Chapter 40 Musculoskeletal Care modalities
The nurse is caring for a patient who had a total hip replacement. What lethal postoperative complication should the nurse closely monitor for? A.) Atelectasis B.) Hypovolemia C.) Pulmonary embolism D.) Urinary tract infection
ANswer: C.) Pulmonary embolism Rationale: Patients having orthopedic surgery are particularly at risk for venous thromboembolism, including deep vein thrombosis and pulmonary embolism.
Which would be contraindicated as a component of self-care activities for the client with a cast? A.) Cover the cast with plastic to insulate it B.) Cushioning rough edges of the cast with tape C.) Elevate the casted extremity to heart level frequently D.) Do not attempt to scratch the skin under a cast
Answer: A.) Cover the cast with plastic to insulate it
The nurse is caring for a client who lives alone and had a total knee replacement. An appropriate nursing diagnosis for the client is: A.) Risk for ineffective therapeutic regimen management B.) Disturbed body image C.) Situational low self-esteem D.) Risk for avascular necrosis of the joint
Answer: A.) Risk for ineffective therapeutic regimen management
A client has a cast applied to the leg for treatment of a tibia fracture and also has a wound on the leg that requires dressing changes due to drainage. For what should the nurse prepare the client? A.) Cutting of a bivalve cast B.) Cutting a cast window C.) Removal of the cast D.) Insertion of an external fixator
Answer: B.) Cutting a cast window Rationale: After the cast dries, a cast window, or opening, may be cut. This usually is done when the client reports discomfort under the cast or has a wound that requires a dressing change. The window permits direct inspection of the skin, a means to check the pulse in a casted arm or leg, or a way to change a dressing. A bivalve cast is when the cast is cut in two if the leg swells or if the client is being weaned from a cast, when a sharp x-ray is needed, or as a splint for immobilizing painful joints when a client has arthritis. The cast should not be removed due to the instability of a fracture. The client's condition does not indicate an external fixator is required.
Conservative treatment of a compressed nerve root is first line treatment. What conservative treatment is used to increase the distance between vertebrae and decrease severe muscle spasm? A.) Skeletal traction B.) Sleeping on a hard mattress with a bed board C.) Cool, moist compresses D.) Skin traction
Answer: D.) Skin traction Rationale: Skin traction, which can be applied in the home, is used to decrease severe muscle spasm as well as increase the distance between adjacent vertebrae, keep the vertebrae correctly aligned, and, in many instances, relieve pain. Treatment relieves symptoms for an extended period.
The nurse is assigned to care for a client who has had a total knee arthroplasty yesterday. What type of pharmacologic therapy does the nurse anticipate administering to this client to prevent complications related to the surgery? A.) Antidysrhythmic therapy B.) Antianginal therapy C.) Antineoplastic therapy D.) Anticoagulation therapy
Answer: D.) Anticoagulation therapy
A client who is undergoing skeletal traction reports pressure on bony areas. Which action would be most appropriate to provide comfort for the client? A.) Assisting with range-of-motion and isometric exercises. B.) Changing the client's position within prescribed limits. C.) Administering prescribed analgesics. D.) Applying warm compresses.
Answer: B.) Changing the client's position within prescribed limits.
Which action would be most important postoperatively for a client who has had a knee or hip replacement? A.) Providing crutches to the client. B.) Assisting in early ambulation. C.) Using a continuous passive motion (CPM) machine. D.) Encouraging expressions of anxiety.
Answer: B.) Assisting in early ambulation.
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."
Answer: - "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."
Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education? A.) "The client is receiving physical therapy twice per day, so the client doesn't need a continuous passive motion device." B.) "The continuous passive motion device can decrease the development of adhesions." C.) "Bleeding is a complication associated with the continuous passive motion device." D.) "Monitoring skin integrity is important while the continuous passive motion device is in place."
Answer: A.) "The client is receiving physical therapy twice per day, so the client doesn't need a continuous passive motion device."
A client with a long arm cast continues to complain of unrelieved throbbing pain even after receiving opioid pain medication. Which is the priority action by the nurse? A.) Assess for complications. B.) Assess for previous opioid drug use. C.) Reposition the client for comfort. D.) Teach relaxation techniques.
Answer: A.) Assess for complications. Rationale: Unrelieved pain can be an indicator of a complication, such as compartment syndrome. Previous opioid drug use should not influence a complete and thorough assessment. Repositioning the client for comfort may be appropriate once all indications of a complication are ruled out. It is appropriate to teach relaxation techniques to help ease the pain, but assessing for a complication remains the highest priority.
A group of students is reviewing information about cast composition in preparation for a discussion on the advantages and disadvantages of each. The students demonstrate understanding of the topic when they cite which of the following as an advantage of a plaster cast? A.) Better molding to the client B.) Quicker drying C.) Longer lasting D.) More breathable
Answer: A.) Better molding to the client Rationale: Plaster casts require a longer time for drying but mold better to the client and are initially used until the swelling subsides. Fiberglass casts dry more quickly, are lighter in weight, longer lasting, and breathable.
Which is not a guideline for avoiding hip dislocation after replacement surgery. A.) The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes. B.) Keep the knees apart at all times. C.) Put a pillow between the legs when sleeping. D.) Never cross the legs when seated.
Answer: A.) The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes. Rationale: Guidelines for avoiding hip dislocation after replacement surgery specify that the hip should not be flexed to put on clothing such as pants, stockings, socks, or shoes. Clients should keep the knees apart at all times, put a pillow between the legs when sleeping, and never cross the legs when seated.
Arthrodesis is: A.) fusion of a joint (most often the wrist or knee) for stabilization and pain relief. B.) total reconstruction or replacement of a joint (most often the knee or hip) with an artificial joint to restore function and relieve pain. C.) replacement of one of the articular surfaces in a joint, such as the femoral head but not the acetabulum. D.) cutting and removal of a wedge of bone (most often the tibia or femur) to change the bone's alignment, thereby improving function and relieving pain.
Answer: A.) fusion of a joint (most often the wrist or knee) for stabilization and pain relief. Rationale: Arthrodesis is fusion of a joint (most often the wrist or knee) for stabilization and pain relief. Arthroplasty is total reconstruction or replacement of a joint (most often the knee or hip) with an artificial joint to restore function and relieve pain. Hemiarthroplasty is the replacement of one of the articular surfaces in a joint, such as the femoral head but not the acetabulum. Osteotomy is the cutting and removal of a wedge of bone (most often the tibia or femur) to change the bone's alignment, thereby improving function and relieving pain.
A client with a right leg fracture is returning to the orthopedist to have the cast removed. During cast removal, it is important for the nurse to assure: A.) the client that he or she won't be cut. B.) that the cast cutter blade is new. C.) that pedal pulses are present. D.) that the leg will be as good as new.
Answer: A.) the client that he or she won't be cut. Rationale: Casts are removed with a mechanical cast cutter. Cast cutters are noisy and frightening but the blade does not penetrate deep enough to cut the client. The client needs reassurance that the machine will not cut into the skin. The other options are either irrelevant or not something the nurse knows for certain at this time.
A client in the emergency department is being treated for a wrist fracture. The client asks why a splint is being applied instead of a cast. What is the best response by the nurse? A.) "You would have to stay here much longer because it takes a cast longer to dry." B.) "A splint is applied when more swelling is expected at the site of injury." C.) "It is best if an orthopedic doctor applies the cast." D.) "Not all fractures require a cast."
Answer: B.) "A splint is applied when more swelling is expected at the site of injury."
The client displays manifestations of compartment syndrome. What treatment will the nurse expect the client to be scheduled for? A.) An open reduction B.) A fasciotomy C.) A total hip replacement D.) A total knee replacement
Answer: B.) A fasciotomy
The nurse is caring for a client who sustained rib fractures in an automobile accident. What symptoms does the nurse recognize as a complication of rib fractures and should immediately be reported to the physician? A.) Blood pressure of 140/90 mm Hg B.) Crackles in the lung bases C.) Client complains of pain in the affected rib area when taking a deep breath D.) Heart rate of 94 beats/minute
Answer: B.) Crackles in the lung bases Rationale: Crackles in the lung bases can be an indicator that the client has developed pneumonia from shallow respirations. The blood pressure is high but may be due to pain. It is expected that the client will have pain in the rib area when taking deep breaths. A heart rate of 94 beats/minute is within normal range.
Which is an inappropriate use of traction? A.) Immobilize a fracture B.) Decrease space between opposing structures C.) Reduce deformity D.) Minimize muscle spasms
Answer: B.) Decrease space between opposing structures Rationale: Traction is done to increase the space between opposing surfaces. Traction is used to minimize muscle spasms, to reduce, align, and immobilize fractures, and to reduce deformity.
A patient in pelvic traction needs circulatory status assessed. How should the nurse assess for a positive Homans' sign? A.) Have the patient extend both hands while the nurse compares the volume of both radial pulses. B.) Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg. C.) Have the patient plantar flex both feet while the nurse performs the blanch test on all of the patient's toes. D.) Have the patient squeeze the nurse's hands with his or her hands to evaluate any difference in strength.
Answer: B.) Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg. Rationale: The nurse should assess for pain on passive flexion of each foot, which could indicate deep vein thrombosis.
The nurse assesses a client after total right hip arthroplasty and observes a shortening of the extremity. The client reports severe pain in the right side of the groin. What is the priority action of the nurse? A.) Apply Buck's traction. B.) Notify the health care provider. C.) Externally rotate the extremity. D.) Bend the knee and rotate the knee internally.
Answer: B.) Notify the health care provider. Rationale: If any clinical manifestations of dislocation of the prosthesis occur, including acute groin pain in the affected hip or shortening of the affected extremity, the nurse (or the client, if at home) must immediately notify the surgeon, because the hip must be reduced and stabilized promptly so that the leg does not sustain circulatory and nerve damage. After closed reduction, the hip may be stabilized with Buck's traction or a brace to prevent recurrent dislocation. As the muscles and joint capsule heal, the chance of dislocation diminishes. Stresses to the new hip joint should be avoided for the first 8 to 12 weeks, when the risk of dislocation is greatest.
A client arrives in the emergency department with a suspected bone fracture of the right arm. How does the nurse expect the client to describe the pain? A.) A dull, deep, boring ache B.) Sharp and piercing C.) Similar to "muscle cramps" D.) Sore and aching
Answer: B.) Sharp and piercing Rationale: The nurse must carefully evaluate pain associated with the musculoskeletal condition, asking the client to indicate the exact site and to describe the character and intensity of the pain using a pain rating scale. Most pain can be relieved by elevating the involved part, applying ice or cold packs, and administering analgesic agents as prescribed. Pain associated with the underlying condition (e.g., fracture, which is sharp and piercing) is frequently controlled by immobilization. Pain due to edema that is associated with trauma, surgery, or bleeding into the tissues can frequently be controlled by elevation and, if prescribed, intermittent application of ice or cold packs. Ice bags (one third to one half full) or cold application devices are placed on each side of the cast, if prescribed, making sure not to indent or wet the cast. Unrelieved or disproportionate pain may indicate complications. Pain associated with compartment syndrome is relentless and is not controlled by modalities such as elevation, application of ice or cold, and usual dosages of analgesic agents. Severe burning pain over bony prominences, especially the heels, anterior ankles, and elbows, warns of an impending pressure ulcer. This may also occur from too-tight elastic wraps used to hold splints in place.
Which principle applies to the client in traction? A.) Weights should rest on the bed. B.) Skeletal traction is never interrupted. C.) Knots in the ropes should touch the pulley. D.) Weights are removed routinely.
Answer: B.) Skeletal traction is never interrupted. Rationale: Skeletal traction is applied directly to the bone and is never interrupted. To be effective, the weights must hang freely and not rest on the bed or floor. Knots in the rope or the footplate must not touch the pulley or the foot of the bed. Traction must be continuous to be effective in reducing and immobilizing fractures.
Which nursing action would help prevent deep vein thrombosis in a client who has had an orthopedic surgery? A.) Instruct about using client-controlled analgesia, if prescribed B.) Instruct about exercise, as prescribed C.) Apply antiembolism stockings D.) Apply cold packs
Answer: C.) Apply antiembolism stockings Rationale: Applying antiembolism stockings helps prevent deep vein thrombosis (DVT) in a client who is immobilized due to orthopedic surgery. Regular administration of analgesics controls and prevents escalation of pain, while ROM exercises help maintain muscle strength and tone and prevent contractions. On the other hand, cold packs are applied to help reduce swelling; cold does not prevent deep vein thrombosis.
The client returns to the nursing unit following an open reduction with internal fixation of the right hip. Nursing assessment findings include temperature 100.8 degrees Fahrenheit, heart rate 112 beats per minute, respiratory rate 28 breaths per minute, and blood pressure 86/58. There is no urine in the Foley catheter collection bag. The nurse interprets these findings as indicating which complication? A.) Osteomyelitis B.) Urinary retention C.) Hypovolemic shock D.) Atelectasis
Answer: C.) Hypovolemic shock Rationale: Indicators of hypovolemic shock include a heart rate greater than 100 beats per minute, a blood pressure less than 90/60 mm Hg, and urine output less than 30 ml per hour.
A client has severe osteoarthritis in the left hip and is having surgery to replace both articular surfaces of the hip. What type of surgical procedure will the nurse prepare the client for? A.) Arthrodesis B.) Hemiarthroplasty C.) Total arthroplasty D.) Osteotomy
Answer: C.) Total arthroplasty Rationale: A total arthroplasty is a replacement of both articular surfaces within one joint. An arthrodesis is a fusion of a joint for stabilization and pain relief and is usually done on a wrist or knee. A hemiarthroplasty is the replacement of one of the articular surfaces in a joint, such as the femoral head but not the acetabulum. An osteotomy is the cutting and removal of a wedge of bone to change the bone's alignment, thereby improving function and relieving pain.
A variety of complications can occur after a leg amputation. Which is not a possibility in the immediate postoperative period? A.) hematoma B.) hemorrhage C.) osteomyelitis D.) infection
Answer: C.) osteomyelitis
The nurse is providing instructions to the client who is being prepared for skeletal traction. Which statement by the client indicates teaching was effective? A.) "I will wear a boot with weights attached." B.) "A belt will go around my pelvis and weights will be attached." C.) "The traction can be removed once a day so I can shower." D.) "Metal pins will go through my skin to the bone."
Answer: D.) "Metal pins will go through my skin to the bone." Rationale: In skeletal traction, metal rods or pins are used to apply continuous traction directly to the bone. Weights are used to apply the traction. Casts, external fixators, or splints are used when the traction is discontinued.
Which orthopedic surgery is done to correct and align a fracture after surgical dissection and exposure of the fracture? A.) Arthrodesis B.) Joint arthroplasty C.) Total joint arthroplasty D.) Open reduction
Answer: D.) Open reduction Rationale: An open reduction is the correction and alignment of the fracture after surgical dissection and exposure of the fracture. Arthrodesis is immobilizing fusion of a joint. A joint arthroplasty or replacement is the replacement of joint surfaces with metal or synthetic materials. A total joint arthroplasty is the replacement of both the articular surfaces within a joint with metal or synthetic materials.
A client is brought to the emergency department by a softball team member who states the client and another player ran into each other, and the client is having severe pain in the right shoulder. What symptoms of a fractured clavicle does the nurse recognize? A.) Client complains of tingling and numbness in the right shoulder. B.) Right shoulder is elevated above the left. C.) Client complains of pain in the unaffected shoulder. D.) Right shoulder slopes downward and droops inward.
Answer: D.) Right shoulder slopes downward and droops inward. Rationale: The client with a fractured clavicle has restricted motion, and the affected shoulder appears to slope downward and droop inward. The client will have pain, not typically tingling and numbness in the right shoulder. Pain is not felt in the unaffected shoulder.
Which is an inaccurate principle of traction? A.) The weights are not removed unless intermittent treatment is prescribed. B.) The weights must hang freely. C.) The client must be in good alignment in the center of the bed. D.) Skeletal traction is interrupted to turn and reposition the client.
Answer: D.) Skeletal traction is interrupted to turn and reposition the client.
A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan? A.) Apply the traction straps snugly. B.) Assess the client's level of consciousness. C.) Remove the traction at least every 8 hours. D.) Teach the client how to prevent problems caused by immobility.
Answer: D.) Teach the client how to prevent problems caused by immobility. Rationale: By teaching the client about prevention measures, the nurse can help prevent problems caused by immobility, such as hypostatic pneumonia, muscle contracture, and atrophy. The nurse applies traction straps for skin traction — not skeletal traction. For a client in skeletal traction, the nurse should assess the affected limb, rather than assess the level of consciousness. Removing skeletal traction is the physician's responsibility — not the nurse's.
