Exam 4 - Common
Which radiographic test is used to view the entire skeleton? 1 Bone scan 2 Gallium and thallium scan 3 Computed tomography (CT) 4 Magnetic resonance imaging (MRI) scan
Answer 1 A bone scan is a radionuclide test in which radioactive material is injected so that the client's entire skeleton can be viewed. Gallium and thallium scans are similar to bone scans but are more specific and sensitive in detecting bone disorders. A CT scan is used to detect musculoskeletal problems, primarily in the vertebral column and joints. An MRI scan is used to diagnose musculoskeletal disorders.
Which physiologic changes of the musculoskeletal system are related to aging? Select all that apply. 1 Slowed movement 2 Cartilage degeneration 3 Increased bone density 4 Increased range of motion 5 Increased bone prominence
Answers 1, 2, and 5 The physiologic changes of the musculoskeletal system related to aging are slowed movements, cartilage degeneration, increased bone prominence, decreased bone density, and decreased range of motion.
A 70-year-old client is diagnosed with cartilaginous degeneration. Which action should the nurse take? 1. Advise the client to use moist heat 2. Teach the client isometric exercises 3. Provide the client with supportive armchairs 4. Demonstrate weight-bearing exercises to the client
Answer 1 Clients with cartilaginous degeneration are advised to take moist heat showers because they increase blood flow to the region. Isometric exercises are indicated for clients with muscular atrophy. Sitting in a supportive armchair provides support to bony structures and prevents further deformities in a client with kyphosis. Weight-bearing exercises are indicated in clients with decreased bone density.
After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. What is the nurse's greatest concern at this time? 1 Addressing the pain 2 Reversing feelings of hopelessness 3 Promoting mobility in the residual limb 4 Acknowledging the grieving for the lost limb
Answer 1 Phantom limb sensation is a real experience with no known cause or cure. The pain must be acknowledged and interventions to relieve the discomfort explored. There are no data indicating that the client is hopeless. Although promoting mobility in the residual limb may be effective for some people, it may not be effective for others; all possible interventions should be explored. There are no data indicating that the client is grieving.
Which joint in the human body is an example of a condyloid joint? 1 Wrist joint 2 Elbow joint 3 Shoulder joint 4 Sacroiliac joint
Answer 1 The wrist joint is an example of a condyloid joint. It is a joint between the radial and carpals. The elbow joint is an example of a hinge joint. The shoulder joint is an example of a ball and socket joint. The sacroiliac joint is an example of a gliding joint. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.
The nurse is caring for a client with a long leg cast. Which clinical findings indicate compromised circulation? Select all that apply. 1. Foul odor 2. Swelling of the toes 3. Drainage on the cast 4. Increased temperature 5. Prolonged capillary refill
Answer 2 and 5 Constriction of circulation decreases venous return and increases pressure within the vessels. Fluid then moves into the interstitial spaces, causing edema. Impaired circulation is evidenced by prolonged capillary refill after the toes are compressed. A foul odor, drainage on the cast, or an increased temperature may indicate the presence of an infection.
The nurse is providing discharge teaching to a patient who had a myelogram. What would the nurse include in the teaching plan? a. Take acetaminophen (Tylenol) to prevent a fever. b. Remain flat in bed for 24 to 48 hours to prevent pain. c. Decrease fluid intake for 4 to 8 hours to prevent nausea. d. Report a headache that is worse when sitting or standing.
Answer: D Rationale: The main risk after a myelogram is a spinal headache. Patients should be taught to report a headache to the health care provider. The headache usually resolves in 1 to 2 days with rest and fluids. Fluid intake should be increased to hasten absorption or residual contrast, to replace cerebrospinal fluid, and to reduce the risk of headache. Bed rest is usually indicated for a few hours after testing. A fever should be reported; it may indicate an infection and is not expected after a myelogram.
The nurse considers that a 70-year-old female client can best limit further progression of osteoporosis by doing what? 1 Taking supplemental calcium and vitamin D 2 Increasing the consumption of eggs and cheese 3 Taking supplemental magnesium and vitamin E 4 Increasing the consumption of milk and milk products
Answer 1 Research demonstrates that women past menopause need at least 1500 mg of calcium a day, which is almost impossible to obtain through dietary sources; because the average daily consumption of calcium is 300 to 500 mg. Vitamin D promotes the deposition of calcium into the bone. Consumption of eggs and cheese does not contain adequate calcium to meet requirements to prevent osteoporosis; these do not contain vitamin D unless fortified. If large amounts of magnesium are present, calcium absorption is impeded because magnesium and calcium absorption are competitive; vitamin E is unrelated to osteoporosis. Milk and milk products may not be consumed in quantities adequate to meet requirements to prevent osteoporosis.
A nurse receives a change-of-shift report for a client who had a total hip replacement 24 hours ago. After reviewing the client's clinical record and completing a physical assessment, the nurse should conclude that the client is experiencing which complication? 1. Fat embolism 2. Urinary retention 3. Hypovolemic shock 4. Pulmonary embolism
Answer 1 The client most likely is experiencing fat embolism syndrome (FES). The average time of onset of FES is 18 to 24 hours after injury to long bones or a crushing injury. Fat globules and tissue thromboplastin exit from bone marrow and local tissue as a result of injury. Fat molecules enter venous circulation, move to lungs, and embolize small capillaries. Petechial rash on the neck, chest, conjunctivae, or axillae is a classic sign of FES (occurs in 50% to 60% of clients with FES). Increased temperature, pulse rate, and respirations are associated with FES; 75% of clients with FES exhibit neurologic signs, such as altered mental state, restlessness, agitation, lethargy, confusion, or coma. The client is not experiencing urinary retention, because output indicates adequate hourly output of at least 50 mL/hr. The client is not experiencing hypovolemic shock. Although the client may experience tachypnea, tachycardia, and an increased temperature with hypovolemic shock, the blood pressure will decrease and the urine output will decrease to less than 30 mL/hr. The client is not experiencing a pulmonary embolism; this is more likely to occur 4 to 10 days after trauma. Although tachypnea, tachycardia, an increased temperature, restlessness, and agitation are common with pulmonary embolism, the client is not exhibiting sudden chest pain, dyspnea, cough, hemoptysis, or areas of dullness or crackles when auscultating breath sounds.
A client injures an amphiarthrodial joint. Which joint did the client injure? 1 Knee joint 2 Pelvic joint 3 Elbow joint 4 Cranial joint
Answer 2 Amphiarthrodial joints are those that permit slight movements. The pelvic joint is an example of amphiarthrodial joint. Knee and elbow joints are the examples of diarthrodial joints, which are freely movable. A cranial joint is an example of a synarthrodial joint, which is immovable.
A client sustains a fractured right femur after an automobile accident and is admitted to the hospital's emergency department. Which assessment is the priority? 1 Turn the client to the side-lying position. 2 Take the client's pedal pulse in the affected extremity. 3 Instruct the client to wiggle the toes of the right foot. 4 Ask the client if numbness or tingling is present in the right foot.
Answer 2 Monitoring a pedal pulse will assess the circulation to the foot. Palpate the pulse distal to the injury. Turning the client to the side-lying position is contraindicated if a fracture of the femur is suspected; moving this client can cause further trauma. The inability to wiggle the toes indicates neurologic, not circulatory, impairment. The presence of numbness or tingling indicates that paresthesia is present, indicating neurologic damage. Circulation is the priority in this situation.
The nurse is teaching an elderly client isometric exercises. Which physiologic condition does the client have? 1. Kyphosis 2. Muscle atrophy 3. Decreased bone density 4. Decreased range of motion (ROM)
Answer 2 Muscle atrophy occurs due to muscular weakness; isometric exercises can help increase muscular strength. Kyphosis can be reduced by introducing the client to proper body mechanics and instructing the client to sit in supportive chairs with arms. Complications associated with decreased bone density can be reduced by teaching safety tips to prevent falls and by reinforcing the need to exercise. The nurse should assess the client's ability to perform activities of daily living and mobility in a client with a decreased ROM.Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.
A nurse teaches about osteochondroma. Which information should the nurse include in the teaching session? 1 It is a common malignant tumor. 2 It occurs most often in the age group of 10 to 25. 3 It has a high rate of local occurrence after surgery. 4 It frequently arises in cancellous ends of arm and leg bones.
Answer 2 Osteochondroma is common in the age group of 10 to 25 years. It is a primary benign tumor. Osteoclastoma has a high rate of local occurrence after surgery and chemotherapy. Osteoclastoma frequently arises in cancellous ends of arm and leg bones; osteocondroma occurs in the metaphyseal portion of long bones.
A client returns from surgery after a right below-the-knee amputation with the residual limb elevated on a pillow to prevent edema. In which position should the nurse place the client after the first postoperative day? 1 With the residual limb immobilized 2 Turn client to prone position at least three times a day 3 For short periods in the right side-lying position 4 With the residual limb elevated for a total of three days
Answer 2 Positioning the client in the prone position for short periods helps prevent hip flexion contractures. The client's residual limb should not be immobilized. Exercises to prevent contractures are begun as soon as possible. Positioning the client in the right side-lying position can cause trauma to the incision site and should be avoided. The client's residual limb should not be elevated for more than 48 hours because hip flexion contractures can result. Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer.
Shoulder immobilization is prescribed after surgical repair of a client's rotator cuff. Which criterion should the nurse use to determine that appropriate alignment is achieved by the immobilizer device? 1. Forearm moves freely. 2. Upper arm is in abduction. 3. Hand is lower than the elbow. 4. Upper arm lies close to the chest.
Answer 4 A shoulder immobilization device supports the upper arm in adduction, with the elbow bent to minimize tension in the operative area. The forearm is supported with the hand and elbow level to each other. There is limited motion in the forearm with a shoulder immobilization device in place. The upper arm is in adduction, not abduction. The forearm is kept horizontal, with the hand and elbow level to each other to prevent dependent edema.
A client with a fracture is found to have compartment syndrome. Which interventions will be contraindicated? Select all that apply. 1. Splitting the cast in half 2. Applying cold compresses 3. Reducing the traction weight 4. Loosening the client's bandage 5. Elevating the extremity above heart level
Answer 2 and 5 Cold compresses and elevating above the heart level are contraindicated for compartment syndrome. Compartment syndrome is a condition in which swelling and increased pressure within a limited space (a compartment) press on and compromise the function of blood vessels, nerves, and tendons that run through that compartment. Application of cold compresses could result in vasoconstriction and exacerbate compartment syndrome. Elevating the extremity above heart level could lower venous pressure and slow arterial perfusion. Splitting the cast in half decreases pressure and is beneficial in treating compartment syndrome. Reducing traction weight is beneficial because it decreases external circumferential pressure. Loosening the bandage is beneficial because it decreases pressure.Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options are likely related to the situation, but only some of the options may be related directly to the situation.
Which principle should the nurse consider when assisting a client with crutches to learn the four-point gait? 1 Elbows should be kept in rigid extension. 2 Most of the weight should be supported by axillae. 3 The client must be able to bear weight on both legs. 4 The affected extremity should be kept off the ground.
Answer 3 In the four-point gait, the client brings the left crutch forward first, followed by the right foot; then the right crutch is brought forward, followed by the left foot. Thus, both legs must be able to bear some weight. Although the arms are extended to allow the hands to bear weight, the elbows are not maintained in this position. Pressure on the axillae may damage nerves in the area. Both extremities must be able to bear weight. STUDY TIP: A helpful method for decreasing test stress is to practice self-affirmation. After you have adequately studied and really know the material, start looking in the mirror each time you pass one and say to yourself—preferably out loud—"I know this material, and I will do well on the test." After several times of watching and hearing yourself reaffirm your knowledge, you will gain inner confidence and be able to perform much better during the test period. This technique really works for students who are adventurous enough to use it. It may feel silly at first, but if it works, who cares? It will work for performing skills in clinical as well, as long as you have practiced the skill sufficiently.
A client with a distal femoral fracture has a long leg cast applied. Which important element of a discharge program should the nurse focus on when teaching crutch-walking? 1 Establishing a schedule for pain medication 2 Maintaining a fixed schedule of daily activities 3 Modifying the home environment to prevent accidents 4 Understanding that a more sedentary lifestyle is necessary
Answer 3 Modifications in the home may be needed to permit safe use of crutches. Pain medications should not be required on a regular basis. The client may vary the schedule of activities based on abilities and responses to activities. The client does not have to be sedentary; crutches are used for ambulation.
During a follow-up visit, a nurse finds that flexion contractures have developed in a client with osteoarthritis (OA). Which factor may have led to this condition? 1. Wearing shoes without insoles 2. Elevating the legs 8 to 12 inches 3. Using large pillows under the knees or head 4. Placing a small pillow under the head in the supine position
Answer 3 The use of large pillows under the knees or head may result in flexion contractures that keep the client from straightening the knees fully. A client with OA will have severe pain in the affected joint during or after movement. In this case, the client should be taught to position the joints in the functional position. Wearing shoes without insoles may result in pressure on painful metatarsal joints. The legs may be elevated 8 to 12 inches (20 to 30 cm) to reduce back discomfort associated with OA. A small pillow can be used under the head when the client is in the supine position to reduce discomfort, but the use of other pillows should be avoided.
A stationary (nonrolling) walker has been prescribed for a client to aid in ambulation. Which instruction is the best description the nurse can provide when teaching a client how to use a walker? 1. Place the back walker leg tips about an arm's length ahead of the feet, shift the body weight to the walker, and step forward. 2. Move the walker about an arm's length ahead while stepping forward and transferring body weight to all walker leg tips. 3. Put the front walker leg tips about an arm's length ahead of the feet, shift the body weight to the walker, and step forward. 4. Position the front walker leg tips onto the floor about an arm's length ahead of the feet and step forward until all tips touch the floor.
Answer 3 There are three critical concepts to this instruction: Stability, position, and weight bearing. Having all four walker leg tips on the floor provides stability. Positioning the front (not the back) walker leg tips at about an arm's length forward is a safe distance ahead to transfer weight. Putting weight on the walker equalizes weight bearing on the upper and lower extremities. Conversely, placing the back walker leg tips at about arm's length in front of the feet, shifting the body weight to the walker, and stepping forward places the walker too far in front of the client for safe transfer of body weight and all four legs must be touching the floor. It is also not possible to move the walker while also having it bear weight simultaneously. All of the walker leg tips should be touching the floor when the client is stepping forward.
A nurse administers an estrogen agonist to a client. Which nursing actions would be beneficial? Select all that apply. 1. Observing the client for signs of hypercalcemia 2. Ensuring that the client has a dental examination before starting the drug 3. Teaching the client about signs and symptoms of venous thromboembolism (VTE) 4. Monitoring the client's liver function tests (LFTs) in collaboration with the primary healthcare provider 5. Observing the client for central nervous system (CNS) adverse effects, such as drowsiness, anxiety, and agitation
Answer 3 and 4 Estrogen agonists may cause adverse effects that result in VTE; the client should be taught about the signs and symptoms of VTE that may occur in the first four months of estrogen agonist therapy. Monitoring LFTs in collaboration with the primary healthcare provider is also beneficial because this action may reduce the risk of hepatic disease. Clients taking calcium supplements should be observed for signs of hypercalcemia. Ensuring that the client has had a dental examination before starting bisphosphonate therapy would avoid jaw or maxillary osteonecrosis. Clients taking bisphosphonates should also be observed for CNS adverse effects, such as drowsiness, anxiety, and agitation.
A client with osteomyelitis receiving ciprofloxacin therapy is taught about the pros and cons of the therapy. Which statement made by the client indicates effective learning? 1. "I should go for a weekly change of dressing." 2. "I should stop taking the medication once symptoms decrease." 3. "I should not the remove soiled dressing without someone's assistance." 4. "I should contact the primary healthcare provider in case of white patches in the mouth."
Answer 4 Ciprofloxacin causes adverse effects like formation of whitish-yellow or curd-like lesions in the mouth and itching in the perianal area. Therefore, the client's statement that the primary healthcare provider should be contacted in case of white patches in the mouth indicates effective learning. Dressings should be changed once soiled, not weekly. The client must take the antibiotic even after the symptoms have subsided and feels better. If the drug is abruptly discontinued, this may cause drug resistance. There are no restrictions as to who should change the dressing; the client can also change the dressing as needed.Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.
Which assessment finding supports the nurse's conclusion that a prosthesis for a client with an above-the-knee amputation fits correctly? 1. Skin that is cool to the touch 2. Shrinking of the residual limb 3. Absence of phantom limb pain 4. Evenly darkened skin of the residual limb
Answer 4 Even distribution of hemosiderin (iron-rich pigment) in the tissue in response to pressure of the prosthesis indicates a proper fit. Cool skin may indicate inadequate tissue perfusion, which may be caused by progression of the disease, inadequate wound healing, or excessive pressure from the prosthesis. Shrinking of the residual limb results in an improper fit. Absence of phantom limb pain is unrelated to a proper fit.
A nurse records a 3 for a client during an assessment of muscle strength. According to the muscle strength scale, what does a score of 3 indicate in the client? 1. Absence of muscular contraction 2. Active movement against full resistance 3. Barely detectable contraction with palpation 4. Active movement against gravity only, and not against resistance
Answer 4 The muscle-strength test is useful to grade the strength of a client's muscles during contraction. The presence of active movement against gravity and not against resistance receives a score of 3 as per the muscle-strength scale. The complete absence of muscular contraction is scored as 0. The active movement against full resistance without evident fatigue indicates normal muscle strength and is scored as 5. Barely detectable contraction indicates weak muscle tone and is scored as 1.
A client with rheumatoid arthritis asks the nurse about ways to decrease morning stiffness. What should the nurse suggest? 1 Wearing loose but warm clothing 2 Planning a short rest break periodically 3 Avoiding excessive physical stress and fatigue 4 Taking a hot tub bath or shower in the morning
Answer 4 Moist heat increases circulation and decreases muscle tension, which help relieve chronic stiffness. Although wearing loose but warm clothing is advisable for someone with arthritis, it does not relieve morning stiffness. Inactivity promotes stiffness. The practice of avoiding excessive physical stress and fatigue is related to muscle fatigue, not to stiffness of joints.
When caring for a patient following a lumbar laminectomy, the nurse should a. place a pillow between the patient's legs before turning to the side. b. elevate the head of the bed 30 degrees and then turn the patient to the side. c. ask the patient to flex the knees and push the heels into the bed during turning. d. have the patient grasp the side rail on the opposite side of the bed to help with turning.
Answer: A Rationale: Place pillows between the legs before turning the patient and when in the side-lying position to provide comfort and ensure alignment. Twisting movements are not allowed. Also, the patient's spine will need to be kept in alignment without flexion of the hips by elevating the head of the bed.
The nurse notices that a patient has a disturbed gait. To further assess this problem, which action should the nurse take? a. Measure the length of both legs. b. Perform deep palpation of the hip joints. c. Test range of motion of the lower extremities. d. Perform muscle-strength testing of the legs.
Answer: A Rationale: When length discrepancies or subjective problems are noted, obtain limb length and circumferential muscle mass measurements. For example, measure leg length when gait disorders are observed. Measure the affected limb between the anterior-superior iliac crest and the bottom of the medial malleolus. Then compare it with the similar measurement of the opposite extremity.
Alendronate (Fosamax) is prescribed for a patient with osteoporosis. The nurse teaches the patient that a. the drug must be taken with food to prevent GI side effects. b. bisphosphonates prevent calcium from being taken from the bones. c. lying down after taking the drug prevents light-headedness and dizziness. d. taking the drug with milk enhances the absorption of calcium from the bowel.
Answer: B Rationale: Alendronate is a bisphosphonate that prevents calcium from being taken from the bones by inhibiting osteoclast-mediated bone resorption. Bisphosphonates should be taken with a full glass of water, 30 minutes before food or other medications, and the patient should remain upright for at least 30 minutes after administration. These precautions aid in drug absorption and decrease gastrointestinal side effects (especially esophageal irritation).
The nurse determines that teaching about management of osteoarthritis of the feet and hands has been effective when the patient says a. "I will be careful to avoid crowds and people with infections." b. "I can use heat to relieve the stiffness when I wake up in the morning." c. "I should exercise my hands every day, especially if they are painful and inflamed." d. "I should avoid the use of glucosamine as it has been shown to have no therapeutic value."
Answer: B Rationale: Effective management of osteoarthritis includes the following: heat therapy for stiffness, including hot packs, whirlpool baths, ultrasound, and paraffin wax baths. The affected joint should be rested during any periods of acute inflammation and maintained in a functional position with splints or braces if necessary. Cortisone injections have a local effect, and the patient will not develop immunosuppression. Nutritional supplements such as glucosamine and chondroitin sulfate may be helpful in some patients for relieving moderate to severe arthritis pain in the knees and improving joint mobility.
A patient has a severely sprained ankle from a sports injury. What should the nurse teach the patient prior to discharge from the urgent care center? a. Alternate cold and heat for 30 minutes each until symptoms are relieved. b. Apply cold for 20 to 30 minutes with breaks of 10 to 15 minutes during the first 2 days. c. Use continuous cold for the first 24 hours and then continuous heat until the symptoms are relieved. d. Apply continuous heat to the ankle for the first 24 hours and then continuous cold until the symptoms are relieved.
Answer: B Rationale: If an injury occurs, immediate care focuses on (1) stopping the activity and limiting movement, (2) applying ice compresses to the injured area, (3) compressing the involved extremity, (4) elevating the extremity, and (5) providing analgesia as necessary. These interventions will decrease local inflammation and pain for most musculoskeletal injuries. Cold (cryotherapy) in several forms can be used to produce hypothermia to the involved part. Physiologic changes that occur in soft tissue as a result of the use of cold include vasoconstriction and reduction in the transmission and perception of nerve pain impulses. These changes result in analgesia and anesthesia, reduction of muscle spasm without changes in muscular strength or endurance, reduction of local edema and inflammation, and reduction of local metabolic requirements. Cold is most useful when applied immediately after the injury has occurred. Ice applications should not exceed 20 to 30 minutes per application, and ice should not be applied directly to the skin. After the acute phase (usually 24 to 48 hours), warm, moist heat may be applied to the affected part to reduce swelling and provide comfort. Heat applications should not exceed 20 to 30 minutes, allowing a "cool-down" time between applications.
The nurse is caring for a 74-year-old woman. What would be a normal age-related finding? a. Kyphosis b. Back pain c. Loss of height d. Spinal crepitation
Answer: C Rationale: Loss of height is an expected age-related change in the elderly. The bone remodeling process is altered in the aging adult. Increased bone resorption and decreased bone formation cause loss of bone density, contributing to the development of osteopenia and osteoporosis.
Which patient would be at greatest risk for developing osteoporosis? a. A 73-year-old man who has five alcoholic drinks per week and limits sun exposure to prevent recurrence of skin cancer. b. An 84-year-old man who has recently been diagnosed with hypothyroidism and is prescribed levothyroxine (Synthroid). c. A 69-year-old woman who had a renal transplant 5 years ago and has been taking prednisone to prevent organ rejection. d. A 55-year-old woman who recently had a hysterectomy with bilateral salpingo-oophorectomy and refuses estrogen therapy.
Answer: C Rationale: Risk factors for osteoporosis include advanced age (>65 years), female gender, low body weight, white or Asian ethnicity, current cigarette smoking, nontraumatic fracture, inactive lifestyle, family history of osteoporosis, diet low in calcium or vitamin D deficiency, excessive use of alcohol (>2 drinks per day), postmenopausal, including premature or surgical menopause, and long-term use of corticosteroids, thyroid replacements, heparin, long-acting sedatives, or antiseizure medications. Long-term corticosteroid (such as prednisone) use is a major contributor to osteoporosis. The other patients have risk factors for osteoporosis, but the 69-year-old female is at highest risk.
A plaster splint is applied with an elastic bandage to the leg of a patient with a fractured tibia in preparation for open reduction and internal fixation. The patient complains of increasing pain in the affected leg and foot that is not relieved by the loosening of the elastic bandage. The most appropriate action by the nurse is to a. elevate the leg on two pillows. b. apply ice over the fracture site. c. notify the health care provider. d. perform neurovascular assessment of the foot.
Answer: D Rationale: Prompt, accurate diagnosis of compartment syndrome is critical. Prevention or early recognition is the key. Regular neurovascular assessments should be performed and documented on all patients with fractures, but especially those with injury of the distal humerus or proximal tibia or soft tissue disruption in these areas. Early recognition and treatment of compartment syndrome is essential to avoid permanent damage to muscles and nerves. One or more of the following six Ps are characteristic of compartment syndrome: (1) paresthesia (numbness and tingling); (2) pain distal to the injury that is not relieved by opioid analgesics and pain on passive stretch of muscle, traveling through the compartment; (3) pressure increases in the compartment; (4) pallor, coolness, and loss of normal color of the extremity; (5) paralysis or loss of function; and (6) pulselessness or diminished/absent peripheral pulses. Carefully assess the location, quality, and intensity of the pain (see Chapter 10). Evaluate the patient's level of pain on a scale of 0 to 10. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Pulselessness and paralysis (in particular) are later signs of compartment syndrome. After completion of the neurovascular assessment, the nurse should notify the health care provider immediately of a patient's changing condition.
A patient is to undergo skin grafting with the use of cultured epithelial autografts for full-thickness burns. The nurse explains to the patient that this treatment involves a. Shaving a split-thickness layer of the patient's skin to cover the burn wound. b. Using epidermal growth factor to cultivate cadaver skin for temporary wound coverage. c. Growing small specimens of the patient's skin into sheets to use as permanent skin coverage. d. Exposing animal skin to growth factors to decrease antigenicity so it can be used for permanent wound coverage.
Answer: c Rationale: Cultured epithelial autograft (CEA) is a method of obtaining permanent skin from a person with limited available skin for harvesting. CEA is grown from biopsy specimens obtained from the patient's own unburned skin.
When monitoring initial fluid replacement for the patient with 40% TBSA deep partial-thickness and full-thickness burns, which finding is of most concern to the nurse? a. Serum K+ of 4.5 mEq/L b. Urine output of 35 mL/hr c. Decreased bowel sounds d. Blood pressure of 86/72 mm Hg
Answer: d Rationale: Adequacy of fluid replacement is assessed by urine output and cardiac parameters. Urine output should be 0.5 to 1 mL/kg/hr. Mean arterial pressure should be >65 mm Hg, systolic BP >90 mm Hg, and heart rate <120 beats/min. A blood pressure of 86/72 indicates inadequate fluid replacement. However, the MAP is calculated at 77 mm Hg.
A patient who is admitted to a burn unit is hypovolemic. A new nurse asks an experienced nurse about the patient's condition. Which response if made by the experienced nurse is most appropriate? a. "Blood loss from burned tissue is the most likely cause of hypovolemia." b. "Third spacing of fluid into fluid-filled vesicles is usually the cause of hypovolemia." c. "The usual cause of hypovolemia is vaporation of fluid from denuded body surfaces." d. "Increased capillary permeability causes fluid shifts out of blood vessels and results in hypovolemia."
Answer: d Rationale: Hypovolemic shock is caused by a massive shift of fluids out of the blood vessels as a result of increased capillary permeability. Water, sodium, and plasma proteins move into interstitial spaces and other surrounding tissue.
During the emergent phase of burn injury, the nurse assesses for the presence of hypovolemia. In burn patients, hypovolemia occurs primarily as a result of a. Blood loss from injured tissue. b. Third spacing of fluid into fluid-filled vesicles. c. Evaporation of fluid from denuded body surfaces. d. Capillary permeability with fluid shift to the interstitium.
Answer: d Rationale: Hypovolemic shock is caused by a massive shift of fluids out of the blood vessels as a result of increased capillary permeability. Water, sodium, and plasma proteins move into interstitial spaces and other surrounding tissue.