Health & Illness Concepts II Quiz #6
A client who is in halo traction states to the visiting nurse, "I can't get used to this contraption. I can't see properly on the side, and I keep misjudging where everything is." Which therapeutic response would the nurse make to the client? -"If I were you, I would have had the surgery rather than suffer like this." -"Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up and before you move around." -"Why do you feel like this when you could have died from a broken neck? This is the way it is for several months. You need to be more accepting, don't you think? -"No one ever gets used to that thing! It's horrible. Many of our sportspeople who are in it complain vigorously."
-"Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up and before you move around." When the nurse states, "Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up and before you move around" this employs empathy and reflection to the patient. The nurse then offers a strategy for problem-solving, which helps increase the peripheral vision of the client in halo traction.
The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions? -"I will use a straw for drinking." -"I will wash the skin daily under the lamb's wool liner of the vest." -"I will be careful because the device alters balance." -"I will drive only during the daytime."
-"I will drive only during the daytime." The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all because the device impairs the range of vision.
A client has fallen and sustained a leg injury. Which question would the nurse ask to help determine if the client sustained a fracture? -"Does the pain feel like the muscle was stretched?" -"Is the pain sharp and continuous?" -"Does the discomfort feel like a cramp?" -"Is the pain a dull ache?"
-"Is the pain sharp and continuous?" Fracture pain is generally described as sharp, continuous and increasing in frequency. Bone pain is often described as a dull, deep ache. Muscle injury is often described as an aching or cramping pain, or soreness. Strains result from trauma to a muscle body or the attachment of a tendon from overstretching or overextension.
The nurse performs a neurovascular assessment on a client with a newly applied cast. The nurse would determine that there is a need for close observation and a need for follow-up if which is noted? -Sensation when the area distal to the cast is pinched -Capillary refill greater than 6 seconds -Blanching of the nail bed when it is depressed -Palpable pulses distal to the cast
-Capillary refill greater than 6 seconds To assess for adequate circulation, the nail bed of each finger or toe is depressed until it blanches and then the pressure is released. This is known as capillary refill time. Optimally, the color will change from white to pink rapidly (less than 3 seconds). If this does not occur, the toes or fingers will require close observation and follow-up. Palpable pulses and sensations distal to the cast are expected. However, if pulses could not be palpated or if the client complained of numbness or tingling, the primary health care provider should be notified.
During the postoperative period, the client who underwent a hip replacement reports pain the calf area. What action would the nurse take? -Lightly massage the calf area to relieve the pain -Ask the client to walk and observe the gait -Administer as needed (PRN) morphine sulfate as prescribed for postoperative pain -Check the calf area for temperature, color, and size
-Check the calf area for temperature, color, and size The nurse monitors the postoperative client for complications such as deep vein thrombosis, pulmonary emboli, and wound infection. Pain in the calf area could indicate a deep vein thrombosis. Change in color, temperature, or size of the client's calf cold also indicate this complication. Asking the client to walk or massaging the calf could cause a possible thrombosis to break loose resulting in an embolus. Administering pain medication for this client is not the appropriate nursing action since further assessment needs to take place.
The nurse is performing pin-site care on a client in skeletal traction. Which normal finding would the nurse expect to note when assessing the in sites? -Redness and swelling around the pin sites -Warm skin around the pin sites -Clear drainage from the pin sites -Numbness at the pin sites
-Clear drainage from the pin sites A small amount of clear drainage ("weeping") may be expected after cleaning and removing crusting around the pin sites of skeletal traction. Warmth, numbness, redness and swelling around the pin sites may be indicative of an infection.
After a cervical spine fracture, this device (refer to figure) is placed on the client. The nurse creates a discharge plan for the client to ensure safety and includes which measures? Select all that apply. Scroll down to review the 5 answer choices. -Instruct the client to bend at the waist to pick up needed items -Demonstrate the procedure for scanning the environment for vision -Teach the client how to ambulate with a walker -Teach the spouse to use the metal frame to assist the client to turn in bed -Inform the client about the importance of wearing rubber-soled shoes.
-Demonstrate the procedure for scanning the environment for vision -Teach the client how to ambulate with a walker -Inform the client about the importance of wearing rubber-soled shoes. The client with a halo fixation device should be taught that the use of a walker and rubber-soled shoes may help prevent falls and injury and are therefore also helpful. It is helpful for the client to scan the environment visually because the client's peripheral vision is diminished from keeping the neck in a stationary position. The client with a halo fixation device should avoid bending at the waist because the halo vest is heavy, and the client's trunk is limited in flexibility. The nurse instructs the client and family that the metal frame on the device is never used to move or lift the client because this will disrupt the attachment to the client's skull, which is stabilizing the fracture.
An adult client who experienced a fractured left tibia has a long leg cast and is using crutches to ambulate. In caring for the client, the nurse assesses for which sign/symptom that indicates a complication associated with crutch walking? -Weak biceps brachii -Triceps muscle weakness -Forearm muscle weakness -Left leg discomfort
-Forearm muscle weakness Forearm muscle weakness is a sign of radial nerve injury caused by crutch pressure on the axillae. When a client lacks upper body strength, especially in the flexor and extensor muscles of the arms, he or she frequently allows weight to rest on the axillae and on the crutch pads instead of using the arms for support while ambulating with crutches. Leg discomfort is expected as a result of the injury. Weak biceps brachii is not a complication of crutch walking but rather caused by an injury to the brachial plexus itself. Triceps muscle spasms may occur as a result of increased muscle use but is not a complication of crutch walking.
A client who experienced a fractured right ankle has a short leg cast applied in the emergency department. During discharge teaching, which information would the nurse provide to the client to prevent complications? -Weight-bearing on the right leg is allowed once the cast feels dry -Expect burning and tingling sensations under the cast for 3 to 4 days -Keep the right ankle elevated above the heart level with pillows for 24 hours -Trim the rough edges of the cast after it is dry
-Keep the right ankle elevated above the heart level with pillows for 24 hours Leg elevation is important to increase venous return and decrease edema. Edema can cause compartment syndrome, a major complication of fractures and casting. The client and/or family may be taught how to 'petal' the cast the prevent skin irritation and breakdown, but rough edges, if trimmed, can fall into the cast and cause a break in the skin integrity. Weight bearing on a fractured extremity is prescribed by the primary health care provider during follow-up examination, after radiographs are obtained. Additionally, a walking heel or cast shoe may be added to the cast if the client is allowed to bear weight and walk on the affected leg. Although the client may feel heat after the cast is applied, burning and/or tingling sensations indicate nerve damage or ischemia and are not expected. The complaints should be reported immediately.
The nurse is caring for a client who has been placed in Buck's extension traction while awaiting surgical repair of a fractured femur, would perform a complete neurovascular assessment of the affected extremity that includes which interventions. Select all that apply. Scroll down to view all 5 answer choices. -Level of pain in the affected leg -Capillary refill of the affected toes -Pulse in the affected extremity -Skin color of the affected extremity -Bilateral lung sounds
-Level of pain in the affected leg -Capillary refill of the affected toes -Pulse in the affected extremity -Skin color of the affected extremity A complete neurovascular assessment of an extremity includes color, sensation, movement, capillary refill, and pulse of the affected extremity.
The nurse is caring for a client who had an orthopedic injury of the leg that required surgery and the application of a cast. Postoperatively, which nursing assessment is of highest priority to assure client safety? -Monitoring for bladder distention -Monitoring for extremity shortening -Monitoring for blanching ability of toenail beds -Monitoring for heel breakdown
-Monitoring for blanching ability of toe nail beds With cast application, concern for compartment syndrome development is of the highest priority. If postsurgical edema compromises circulation, the client will demonstrate numbness, tingling, loss of blanching of toenail beds, and pain that will not be relieved by opioids. Although heel breakdown, bladder distention, or extremity lengthening or shortening can occur, these complications are not potentially life-threatening complications.
A client with a C4 spinal cord injury has been placed in traction with cervical tongs. Nursing care should include: -Elevating the head of the bed 90o -Releasing the traction for five minutes each shift -Performing sterile pin care as ordered -Loosening the pins if the client complains of a headache
-Performing sterile pin care as ordered Nursing care of the client with cervical tongs includes performance of sterile pin care and assessment of the site. The other answers alter the traction and could result in serious injury or death of the client; therefore, they are incorrect.
The nurse is assessing the casted extremity of a client for signs of infection. Which finding is indicative of the presence of an infection? -Diminished distal pulse -Dependent edema -Presence of warm areas on the cast -Coolness and pallor of the skin
-Presence of warm areas on the cast Manifestations of infection under a casted area include a musty odor or purulent drainage from the cast or the presence of areas on the cast that are warmer than others. The primary health care provider should be notified if any of these occur. Dependent edema, diminished arterial pulse, and coolness and pallor of the skin all signify impaired circulation in the distal extremity.
A client with a spinal cord injury is at risk of developing foot drop. What intervention would the nurse use as a preventive measure? -Application of pneumatic boots -Regular use of posterior splints or high-top sneakers -Mole skin-lined heel protectors -Avoiding dorsal flexion of the foot
-Regular use of posterior splints or high-top sneakers The effective means of preventing foot drop (plantar flexion) is the use of posterior splints or high-top sneakers. Dorsal flexing of the foot would help to counteract the effects of foot drop. Heel protectors protect the skin but do not prevent foot drop. Pneumatic boots prevent deep vein thrombosis but not foot drop.
A client has a hip fracture repair with a prosthetic implant placed. On the day after the implant, the nurse finds the client surrounded by papers from his briefcase and planning a phone meeting. The nurse plans to discuss activities with the client and would base the discussion on which information? -Not keeping up with his job will increase the client's stress level -Setting limits on a client's behavior is a mandated nursing role -Rest is an essential component of bone healing. -Involvement in his job will keep the client from becoming bored
-Rest is an essential component of bone healing. Rest is an essential component of bone healing. Nurses can help clients understand the importance of rest and find ways to balance work demands to promote healing. Nurses cannot demand these changes, but they need to encourage clients to choose them. Setting limits on a client's behavior is not a mandated nursing role. It may relieve stress to do work; however, during the immediate period after the cast is applied, it may not be therapeutic.
Paralysis from the damaged cellular structures (neurons) in a client with a spinal cord injury may affect: (choose all that apply) -Sensation -Mobility -Bladder and Bowel function -Sexual function
-Sensation -Mobility -Bladder and Bowel function -Sexual function Paralysis from the damaged cellular structures (neurons) in a client with a spinal cord injury may affect mobility, sexual function, sensation, and bladder and bowel function.
The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? -Pain on palpation at the pin sites -Redness around the pin sites -Clear, watery drainage from the pin sites -Thick, yellow drainage from the pin sites
-Thick, yellow drainage from the pin sites The nurse should monitor for signs of infection such as inflammation, purulent drainage, and pain at the pin site. However, some degree of inflammation, pain at the pin site, and serous drainage would be expected; the nurse should correlate assessment findings with other clinical findings, such as fever, elevated white blood cell count, and changes in vital signs. Additionally, the nurse should compare any findings to baseline findings to determine if there were any changes.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. Scroll down to see the 5 answer choices. -Ensuring that the client has a bowel movement at least once a week -Limiting bladder catheterization to once every 12 hours -Turning and repositioning the client at least every 2 hours -Keeping the linens wrinkle-free under the client -Preventing unnecessary pressure on the lower limbs
-Turning and repositioning the client at least every 2 hours -Keeping the linens wrinkle-free under the client -Preventing unnecessary pressure on the lower limbs The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize the risk in these areas.
The nurse prepares to transfer the client with a newly applied leg cast into the bed using which method? -Supporting the cast with the fingertips only -Placing ice on top of the cast -Asking the client to support the cast during transfer -Using the palms of the hands and soft pillows to support the cast
-Using the palms of the hands and soft pillows to support the cast The palms or the flat surface of the extended fingers should be used when moving a wet cast to prevent indentations. Pillows are used to support the curves of the cast to prevent cracking or flattening of the cast from the weight of the body. Half-full bags of ice may be placed next to the cast to prevent swelling, but this would be done after the client is placed in bed. Asking the client to support the cast during transfer is inappropriate.
The nurse, caring for a client with Buck's traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction? -Complaints of leg discomfort -Drainage at the pin sites -Weak pedal pulses -Toes are warm and demonstrate a brisk capillary refill
-Weak pedal pulses Buck's traction is skin traction. Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage or prefabricated boot used to secure this type of traction. Skeletal (not skin) traction uses pins. Discomfort is expected. Warm toes with brisk capillary refill is a normal finding.
