Chapter 42: Management of Patients w/ musculoskeletal trauma

A client has had surgical repair of a hip injury after joint manipulation was unsuccessful. After surgery, the nurse implements measures to prevent complications. Which complications is the nurse seeking to prevent? Select all that apply. - skin breakdown - wound infection - pneumonia - diarrhea

Answer: - skin breakdown - wound infection - pneumonia

Which is not one of the general nursing measures employed when caring for the client with a fracture? A.) cranial nerve assessment B.) administering analgesics C.) providing comfort measures D.) assisting with ADLs

Answer: A.) cranial nerve assessment Rationale: Cranial nerve assessment would only be carried out for head-related injuries or diseases. General nursing measures include administering analgesics, providing comfort measures, assisting with ADLs, preventing constipation, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing client for self-care.

Two days after application of a cast to treat a fractured femur, the client reports severe, deep, and constant pain in the leg. What will the nurse suspect? A.) Chronic venous insufficiency. B.) Compartment syndrome. C.) Phlebitis. D.) Infection.

Answer: B.) Compartment syndrome. Rationale: Compartment syndrome refers to the compression of nerves, blood vessels, and muscle within a closed space. This leads to tissue death from lack of oxygenation.

The nurse caring for a client, who has been treated for a hip fracture, instructs the client not to cross their legs and to have someone assist with tying their shoes. Which additional instruction should the nurse provide to client? A.) Do not flex the hip more than 30 degrees. B.) Do not flex the hip more than 60 degrees. C.) Do not flex the hip more than 90 degrees. D.) Do not flex the hip more than 120 degrees.

Answer: C.) Do not flex the hip more than 90 degrees. Rationale: Proper alignment and supported abduction are encouraged for hip repairs. Flexion of the hip more than 90 degrees can cause damage to the a repaired hip fracture.

A client sustains an injury to the ligaments surrounding a joint. What will the nurse identify this injury as? A.) Strain B.) Contusion C.) Sprain D.) Fracture

Answer: C.) Sprain Rationale: A sprain is an injury to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A contusion is a soft tissue injury resulting from a blow or blunt trauma. A fracture is a break in the continuity of a bone.

A patient sustains an open fracture of the left arm after an accident at the roller skating rink. What does emergency management of this fracture involve? (Select all that apply.) - Covering the area with a clean dressing if the fracture is open - Immobilizing the affected site - Splinting the injured limb - Asking the patient if he or she is able to move the arm - Wrapping the arm in an ace bandage

Answer: - Covering the area with a clean dressing if the fracture is open - Immobilizing the affected site - Splinting the injured limb Rationale: Immediately after injury, if a fracture is suspected, the body part must be immobilized before the patient is moved. Adequate splinting is essential. Joints proximal and distal to the fracture also must be immobilized to prevent movement of fracture fragments. In an upper extremity injury, the arm may be bandaged to the chest, or an injured forearm may be placed in a sling. The neurovascular status distal to the injury should be assessed both before and after splinting to determine the adequacy of peripheral tissue perfusion and nerve function. With an open fracture, the wound is covered with a sterile dressing to prevent contamination of deeper tissues.

Which type of fracture involves a break through only part of the cross-section of the bone? A.) Incomplete B.) Comminuted C.) Open D.) Oblique

Answer: A.) Incomplete Rationale: An incomplete fracture involves a break through only part of the cross-section of the bone. A comminuted fracture is one that produces several bone fragments. An open fracture is one in which the skin or mucous membrane wound extends to the fractured bone. An oblique fracture runs across the bone at a diagonal angle of 45 to 60 degrees.

What assessment findings of the leg are consistent with a fracture of the femoral neck? A.) Shortened, adducted, and externally rotated B.) Shortened, abducted, and internally rotated C.) Adducted and internally rotated D.) Abducted and externally rotated

Answer: A.) Shortened, adducted, and externally rotated

A client has been in a motor vehicle collision. Radiographs indicate a fractured humerus; the client is awaiting the casting of the upper extremity and admission to the orthopedic unit. What is the primary treatment for musculoskeletal trauma? A.) immobilization B.) surgical repair C.) external rotation D.) enhancing complications

Answer: A.) immobilization Rationale: Treatment of musculoskeletal trauma involves immobilization of the injured area until it has healed.

Which factor inhibits fracture healing? A.) Increased vitamin D and calcium in the diet B.) Age of 35 years C.) History of diabetes D.) Immobilization of the fracture

Answer: C.) History of diabetes

Two days after surgery to amputate the left lower leg, a client reports pain in the missing extremity. Which action by the nurse is most appropriate? A.) Administer medication, as ordered, for the reported discomfort. B.) Contact the health care provider. C.) Initiate a consult with a psychologist. D.) Do nothing because it isn't possible to have pain in a missing limb.

Answer: A.) Administer medication, as ordered, for the reported discomfort. Rationale: The sensation of pain and discomfort in an amputated extremity is known as phantom pain. Phantom pain is a normal occurrence after an amputation. It should be treated with medication. The nurse doesn't need to contact the health care provider at this time. Consultation with the psychologist isn't indicated, and the nurse shouldn't take this action without consulting the health care provider.

A client is admitted to the emergency room after being hit by a car while riding a bicycle. The client sustained a fracture of the left femur, and the bone is protruding through the skin. What type of fracture does the nurse recognize requires emergency intervention? A.) Compound B.) Greenstick C.) Oblique D.) Spiral

Answer: A.) Compound Rationale: A compound fracture is a fracture in which damage also involves the skin or mucous membranes with the risk of infection great. A greenstick fracture is where one side of the bone is broken and the other side is bent; it does not protrude through the skin. An oblique fracture occurs at an angle across the bone but does not protrude through the skin. A spiral fracture twists around the shaft of the bone but does not protrude through the skin.

A nurse is assigned to support a patient while a cast is being applied to treat a greenstick fracture. The nurse documents that this fracture is classified as what type of fracture? A.) Closed B.) Incomplete C.) Stress D.) Compression

Answer: B.) Incomplete Rationale: A greenstick fracture involves a break through only part of the cross-section of the bone.

Elderly clients who fall are most at risk for which injuries? A.) Wrist fractures B.) Humerus fractures C.) Pelvic fractures D.) Cervical spine fractures

Answer: C.) Pelvic fractures Rationale: Elderly clients who fall are most at risk for pelvic and lower extremity fractures. These injuries are devastating because they can seriously alter an elderly client's lifestyle and reduce functional independence. Wrist fractures usually occur with falls on an outstretched hand or from a direct blow. Such fractures are commonly found in young men. Humerus fractures and cervical spine fractures aren't age-specific.

A client has been diagnosed with a muscle strain. What does the physician mean with the term "strain"? A.) injury resulting from a blow or blunt trauma B.) injuries to ligaments surrounding a joint C.) stretched or pulled beyond its capacity D.) subluxation of a joint

Answer: C.) stretched or pulled beyond its capacity

A client who has fallen and injured a hip cannot place weight on the leg and is in significant pain. After radiographs indicate intact but malpositioned bones, what would the physician diagnose? A.) strain B.) sprain C.) fracture D.) dislocation

Answer: D.) dislocation Rationale: In joint dislocation, radiographic films show intact yet malpositioned bones. Arthrography or arthroscopy may reveal damage to other structures in the joint capsule. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. Sprains are injuries to the ligaments surrounding a joint. A fracture is a break in the continuity of a bone.

Which term refers to a blunt force injury to soft tissue? A.) Contusion B.) Dislocation C.) Strain D.) Fracture

Answer: A.) Contusion Rationale: A contusion is blunt force injury to soft tissue. A dislocation is a separation of joint surfaces. A strain is a musculotendinous injury. A fracture is a break in the continuity of the bone.

An important nursing assessment, post fracture, is to evaluate neurovascular status. Therefore, the nurse should check for: A.) Crepitus. B.) Shortening and deformity. C.) Capillary refill. D.) Swelling and discoloration.

Answer: C.) Capillary refill. Rationale: Assessment for neurovascular impairment includes checking for weak pulses or delayed capillary refill (normal is <2 seconds).

A client who plays tennis is experiencing elbow discomfort. Following assessment, the client receives a diagnosis of tendinitis, epicondylitis, or tennis elbow. What symptoms and signs did the client have? Select all that apply. - pain radiating down the dorsal surface of the forearm - weak grasp - pain or burning in one or both hands - pain more prominent at night

Answer: - pain radiating down the dorsal surface of the forearm - weak grasp Rationale: Tennis elbow is characterized by pain radiating down the dorsal surface of the forearm and weak grasp. Carpal tunnel syndrome is characterized by pain or burning in one or both hands and pain more prominent at night.

Which general nursing measure is used for a client with a fracture reduction? A.) Promote intake of omega-3 fatty acids B.) Examine the abdomen for enlarged liver or spleen C.) Encourage participation in ADLs D.) Assist with intake of immune-enhancing tube feeding formulas

Answer: C.) Encourage participation in ADLs Rationale: General nursing measures for a client with a fracture reduction include administering analgesics, providing comfort measures, encouraging participation in ADLs, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing the client for self-care. Omega-3 fatty acids have no implications on the diet of a client with a fracture reduction. The nurse does not need to examine the abdomen for enlarged liver or spleen because fracture reduction treatment does not affect these organs. It is unlikely that a client with a fracture reduction will be prescribed immune-enhancing tube feeding formulas.

Which of the following is a term used to describe a soft tissue injury produced by a blunt force? A.) Contusion B.) Sprain C.) Strain D.) Hematoma

Answer: A.) Contusion Rationale: A contusion is a soft tissue injury produced by blunt force, such as a blow, kick, or fall, that results in bleeding into soft tissues (ecchymosis, or bruising). A hematoma develops when the bleeding is sufficient to form an appreciable solid swelling. A strain, or a "pulled muscle," is an injury to a musculotendinous unit caused by overuse, overstretching, or excessive stress. A sprain is an injury to the ligaments and supporting muscle fibers that surround a joint often caused by a trauma, wrenching or twisting motion.

Which may occur if a client experiences compartment syndrome in an upper extremity? A.) Whiplash injury B.) Volkmann's contracture C.) Callus D.) Subluxation

Answer: B.) Volkmann's contracture Rationale: If compartment syndrome occurs in an upper extremity, it may lead to Volkmann's contracture, a claw-like deformity of the hand resulting from obstructed arterial blood flow to the forearm and hand. A whiplash injury is a cervical spine sprain. Callus refers to the healing mass that occurs with true bone formation after a fracture. Subluxation refers to a partial dislocation.

A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis? A.) Keep the affected leg in a position of adduction. B.) Use measures other than turning to prevent pressure ulcers. C.) Prevent internal rotation of the affected leg. D.) Keep the hip flexed by placing pillows under the client's knee.

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

Which nursing diagnosis takes highest priority for a client with a compound fracture? A.) Imbalanced nutrition: Less than body requirements related to immobility B.) Impaired physical mobility related to trauma C.) Infection related to effects of trauma D.) Activity intolerance related to weight-bearing limitations

Answer: C.) Infection related to effects of trauma Rationale: A compound fracture involves an opening in the skin at the fracture site. Because the skin is the body's first line of defense against infection, any skin opening places the client at risk for infection. Imbalanced nutrition: Less than body requirements is rarely associated with fractures. Although Impaired physical mobility and Activity intolerance may be associated with any fracture, these nursing diagnoses don't take precedence because they aren't as life-threatening as infection.

A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in client cast care? A.) "Cover the cast with a blanket until the cast dries." B.) "Keep your right leg elevated above heart level." C.) "Use a knitting needle to scratch itches inside the cast." D.) "A foul smell from the cast is normal."

Answer: B.) "Keep your right leg elevated above heart level." Rationale: The nurse should instruct the client to elevate the leg to promote venous return and prevent edema. The cast shouldn't be covered while drying. Covering the cast will cause heat buildup and prevent air circulation. The client should be instructed not to insert foreign objects into the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection.

A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan? A.) Elevating the stump for the first 24 hours B.) Maintaining the client on complete bed rest C.) Applying heat to the stump as the client desires D.) Removing the pressure dressing after the first 8 hours

Answer: A.) Elevating the stump for the first 24 hours Rationale: Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility. Heat application would be inappropriate because it promotes vasodilation, which may cause hemorrhage and increase pain. The initial pressure dressing usually remains in place for 48 to 72 hours after surgery.

A client with a traumatic amputation of the right lower leg is refusing to look at the leg. Which action by the nurse is most appropriate? A.) Provide wound care without discussing the amputation. B.) Request a referral to occupational therapy. C.) Encourage the client to perform range-of-motion (ROM) exercises to the right leg. D.) Provide feedback on the client's strengths and available resources.

Answer: D.) Provide feedback on the client's strengths and available resources. Rationale: The nurse should encourage the client to look at, and assist with, care of the residual limb. Providing feedback on the client's strengths and resources may allow the client to start to adapt to the body image and lifestyle change. The nurse should also allow time for the client to discuss their feelings related to the amputation. Requesting a referral to occupational therapy and encouraging the client to perform ROM exercises are appropriate but do not address the emotional aspect of losing an extremity.

An older adult client slipped on an area rug at home and fractured the left hip. The client is unable to have surgery immediately and is having severe pain. What interventions should the nurse provide for the patient to minimize energy loss in response to pain? A.) Administer prescribed analgesics around-the-clock. B.) Avoid administering too much medication because the client is older. C.) Administer prescribed pain medication only when the client requests it. D.) Give pain medication to the client after providing care.

Answer: A.) Administer prescribed analgesics around-the-clock.

The client with a fractured left humerus reports dyspnea and chest pain. Pulse oximetry is 88%. Temperature is 100.2 degrees Fahrenheit (38.5 degrees Centigrade); heart rate is 110 beats per minute; respiratory rate is 32 breaths per minute. The nurse suspects the client is experiencing: A.) Complex regional pain syndrome B.) Delayed union C.) Compartment syndrome D.) Fat embolism syndrome

Answer: D.) Fat embolism syndrome

A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction? A.) "Apply ice packs for the first 12 to 18 hours." B.) "Apply heat packs for the first 24 to 48 hours." C.) "Apply ice packs for the first 24 to 48 hours, then apply heat packs." D.) "Apply heat packs for the first 24 hours, then apply ice packs for the next 48 hours."

Answer: C.) "Apply ice packs for the first 24 to 48 hours, then apply heat packs." Rationale: The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing. Applying ice for only 12 to 18 hours may not keep swelling from recurring. Applying heat for the first 24 to 48 hours would worsen, not ease, swelling. Applying ice 48 hours after the injury would be less effective because swelling already has occurred by that time.

An x-ray demonstrates a fracture in which a bone has splintered into several pieces. Which type of fracture is this? A.) Compound B.) Depressed C.) Impacted D.) Comminuted

Answer: D.) Comminuted Rationale: A comminuted fracture may require open reduction and internal fixation. A compound fracture is one in which damage also involves the skin or mucous membranes. A depressed fracture is one in which fragments are driven inward. An impacted fracture is one in which a bone fragment is driven into another bone fragment.

Which of the following disorders results in widespread hemorrhage andmicrothrombosis with ischemia? A.) Disseminated intravascular coagulation (DIC) B.) Avascular necrosis (AVN) C.) Complex regional pain syndrome (CRPS) D.) Fat embolism syndrome (FES)

Answer: A.) Disseminated intravascular coagulation (DIC) Rationale: DIC is a systemic disorder that results in widespread hemorrhage and microthrombosis with ischemia. AVN of the bone occurs when the bone loses its blood supply and dies. CRPS is a painful sympathetic nervous system problem. FES occurs when the fat globules released when the bone is fractured occludes the small blood vessels that supply the lungs, brain, kidneys, and other organs.

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? A.) Sprain B.) Dislocation C.) Subluxation D.) Strain

Answer: A.) Sprain Rationale: 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.

A client is brought to the emergency department after being struck with a baseball bat on the upper arm while diving for a pitched ball. Diagnostic tests reveal that the humerus is not broken but that the client has suffered another type of injury. What type of injury would the physician likely diagnose? A.) contusion B.) sprain C.) strain D.) subluxation

Answer: A.) contusion Rationale: A contusion is a soft tissue injury resulting from a blow or blunt trauma. Sprains are injuries to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A subluxation is a partial dislocation.

In a client with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which complication does the assessments help the nurse to monitor in the client? A.) Disseminated intravascular coagulation B.) Compartment syndrome C.) Carpal tunnel syndrome D.) Fat embolism syndrome

Answer: B.) Compartment syndrome Rationale: The nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable in a client with a dislocation to assess for compartment syndrome. It is a complication associated with dislocation. A client with a dislocation does not experience an increased risk of complications such as disseminated intravascular coagulation, carpal tunnel syndrome, or fat embolism syndrome.

Which of the following would lead a nurse to suspect that a client has a rotator cuff tear? A.) Increased ability to stretch arm over the head B.) Difficulty lying on affected side C.) Pain worse in the morning D.) Minimal pain with movement

Answer: B.) Difficulty lying on affected side Rationale: Clients with a rotator cuff tear experience pain with movement and limited mobility of the shoulder and arm. They especially have difficulty with activities that involve stretching their arm above their head. Many clients find that the pain is worse at night and that they are unable to sleep on the affected side.

A client undergoes open reduction with internal fixation to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan? A.) Performing passive range-of-motion (ROM) exercises on the client's legs once each shift B.) Keeping a pillow between the client's legs at all times C.) Turning the client from side to side every 2 hours D.) Maintaining the client in semi-Fowler's position

Answer: B.) Keeping a pillow between the client's legs at all times Rationale: After open reduction with internal fixation, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period, because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After open reduction with internal fixation, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.

A fracture is considered pathologic when it A.) results in a fragment of bone being pulled away by a ligament or tendon and its attachment. B.) occurs through an area of diseased bone. C.) involves damage to the skin or mucous membranes. D.) presents as one side of the bone being broken and the other side being bent.

Answer: B.) occurs through an area of diseased bone. Rationale: Pathologic fractures can occur without the trauma of a fall. An avulsion fracture results in a fragment of bone being pulled away by a ligament or tendon and its attachment. A greenstick fracture presents as one side of the bone being broken and the other side being bent. A compound fracture involves damage to the skin or mucous membranes.

Which nursing intervention is essential in caring for a client with compartment syndrome? A.) Keeping the affected extremity below the level of the heart B.) Wrapping the affected extremity with a compression dressing to help decrease the swelling C.) Removing all external sources of pressure, such as clothing and jewelry D.) Starting an I.V. line in the affected extremity in anticipation of venogram studies

Answer: C.) Removing all external sources of pressure, such as clothing and jewelry Rationale: Nursing measures should include removing all clothing, jewelry, and external forms of pressure (such as dressings or casts) to prevent constriction and additional tissue compromise. The extremity should be maintained at heart level (further elevation may increase circulatory compromise, whereas a dependent position may increase edema). A compression wrap, which increases tissue pressure, could further damage the affected extremity. There is no indication that diagnostic studies would require I.V. access in the affected extremity.