Chapter 54: Care of Patients with Musculoskeletal Trauma....

A client is admitted to the emergency department after a motorcycle accident with a compound fracture of the left femur. Which action will be most essential for the nurse to take first? A. Check the dorsalis pedis pulses. B. Immobilize the left leg with a splint. C. Administer the prescribed analgesic. D. Place a dressing on the affected area.

A. Check the dorsalis pedis pulses. Rationale A. The first action should be to assess the circulatory status of the leg because the client is at risk for acute compartment syndrome (ACS), which can begin as early as 6 to 8 hours after an injury. Severe tissue damage can also occur if neurovascular status is compromised. B. Immobilization will be needed, but the nurse must assess the client's condition first. C. The nurse needs to first assess the client before administering an analgesic. D. This should be done after the nurse has assessed the client.

The nurse prepares to perform a neurovascular assessment on the client with closed multiple fractures of the right humerus. Which technique will the nurse use? A. Inspect the abdomen for tenderness and bowel sounds. B. Auscultate lung sounds. C. Assess the level of consciousness and ability to follow commands. D. Assess sensation of the right upper extremity.

D. Assess sensation of the right upper extremity. Rationale A. Inspecting the abdomen of the client with multiple fractures is not part of a focused neurovascular assessment. B. Auscultating lung sounds of the client with multiple fractures is not part of a focused neurovascular assessment. C. Because the client does not have a head injury, assessing the client's level of consciousness and ability to follow commands is not part of a focused neurovascular assessment for this client. D. Assessing sensation of the right upper extremity is part of a focused neurovascular assessment for the client with multiple fractures of the right humerus.

Which nursing action will the nurse on the orthopedic unit plan to delegate to unlicensed assistive personnel (UAP)? A. Remove the wound drain for a client who had an open reduction of a hip fracture 3 days ago. B. Assess for bruising on a client who is receiving warfarin (Coumadin) to prevent deep vein thrombosis. C. Teach a client with a right ankle fracture how to use crutches when transferring and ambulating. D. Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago.

D. Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago. Rationale A. Removing a drain requires broader education and is within the scope of practice of licensed nursing staff. B. Assessment requires broader education and is within the scope of practice of a licensed nurse. C. Client teaching requires broader education and is within the scope of practice of a licensed nurse. D. Vital sign assessment is a skill that is within the role of the UAP.

A rock climber has sustained an open fracture of the right tibia after a 20-foot fall. The nurse plans to assess the client for which potential complications? Select all that apply. A. Acute compartment syndrome (ACS) B. Fat embolism syndrome (FES) C. Congestive heart failure D. Urinary tract infection (UTI) E. Osteomyelitis

A. Acute compartment syndrome (ACS) B. Fat embolism syndrome (FES) E. Osteomyelitis Rationale Congestive heart failure is not a potential complication for this client. Pulmonary embolism is a potential complication for venous thromboembolism, which can occur with fracture.

The client's left arm is placed in a plaster cast. Which assessment will the nurse perform before the client is discharged? A. Assess that the cast is dry. B. Ensure that the client has 4 × 4 gauze to take home for placement between the cast and the skin. C. Check the fit of the cast by inserting a tongue blade between the cast and the skin. D. Ensure that the capillary refill of the left fingernail beds is longer than 3 seconds.

A. Assess that the cast is dry. Rationale A. The cast must be dry and free of cracking and crumbling. B. The client should not place anything between the cast and the skin. C. In assessing fit, one finger should easily fit between the cast and the skin. D. Capillary refill longer than 3 seconds indicates impairment of the circulation in the extremity and requires the health care provider's immediate attention.

The nurse plans to refer a client with an amputation and the client's family to which community resource? A. American Amputee Society (AAS) B. Amputee Coalition of America (ACA) C. Community Workers for Amputees (CWA) D. National Amputee of America Society (NAAS)

B. Amputee Coalition of America (ACA) Rationale A. The AAS is not an organization that actually exists. B. The ACA is an available resource for clients with amputations and supports them and their families. C. The CWA is not an organization that actually exists. D. The NAAS is not an organization that actually exists.

The nurse admits an older adult client who sustained a left hip fracture and is in considerable pain. The nurse anticipates that the client will be placed in which type of traction? A. Balanced skin traction B. Buck's traction C. Overhead traction D. Plaster traction

B. Buck's traction Rationale A. Balanced skin traction is indicated for fracture of the femur or pelvis. B. Buck's traction may be applied before surgery to help decrease pain associated with muscle spasm. C. Overhead traction is indicated for fracture of the humerus with or without involvement of the shoulder and clavicle. D. Plaster traction is indicated for wrist fracture.

The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal injury. What information will the nurse include in the teaching plan? A. Avoid contact sports. B. Avoid rigorous exercise. C. Wear helmets when riding a motorcycle. D. Avoid driving in inclement weather.

C. Wear helmets when riding a motorcycle. Rationale A. Telling the general public to avoid contact sports is not realistic. B. Telling the general public to avoid rigorous exercise is not only unrealistic, it is also opposed to what many health care professionals recommend to maintain health. C. Those who ride motorcycles or bicycles should wear helmets to prevent head injury. D. Telling the general public to avoid driving in inclement weather is not realistic.

The client with a fracture asks the nurse about the difference between a compound fracture and a simple fracture. Which statement by the nurse is correct? A. "Simple fracture involves a break in the bone, with skin contusions." B. "Compound fracture does not extend through the skin." C. "Simple fracture is accompanied by damage to the blood vessels." D. "Compound fracture, grade I, involves minimal skin damage."

D. "Compound fracture, grade I, involves minimal skin damage." Rationale A. A grade II compound fracture involves a break in the bone, with skin contusions. B. A simple fracture does not extend through the skin. C. A grade III compound fracture is accompanied by damage to blood vessels. D. A grade I compound fracture involves minimal damage to the skin.

The client is recovering from an above-knee amputation resulting from peripheral vascular disease. Which statement indicates that the client is coping well after the procedure? A. "My spouse will be the only person to change my dressing." B. "I can't believe that this has happened to me. I can't stand to look at it." C. "I do not want any visitors while I'm in the hospital!" D. "It will take me some time to get used to this."

D. "It will take me some time to get used to this." Rationale A. The client is not coping effectively because he or she does not want to participate in self-care. B. The client is not coping effectively because he or she is unwilling to address what has happened. C. The client who does not want to receive visitors is having difficulty coping with the change in body image. D. This statement indicates that the client is expressing acceptance and effective coping.

The older adult client has had a right open reduction internal fixation (ORIF) of a fractured hip. Which intervention will the nurse implement for this client? A. Keep the client's heels off the bed at all times. B. Reposition the client every 3 to 4 hours. C. Administer preventive pain medication during deep-breathing exercises. D. Prohibit the use of antiembolic stockings.

A. Keep the client's heels off the bed at all times. Rationale A. Because the client is an older adult and is more at risk for skin breakdown because of impaired circulation and sensation, the client's heels must be kept off the bed at all times to avoid constant pressure on this sensitive area. B. Repositioning the older adult client must be done every 2 hours to prevent skin breakdown and to inspect the skin for any signs of breakdown. C. Pain medication would not be administered for deep-breathing exercises because this client typically would not experience pain on breathing. D. Antiembolic stockings are not contraindicated for older adults. They help prevent deep vein thrombosis.

The client has undergone an elective below-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse instructs the client to notify the health care provider if which change occurs? A. Observation of a large amount of serosanguineous or bloody drainage B. Mild to moderate pain controlled with prescribed analgesics C. Absence of erythema and tenderness at the surgical site D. Ability to flex and extend the right knee

A. Observation of a large amount of serosanguineous or bloody drainage Rationale A. A large amount of serosanguineous or bloody drainage may indicate hemorrhage or, if an incision is present, that the incision has opened. This requires immediate attention. B. Mild to moderate pain controlled with prescribed analgesics would be a normal finding for this client. C. Absence of erythema and tenderness of the surgical site would be normal findings for this client. D. The client should be able to flex and extend the right knee (limb) after surgery.

The nurse anticipates providing collaborative care for a client with a traumatic amputation of the right hand with which health care team members? Select all that apply. A. Occupational therapist B. Physical therapist C. Psychologist D. Respiratory therapist E. Speech therapist

A. Occupational therapist B. Physical therapist C. Psychologist Rationale The client has an amputation and does not have a respiratory condition that warrants collaborative care with a respiratory therapist.

Which intervention will the nurse suggest to a client with a leg amputation to help cope with loss of the limb? A. Talking with an amputee close to the client's age who has had the same type of amputation B. Drawing a picture of how the client sees himself or herself C. Talking with a psychiatrist about the amputation D. Engaging in diversional activities to avoid focusing on the amputation

A. Talking with an amputee close to the client's age who has had the same type of amputation Rationale A. Meeting with someone of a comparable age who has gone through a similar experience will help the client cope better with his or her own situation. B. Drawing a picture is not therapeutic and may cause more harm than good. C. Unless the client is having serious maladjustment problems or has a coexisting psychological disorder, meeting with a psychiatrist should not be necessary. D. Diversional activities do not help the client deal with loss of the limb.

The client has sustained a fracture of the left tibia. The extremity is immobilized using an external fixation device. Which postoperative instruction will the nurse plan to include in this client's teaching plan? A. Use pain medication as prescribed to control pain. B. Clean the pin site when any drainage is noticed. C. Wear the same clothing that is normally worn. D. Apply Neosporin (bacitracin, neomycin, and polymyxin B) if signs or symptoms of infection develop around pin sites.

A. Use pain medication as prescribed to control pain. Rationale A. The client should be taught the correct use of prescribed pain medication to control pain adequately. B. Pin sites must be cleaned at least every 8 hours and as needed to reduce the risk for infection. C. The client will have to adjust the type of clothing that is worn while the fixation device is in place. D. If signs and symptoms of infection develop around the pin sites, the client must notify the health care provider immediately. Infection at the pin sites places the client at risk for osteomyelitis.

Which statement indicates to the nursing instructor that the nursing student understands the normal healing process of bone after a fracture? A. "A callus is quickly deposited and transformed into bone." B. "A hematoma forms at the site of the fracture." C. "Calcium and vascular proliferation surround the fracture site." D. "Granulation tissue reabsorbs the hematoma and deposits new bone."

B. "A hematoma forms at the site of the fracture." Rationale A. In stage 4 of a healing fracture, callus is gradually reabsorbed and transformed into bone. B. In stage 1, within 24 to 72 hours after a fracture, a hematoma forms at the site of the fracture because bone is extremely vascular. This then prompts the formation of fibrocartilage, providing the foundation for bone healing. C. Stage 3 of bone healing occurs as a result of vascular and cellular proliferation. D. Stage 2 of bone healing occurs within 3 days to 2 weeks after the fracture, when granulation tissue begins to invade the hematoma.

A client has a new synthetic arm cast for a radial fracture. What health care teaching does the nurse include for the client's home care? Select all that apply. A. "Apply heat on the cast for the first 24 hours to increase blood flow for healing." B. "Keep your arm elevated, preferably above your heart, as much as possible." C. "Report severe numbness or inability to move your fingers to your physician." D. "Take your pain medication as needed according to the prescription directions." E. "Don't cover the cast with anything because it will stay wet for 24 hours."

B. "Keep your arm elevated, preferably above your heart, as much as possible." C. "Report severe numbness or inability to move your fingers to your physician." D. "Take your pain medication as needed according to the prescription directions." Rationale The nurse will need to provide some teaching to prepare the client for discharge home. The primary nursing concern is assessment and prevention of neurovascular dysfunction or compromise. The client should immediately report numbness or the inability to move the fingers. The client should be instructed to take pain medication for discomfort that may accompany the fracture. Elevate the fractured extremity higher than the heart, and apply ice for the first 24 to 48 hours as needed to reduce edema. The client should apply ice for the first 24 to 48 hours. Synthetic materials for casts are much more common and include fiberglass and polyester-cotton knit, which are lighter than plaster and require minimal drying time.

Which typical clinical manifestation does the nurse expect to observe for a client with a right tibial fracture? A. Flaccid extremity B. Crepitation of extremity C. Mild pain D. No evidence of edema

B. Crepitation of extremity Rationale A. The client with a fracture will typically have a decreased range of motion (ROM) in the affected extremity, but not flaccidity. B. On assessment, crepitation (a continuous grating sound created by bone fragments) may be heard when the affected extremity is moved. C. Clients with a fractured extremity usually report moderate to severe pain at the site of the fracture or in an adjacent or distal area. D. Swelling is commonly seen at a fracture site. It can occur rapidly and may result in marked neurovascular compromise.

Which information about a client who was admitted with pelvic and bilateral femoral fractures after being crushed by a tractor is most important for the nurse to report to the physician? A. Thighs have multiple oozing abrasions. B. Serum potassium level is 7 mEq/L. C. The client is describing pain at a level 4 (0 to 10 scale). D. Hemoglobin level is 12.0 g/dL.

B. Serum potassium level is 7 mEq/L. Rationale A. This finding is not unusual for a client with this history. B. The elevated potassium level may indicate that the client has rhabdomyolysis and acute tubular necrosis caused by the crush injury. Further assessment and treatment are needed immediately to prevent further renal damage or cardiac dysrhythmias. C. A pain level of 4 is not an unusual finding for a client with this condition. D. A hemoglobin level of 12.0 g/dL is a normal finding.

The client has a grade III compound fracture of the right tibia. To prevent infection, which intervention will the nurse implement? A. Applying Neosporin (bacitracin, neomycin, and polymyxin B) ointment to the site daily with a sterile cotton-tipped swab B. Using strict aseptic technique when cleaning the site C. Leaving the site open to the air to keep it dry D. Assisting the client to shower daily and pat the wound site dry

B. Using strict aseptic technique when cleaning the site Rationale A. Chlorhexidine (Hexicleans), 2 mg/mL solution, is the better cleansing solution for pin site care, not Neosporin ointment. B. Using aseptic technique is the best way to prevent infection. C. A wound of this type should be kept covered. D. The wound site of a compound fracture must not be exposed to a shower. This practice violates maintaining aseptic technique.

A client who had an elective below-the-knee amputation reports pain in the part of his leg that was amputated. What is the nurse's best response to his pain? A. "The pain will go away in a few days or so." B. "That's phantom limb pain and every amputee has that." C. "On a scale of 0 to 10, how would you rate your pain?" D. "The pain is not real, so we don't treat it."

C. "On a scale of 0 to 10, how would you rate your pain?" Rationale The nurse should recognize the client's phantom limb pain as real and treat it aggressively. A combination of drug therapy and complementary and alternative therapies is the best approach for pain management. The phantom limb pain may not subside in a few days. Not all clients who have experienced an amputation have phantom limb pain; it is more common in above-the-knee amputations.

The client is in skeletal traction. Which nursing intervention ensures proper care of this client? A. Ensure that weights are attached to the bed frame or placed on the floor. B. Ensure that pins are not loose, and tighten as needed. C. Inspect the skin at least every 8 hours. D. Remove the traction weights only for bathing.

C. Inspect the skin at least every 8 hours. Rationale A. Weights are not allowed to be placed on the floor. Weights should hang freely at all times. B. Pin sites are checked for signs and symptoms of infection and for security in their position to the fixation and the client's extremity. However, the nurse does not adjust the pins. Any loose pin site or alteration must be reported to the health care provider. C. Inspect the skin every 8 hours for signs of irritation, inflammation, or actual skin breakdown. D. Weights must never be removed without a request from the health care provider.

The nurse is concerned that a client who had an open reduction, internal fixation of his tibia and fibula is at risk for complex regional pain syndrome. What assessment findings at the affected area are common when a client has this complication? Select all that apply. A. Dull, aching pain B. Decrease in sweating C. Muscle spasms D. Skin discoloration E. Paresis F. Edema

C. Muscle spasms D. Skin discoloration E. Paresis F. Edema Rationale Muscle spasms, skin discoloration, paresis, and edema are all manifestations that present in complex regional pain syndrome. The client experiencing this syndrome would have intense, unrelenting, burning pain rather than dull, aching pain, as well as excessive (not decreased) sweating due to dysfunction of the autonomic nervous system.

The client has sustained a rotator cuff tear while playing baseball. The nurse anticipates that the client will receive which immediate conservative treatment? A. Surgical repair of the rotator cuff B. Prescribed exercises of the affected arm C. Sling for the affected arm D. Patient-controlled analgesia with morphine

C. Sling for the affected arm Rationale A. Surgical intervention is not considered conservative treatment. B. Exercises are prohibited immediately after a rotator cuff injury. C. The conservative treatment for this client is to place the injured arm in a sling or immobilizer. D. The client with a rotator cuff injury is treated primarily with nonsteroidal anti-inflammatory drugs (NSAIDs) to manage pain.

An older adult client has multiple tibia and fibula fractures of the left lower extremity after a motor vehicle accident. Which pain medication does the nurse anticipate will be requested for this client? A. Cyclobenzaprine (Flexeril) B. Ibuprofen (Advil, Motrin, Dolgesic, others) C. Meperidine (Demerol) D. Patient-controlled analgesia (PCA) with morphine

D. Patient-controlled analgesia (PCA) with morphine Rationale A. Muscle relaxants are effective for treating pain related to muscle spasms, but they are not adequate for this type of acute pain. B. Ibuprofen (Advil, Motrin, Dolgesic, others) is a nonsteroidal anti-inflammatory that is used to treat mild to moderate pain. Bone pain is very acute. C. Meperidine (Demerol) should never be used for older adults because it has toxic metabolites that can cause seizures. D. Morphine is an opioid narcotic analgesic; given through PCA, it is the most appropriate mode of pain management for this type of acute pain associated with multiple injuries.

The client is brought to the emergency department (ED) via ambulance after a motor vehicle accident. What condition will the nurse assess for first? A. Bleeding B. Head injury C. Pain D. Respiratory distress

D. Respiratory distress Rationale A. Bleeding is the second assessment priority in this case. B. Head injury is the third assessment priority in this case. C. Pain is the fourth assessment priority in this case. D. The client is first assessed for respiratory distress, and any oxygen interventions are instituted accordingly.