAC), formerly called conscious sedation. Immobilization, gentle range-of-motion (ROM) exercises, and discussion about activity restrictions will be implemented after the knee is realigned.

23. A high school teacher with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for a left hand arthroplasty. Which patient statement to the nurse indicates a realistic expectation for the surgery? a. "This procedure will correct the deformities in my fingers." b. "I will not have to do as many hand exercises after the surgery." c. "I will be able to use my fingers with more flexibility to grasp things." d. "My fingers will appear more normal in size and shape after this surgery."

ANS: C The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Hand exercises will be prescribed after the surgery.

32. Following a motorcycle accident, a 58-year-old patient arrives in the emergency department with massive left lower leg swelling. Which action will the nurse take first? a. Elevate the leg on 2 pillows. b. Apply a compression bandage. c. Check leg pulses and sensation. d. Place ice packs on the lower leg.

ANS: C The initial action by the nurse will be to assess the circulation to the leg and to observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate, based on what is observed during the assessment.

33. A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. The initial action by the nurse should be to a. elevate the right leg. b. splint the lower leg. c. check the pedal pulses. d. verify tetanus immunizations.

ANS: C The initial nursing action should be assessment of the neurovascular status of the injured leg. After assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be done if there is an open wound.

18. After the health care provider has recommended amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse isbest? a. "You are upset, but you may lose the foot anyway." b. "Many people are able to function with a foot prosthesis." c. "Tell me what you know about your options for treatment." d. "If you do not want an amputation, you do not have to have it."

ANS: C The initial nursing action should be to assess the patient's knowledge level and feelings about the options available. Discussion about the patient's option to not have the procedure, the seriousness of the condition, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patient's current level of knowledge and emotional state.

35. The second day after admission with a fractured pelvis, a 64-year-old patient suddenly develops confusion. Which action should the nurse take first? a. Take the blood pressure. b. Assess patient orientation. c. Check the oxygen saturation. d. Observe for facial asymmetry.

ANS: C The patient's history and clinical manifestations suggest a fat embolus. The most important assessment is oxygenation. The other actions are also appropriate but will be done after the nurse assesses gas exchange.

34. The day after a 60-year-old patient has an open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the priority nursing diagnosis is a. activity intolerance related to deconditioning. b. risk for constipation related to prolonged bed rest. c. risk for impaired skin integrity related to immobility. d. risk for infection related to disruption of skin integrity.

ANS: D A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis. After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused by immobility are not as likely

22. Which action will the nurse include in the plan of care for a patient who has had a total right knee arthroplasty? a. Avoid extension of the right knee beyond 120 degrees. b. Use a compression bandage to keep the right knee flexed. c. Teach about the need to avoid weight bearing for 4 weeks. d. Start progressive knee exercises to obtain 90-degree flexion.

ANS: D After knee arthroplasty, active or passive flexion exercises are used to obtain a 90-degree flexion of the knee. The goal for extension of the knee will be 180 degrees. A compression bandage is used to hold the knee in an extended position after surgery. Full weight bearing is expected before discharge.

44. After change-of-shift report, which patient should the nurse assess first? a. Patient with a Colles' fracture who has right wrist swelling and deformity b. Patient with a intracapsular left hip fracture whose leg is externally rotated c. Patient with a repaired mandibular fracture who is complaining of facial pain d. Patient with right femoral shaft fracture whose thigh is swollen and ecchymotic

ANS: D Swelling and bruising after a femoral shaft fracture suggest hemorrhage and risk for compartment syndrome. The nurse should assess the patient rapidly and then notify the health care provider. The other patients have symptoms that are typical for their injuries, but do not require immediate intervention.

41. Which finding in a patient with a Colles' fracture of the left wrist is most important to communicate to the health care provider? a. Swelling is noted around the wrist. b. The patient is reporting severe pain. c. The wrist has a deformed appearance. d. Capillary refill to the fingers is prolonged.

ANS: D Swelling, pain, and deformity are common findings with a Colles' fracture. Prolonged capillary refill indicates decreased circulation and risk for ischemia. This is not an expected finding and should be immediately reported.

7. A 48-year-old patient with a comminuted fracture of the left femur has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should a. loosen the traction and help the patient turn onto the unaffected side. b. place a pillow between the patient's legs and turn gently to each side. c. turn the patient partially to each side with the assistance of another nurse. d. have the patient lift the buttocks by bending and pushing with the right leg.

ANS: D The patient can lift the buttocks off the bed by using the left leg without changing the right-leg alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the traction will interrupt the weight needed to immobilize and align the fracture.

21. The nurse is caring for a patient who is to be discharged from the hospital 5 days after insertion of a femoral head prosthesis using a posterior approach. Which statement by the patient indicates a need for additional instruction? a. "I should not cross my legs while sitting." b. "I will use a toilet elevator on the toilet seat." c. "I will have someone else put on my shoes and socks." d. "I can sleep in any position that is comfortable for me."

ANS: D The patient needs to sleep in a position that prevents excessive internal rotation or flexion of the hip. The other patient statements indicate that the patient has understood the teaching.

2. A factory line worker has repetitive strain syndrome in the left elbow. The nurse will plan to teach the patient about a. surgical options. b. elbow injections. c. wearing a left wrist splint. d. modifying arm movements.

ANS: D Treatment for repetitive strain syndrome includes changing the ergonomics of the activity. Elbow injections and surgery are not initial options for this type of injury. A wrist splint might be used for hand or wrist pain.

23. What emergency considerations must be included with facial fractures (select all that apply)? a. Airway patency b. Oral examination c. Cervical spine injury d. Cranial nerve assessment e. Immobilization of the jaw

a, c. Airway patency and cervical spinal cord injury are the emergency considerations with facial fractures. Oral examination and cranial nerve assessment will be done after the patient is stabilized. Immobilization of the jaw is done surgically for a mandibular fracture.

A 72-year-old man tells the nurse that he cannot perform most of the physical activities he could do 5 years ago because of overall joint aches and pains. What can the nurse do to assist the patient to prevent further deconditioning and decrease the risk for developing musculoskeletal problems? a. Limit weight-bearing exercise to prevent stress on fragile bones and possible hip fractures. b. Advise the patient to avoid the use of canes and walkers because they increase dependence on ambulation aids. c. Advise the patient to increase his activity by more frequently climbing stairs in buildings and other environments with steps. d. Discuss use of over-the-counter (OTC) medications to decrease inflammation and pain so that exercise can be maintained.

d. Almost all older adults have some degree of decreased muscle strength, joint stiffness, and pain with motion. The use of mild antiinflammatory agents decreases inflammation and pain and can help the patient to maintain activity and prevent further deconditioning but other prescribed drugs and potential abdominal problems must be considered by the patient. Musculoskeletal problems in the older adult can be prevented with appropriate strategies, especially exercise. Stair walking can create enough stress on fragile bones to cause a hip fracture and use of ramps may help to prevent falls. Walkers and canes should be used as necessary to decrease stress on joints so that activity can be maintained.