ch 37

A client with a recent left above-the-knee amputation states, "I can feel pain in my left toes." Which is the best response by the nurse?

"Describe the pain and rate it on the pain scale." The nurse should recognize phantom pain as real and complete a pain assessment as if the limb were attached. The client's pain should be address and treated appropriately. By telling the client that the toes have been amputated or the pain is really from the nerves in the upper leg, the nurse is negating the client's pain. Opioid pain medication can be effective with phantom pain. (pg. 1187)

A client asks the nurse why his residual limb cannot be elevated on a pillow. What is the best response by the nurse?

"Elevating the leg might lead to a flexion contracture." Elevating the residual limb on a pillow may lead to a flexion contracture; this could jeopardize the client's ability to use a prosthesis. The client does need to turn to both sides but might still be able to do it with the extremity elevated. Elevating the extremity would not increase the risk for compartment syndrome. The limb should not be elevated on pillows or blankets. (pg. 1199)

When discussing physical activities with the client who has just undergone a right total hip replacement, which instruction should the nurse provide?

"Limit hip flexion to 90 degrees." The client should avoid all activities that can result in dislocation of the hip. The affected leg should not cross midline or be turned inward. The hip should not bend more than 90 degrees. Ambulation begins the day following surgery, and weight bearing ambulation may not be restricted, depending on the type of prosthesis. (pg. 1185)

Which instruction should the nurse include when teaching the client following hip replacement surgery? (Select all that apply.) "You may cross your legs at the ankles only." "Place pillows between your legs when you lay on your side." "Avoid bending forward when sitting in a chair." "Use a raised toilet seat and high-seated chair." "It is okay to briefly flex the hip to put on your clothes."

"Place pillows between your legs when you lay on your side." "Avoid bending forward when sitting in a chair." "Use a raised toilet seat and high-seated chair." The client following post hip replacement should not cross the legs, even at the ankle. He or she should avoid bending forward when sitting in a chair, avoid flexing the hip when dressing, and use a raised toilet seat. A pillow should be placed between the legs when side-lying. (pg. 1185)

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

"The client is receiving physical therapy twice per day, so the client doesn't need a continuous passive motion device." Further staff education is needed when the nurse states that the continuous passive motion device isn't needed because the client receives physical therapy twice per day. The continuous passive motion device should be used in conjunction with physical therapy because the device helps prevent adhesions. Bleeding is a complication associated with the continuous passive motion device; skin integrity should be monitored while the device is in use. (1170)

A client is being prepared for a total hip arthroplasty, and the nurse is providing relevant education. The client is concerned about being on bed rest for several days after the surgery. The nurse should explain what expectation for activity following hip replacement?

"The physical therapist will likely help you get up using a walker the day after your surgery." Clients post-THA begin ambulation with the assistance of a walker or crutches within a day after surgery. Wheelchairs are not normally utilized. Baseline levels of mobility are not normally achieved until several weeks after surgery, however. (pg. 1185)

An older adult patient had a hip replacement. When should the patient begin with assisted ambulation with a walker?

24 hours Following hip arthroplasty (total hip replacement), patients begin ambulation with the assistance of a walker or crutches within a day after surgery. (pg. 1199)

A patient had a total hip replacement. What recommended leg position should the nurse ensure is maintained to prevent prosthesis dislocation?

Abduction The nurse educates the patient about protective positioning, which includes maintaining abduction and avoiding internal and external rotation, hyperextension, and acute flexion. (pg. 1159)

A client has undergone a leg amputation. What teachings should the nurse offer such a client to prevent abduction deformity? Select all that apply. Advise the client to use a trochanter roll. Advise the client to adduct the stump so it presses against the other leg when the client is lying on the stomach. Advise the client to use antiembolism stockings on both legs. Advise the client to place pillows between the legs.

Advise the client to use a trochanter roll. Advise the client to adduct the stump so it presses against the other leg when the client is lying on the stomach. Use a trochanter roll to prevent external rotation of the hip and knee. Avoid placing pillows between the legs. If the client is lying on the stomach, the nurse should advise the client to adduct the stump so it presses against the other leg. Adduction stretches flexor muscles and prevents abduction deformity. The client should only use an antiembolism stocking on the unaffected leg.

When is it advisable for the nurse to apply heat to a sprain or a contusion?

After 2 days It is advisable to apply heat on a sprain or a contusion 2 days after a sprain or a contusion has occurred. This is because after 2 days swelling is not likely to increase and as a result heat application reduces pain and relieves local edema by improving circulation. Delaying the application of heat prolongs the pain and increased the risk of local edema. (pg. 1153)

A nurse is caring for a client who is in skeletal traction. To prevent the complication of skin breakdown in a client with skeletal traction, what action should be included in the plan of care?

Assess the pin insertion site every 8 hours. The pin insertion site should be assessed every 8 hours for inflammation and infection. Loose cover dressings should be applied to pin sites. The client should be encouraged to use the overhead trapeze to shift weight for repositioning. Isometric exercises should be done 10 times an hour while awake. (pg. 1176)

A patient has stepped in a hole in the yard, causing an ankle injury. The ankle is edematous and painful to palpation. How long should the nurse inform the patient that the acute inflammatory stage will last?

Between 24 and 48 hours After the acute inflammatory stage (e.g., 24 to 48 hours after injury), intermittent heat application (for 15 to 30 minutes, four times a day) relieves muscle spasm and promotes vasodilation, absorption, and repair. (pg. 1153)

Which cleansing solution is the most effective for use in completing pin site care?

Chlorhexidine Chlorhexidine solution is recommended as the most effective cleansing solution; however, water and saline are alternate choices. Hydrogen peroxide and betadine solutions have been used, but they are believed to be cytotoxic to osteoblasts and may actually damage healthy tissue. (pg. 1176, 1777)

Which assessment findings would the nurse expect to find in the postoperative client experiencing fat embolism syndrome?

Column B Fat embolism syndrome is characterized by fever, tachycardia, tachypnea, and hypoxia and other manifestations of respiratory failure. Arterial blood gas findings include a partial pressure of oxygen (PaO2) less than 60 mm Hg, with early respiratory alkalosis and later respiratory acidosis. (pg. 1162)

A client who has extremity right wrist fracture complains of severe burning pain, frequent changes in the skin from hot and dry to cold, and feeling clammy skin that is shiny and growing more hair in the injured extremity. The nurse should anticipate providing care for what complication?

Complex regional pain syndrome The symptoms reported by the client are consistent with complex regional pain syndrome. Avascular necrosis is manifested by pain and limited movement. Pain and decreased function are the prime indicators of reaction to an internal fixation device. Heterotrophic ossification causes muscular pain and limited muscular contraction and movement. (pg. 1161-1165)

Which would be contraindicated as a component of self-care activities for the client with a cast?

Cover the cast with plastic to insulate it The cast should be kept dry, but do not cover it with plastic or rubber because this causes condensation, which dampens the cast and skin. The other activities are consistent with cast care. (pg. 1177)

Which intervention would the nurse implement with the client in skeletal traction? Select all that apply. Apply 8-pound weight to the rope. Ensure the pins or wires are covered with caps. Remove foam boot and inspect skin daily. Position trapeze within the client's reach. Instruct the client on isometric exercises for immobilized extremity.

Ensure the pins or wires are covered with caps. Position trapeze within the client's reach. Nursing care of the client in skeletal traction includes ensuring the trapeze is within the client's reach and the pins or wires are covered with caps. The nurse instructs the client on isometric exercises for the immobilized extremity. A foam boot is used with Buck's traction (skin traction) not skeletal traction. An 8-pound weight is used with Buck's traction, whereas a 15- to 25-pound weight is applied in skeletal traction.

The client is scheduled for a meniscectomy of the right knee. The nurse would plan postoperative care based on what surgical procedure?

Excision of damaged joint fibrocartilage The most common site for meniscectomy is the knee; the procedure refers to the excision of damaged joint fibrocartilage. Fasciotomy refers to the incision and diversion of the muscle fascia to relieve muscle constriction. Hemiarthroplasty refers to the replacement of one of the articular surfaces of a joint. Total joint arthroscopy is the replacement of a joint with synthetic material. (pg. 1157)

The nurse is caring for a patient postoperatively following orthopedic surgery. The nurse assesses an oxygen saturation of 89%, confusion, and a rash on the upper torso. What does the nurse suspect is occurring with this patient?

Fat emboli syndrome Fat embolism syndrome (FES) (see Chapter 43) may occur with orthopedic surgery. The nurse must be alert to any signs and symptoms that may suggest the development of FES. These may include respiratory distress; onset of delirium or any acute change in level of consciousness; and development of unusual skin rashes, especially a papular rash on the upper torso. (1162)

The nurse is very concerned about the potential debilitating complication of peroneal nerve injury. What symptom does the nurse recognize as a result of that complication?

Foot drop Injury to the peroneal nerve as a result of pressure is a cause of foot drop (the inability to maintain the foot in a normally flexed position). Consequently, the patient drags the foot when ambulating. (pg. 1175)

To reduce the incidence of complications in a client in traction, which intervention should be included in the care plan?

Increase fiber intake. Immobility increases the incidence of constipation. Increasing fiber intake will reduce GI complications. The weights in traction should never be removed. Inactivity results in fewer calories being burned. Increasing calories would be counterproductive. Reducing fluids will increase the likelihood of constipation. (pg. 1178)

Pulselessness, a very late sign of compartment syndrome, may signify

Lack of distal tissue perfusion Pulselessness is a very late sign that may signify lack of distal tissue perfusion. The other answers do not apply. (pg. 1163)

A client is seen in the orthopedic clinic for complaints of severe pain in the left hip. After a series of diagnostic tests, the client is diagnosed with severe degenerative joint disease of the left hip and suggested to have the hip reconstructed. What procedure will the nurse schedule the client for?

Left hip arthroplasty Clients with arthritis, trauma, hip fracture, or a congenital deformity may have an arthroplasty, or reconstruction of the joint. This procedure uses an artificial joint that restores previously lost function and relieves pain. An arthroscopy is not used to reconstruct a diseased hip. A closed reduction is not an invasive surgical procedure and would not be used to reconstruct the hip. An open reduction and internal fixation is not the treatment for reconstruction of the hip related to a diseased hip. (pg. 1185)

After a traumatic back injury, a client requires skeletal traction. Which intervention takes priority?

Maintaining traction continuously to ensure its effectiveness The nurse must maintain skeletal traction continuously to ensure its effectiveness. The nurse should assess skin for breakdown; however, maintaining skeletal traction takes priority. Traction weights must hang freely to be effective; they should never be supported. The nurse should increase, not restrict, the client's fluid and fiber intake (unless contraindicated by a concurrent illness) to prevent constipation associated with complete bed rest. (pg. 1776)

A client broke his arm in a sports accident and required the application of a cast. Shortly following application, the client reported an inability to straighten his fingers and was subsequently diagnosed with Volkmann contracture. What pathophysiologic process caused this complication?

Obstructed arterial blood flow to the forearm and hand Volkmann contracture occurs when arterial blood flow is restricted to the forearm and hand and results in contractures of the fingers and wrist. It does not result from nerve pressure, skin irritation, or spasms. (pg. 1180)

A client is having a cast applied for a fractured leg that extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position. What type of cast is the client having applied?

Short leg cast A short leg cast extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position. A long leg cast extends from the junction of the upper and middle third of the thigh to the base of the toes. The knee may be slightly flexed. A walking cast is a short or long leg cast reinforced for strength. A hip spica cast encloses the trunk and a lower extremity. (pg. 1166)

What assessment findings of the leg are consistent with a fracture of the femoral neck?

Shortened, adducted, and externally rotated With fractures of the femoral neck, the leg is shortened, adducted, and externally rotated. (pg. 1184)

A client reports pain in the right knee, stating, "My knee got twisted when I was going down the stairs." The client was diagnosed with an injury to the ligaments and tendons of the right knee. Which terminology, documented by the nurse, best reflects the injury?

Sprain A sprain is an injury to the ligaments and tendons surrounding a joint, usually caused by a wrenching or twisting motion. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation or dislocation of joint surfaces. Strain refers to a muscle pull or tear. (pg. 1153)

Six weeks after an above-the-knee amputation (AKA), a client returns to the outpatient office for a routine postoperative checkup. During the nurse's assessment, the client reports symptoms of phantom pain. What should the nurse tell the client to do to reduce the discomfort of the phantom pain?

Take opioid analgesics as prescribed. Opioid analgesics may be effective in relieving phantom pain. Heat, immobility, and elevation are not noted to relieve this form of pain. (pg. 1197)

A patient falls while skiing and sustains a supracondylar fracture. What does the nurse know is the most serious complication of a supracondylar fracture of the humerus?

Volkmann's ischemic contracture The most serious complication of a supracondylar fracture of the humerus is Volkmann contracture (an acute compartment syndrome), which results from antecubital swelling or damage to the brachial artery. (pg. 1180)