nur 116 - Davis Advantage / Edge - Musculoskeletal Trauma and Complications

How would the nurse explain to the client the difference between a strain and a sprain? "A sprain is the tearing of a muscle, tendon, or ligament; a strain is the stretching of a muscle, tendon, or ligament." "A sprain is stretching of a muscle, tendon, or ligament; a strain is the tearing of a muscle, tendon, or ligament." "A sprain is the stretching or tearing of a muscle or tendon; a strain is the stretching or tearing of a ligament." "A sprain is the stretching or tearing of a ligament; a strain is the stretching or tearing of a muscle or tendon."

"A sprain is the stretching or tearing of a ligament; a strain is the stretching or tearing of a muscle or tendon."

A nurse is teaching about second-degree sprains. Which statement indicates a need for further teaching? "It can also be considered as a moderate sprain." "It prevents a patient from ambulating due to joint instability." "It leads to increased swelling, ecchymosis, pain, and altered weight-bearing mobility." "It results from a significantly moderate amount of tearing in the ligament fibers."

"It prevents a patient from ambulating due to joint instability." Rationale: In a second-degree sprain, the joint remains intact and the ligament is not completely torn. However, a third-degree sprain prevents a patient from ambulating due to joint instability. Test Taking Tips: Look for the incorrect answer.

The nurse is caring for a client post-open reduction internal fixation surgery. Which complications should the nurse monitor for? Select all that apply. Respiratory distress Fat embolism syndrome Elevated blood urea nitrogen and creatinine Elevated serum potassium Hypovolemia

*** Respiratory distress Fat embolism syndrome Elevated blood urea nitrogen and creatinine Hypovolemia

Which nursing actions should a nurse take for a patient who has undergone amputation? Select all that apply. Place a pillow under the remaining portion of the lower extremity. Administer analgesics as per the order. Apply ice for at least an hour on the site. Apply a rigid cast or splint. Encourage intake of additional protein- and carbohydrate-rich foods.

Administer analgesics as per the order. Apply a rigid cast or splint. Encourage intake of additional protein- and carbohydrate-rich foods. Rationale: To prevent prostaglandin formation and promote movement, function, and participation in rehabilitation, the nurse should administer analgesics to the patient . Rationale: The nurse should apply a rigid cast/splint as it helps decrease edema by compressing the residual limb for a better fitting into the prosthesis. Rationale: To promote quick healing, the nurse should encourage the patient to consume additional protein- and carbohydrate-rich foods. Test Taking Tips: Consider priority actions for rehabilitation.

Which should a nurse keep in mind when caring for a patient with a traumatic amputation? Select all that apply. Apply a tourniquet to the remaining limb. Salvage surgery may be ordered for the patient by the primary healthcare provider. A coagulation panel, complete blood count (CBC), and serum lactate baseline level should be established. The Phalen test may be performed on the patient . The Steinman test may be performed on the patient .

Apply a tourniquet to the remaining limb. Salvage surgery may be ordered for the patient by the primary healthcare provider. A coagulation panel, complete blood count (CBC), and serum lactate baseline level should be established. Rationale: When caring for a patient with traumatic amputations the nurse should apply a tourniquet to the remaining limb. This helps in stopping both arterial and venous bleeding. Rationale: To control hemorrhage, reattach limbs, or remove the damaged tissue, salvage surgery may be ordered for a patient with a traumatic amputation. Rationale: To start an immediate blood transfusion, a coagulation panel, CBC, and serum lactate baseline level should be established for a patient with traumatic amputation. Test Taking Tips: Consider priorities.

Identify the postoperative nursing processes for a client who has had an orthopedic surgical revision for a fracture (open reduction internal fixation - ORIF) and has developed compartment syndrome. Nursing Actions Begin total parenteral nutrition Assist with dressing removal Prepare client for fasciotomy Place the client in high semi-Fowler's position Prepare to administer antibiotics Begin preoperative teaching

Assist with dressing removal Prepare client for fasciotomy Begin preoperative teaching CORRECT. As compartment syndrome is considered a medical emergency, you should be prepared to assist the orthopedic surgeon with removal of surgical dressing. Additionally, you should anticipate that the client will undergo a fasciotomy to relieve pressure in the compartment and begin preoperative teaching for this procedure. Maintaining the client in a high semi-Fowler's position is not required. TPN would only be indicated if there were additional comorbidities that warrant this intervention. Antibiotics will not correct the problem.

Which type of fracture creates an external wound that exposes the fracture site? Complete Simple Compound Incomplete

Compound Rationale: When the bone pieces protrude through the skin and create an external wound that exposes the fracture site, it is known as a compound or open type of fracture. Test Taking Tips: Differentiate between fracture types.

The nurse is viewing an x-ray of a patient who has experienced a fracture. The image shows malalignment of bone fragments at the fracture site. What type of fracture should the nurse document? Oblique Spiral Displaced Depressed

Displaced Rationale: A displaced fracture indicates malalignment of bone fragments at the fracture site. Test Taking Tips: Do not confuse fracture types.

Which is an example of low-energy trauma with reference to fractures? Falls Motor vehicle collisions Injury from contact sports Bicycle accident

Falls Rationale: Falls are an example of low-energy trauma. Test Taking Tips: Differentiate between low-energy and high-energy.

Identify the postoperative nursing processes for a client who has had an orthopedic surgical revision for a fracture (open reduction internal fixation - ORIF) and has developed compartment syndrome. Additional Potential Complications Fat embolism syndrome Hypervolemia Ketoacidosis Respiratory distress Hypovolemia Venous thromboemboli

Fat embolism syndrome Respiratory distress Hypovolemia Venous thromboemboli CORRECT. A client who has had ORIF is at risk for numerous complications, including but not limited to fat embolism syndrome, respiratory distress, hypovolemia, and venous thromboemboli. Development of hypervolemia and ketoacidosis would not typically occur.

The nurse is teaching a community group about carpal tunnel syndrome (CTS). What should be included in teaching? It is the most frequent compression neuropathy of the legs. This syndrome usually occurs in children. Men are four to five times more likely to get CTS than are women. Higher occurrences are seen in computer operators and construction workers.

Higher occurrences are seen in computer operators and construction workers. Rationale: Carpal tunnel syndrome (CTS) is found mostly in computer operators, construction workers, and others who have jobs requiring repetitive motions of the hands. Test Taking Tips: Risk factors for carpal tunnel syndrome include age, type of employment, and gender.

Which is true regarding a compression fracture? It occurs around the shaft of the bone. It occurs at a 45° angle across the cortex of the bone. It occurs as a result of overstretching and tearing of a tendon or ligament. It occurs as a result of excessive force along the axis of cancellous bone.

It occurs as a result of excessive force along the axis of cancellous bone. Rationale: A compression fracture occurs as a result of excessive force along the axis of cancellous bone that results in the bone collapsing on its own. Test Taking Tips: Do not confuse fracture types.

The nurse is caring for an older client who has been diagnosed with osteoporosis. The nurse explains to the client that vertebral compression fractures are common with osteoporosis and can result in which condition? Lordosis Scoliosis Spinosis Kyphosis

Kyphosis

Which statement best describes a strain? Dislocation injury Compression injury Ligament injury Muscle or tendon injury

Muscle or tendon injury

The nurse is performing an assessment for a patient with a cast experiencing pain at rest, pressure, and paresthesia of the distal extremity. What could cause these symptoms? Rhabdomyolysis Neurovascular compromise Hypovolemia Hypoxia

Neurovascular compromise Rationale: The presence of the 6 P's indicates neurovascular compromise, which can result in hemorrhage, compartment syndrome, infection, or permanent loss of function. Test Taking Tips: Consider the 6 P's.

Identify the postoperative nursing processes for a client who has had an orthopedic surgical revision for a fracture (open reduction internal fixation - ORIF) and has developed compartment syndrome. Most Common Symptoms Pallor Paralysis Paresthesia Pulselessness Pain Pressure Pigment Paraplegia

Paresthesia Pain Pressure Pallor Paralysis Pulselessness CORRECT. The most common symptoms of compartment syndrome are the "six Ps"; passive pain at rest, along with pressure, paresthesia, pallor, paralysis, and pulselessness. Pallor, paralysis, and pulselessness are considered to be late findings. Pigment and paraplegia are not symptoms.

Identify the postoperative nursing processes for a client who has had an orthopedic surgical revision for a fracture (open reduction internal fixation - ORIF) and has developed compartment syndrome. Compartment Syndrome Assessments Absence of pain Pain upon ambulation when assisted by physical therapist (PT) Passive pain at rest Numbness in operative extremity Minimal hair growth compared to the other leg Pressure at the surgical site

Passive pain at rest Numbness in operative extremity Pressure at the surgical site CORRECT. Passive pain at rest may cause the nurse to suspect the development of compartment syndrome. Paresthesia may also indicate compromised vascular perfusion to the affected limb. Pressure at the surgical site indicates inflammation and is an early symptom of compartment syndrome. Absence of pain and pain upon ambulation when assisted by PT are expected findings after this type of procedure. Minimal hair growth can be affected by factors other than surgical intervention.

The nurse is caring for a client with a blunt trauma and tissue injury to the lower extremity. Which signs could develop in a client with compartment syndrome? Increased pain in the affected extremity upon ambulation Numbness in the toes of the affected extremity Passive pain at rest in the affected extremity Absence of pain in the affected extremity

Passive pain at rest in the affected extremity

The nurse is caring for a client with a recent lower extremity injury. During the physical assessment, the nurse should include which components during inspection and palpation of the injury? Select all that apply. Pulselessness Pallor Reflexes Sensation Movement

Reflexes Sensation Movement

The nurse is caring for a patient with this type of traction. What is the purpose? Relieve muscle spasms Extend the bone in preparation for amputation Bone stabilization Alignment for healing

Relieve muscle spasms Rationale: Skin traction utilizes a flexible harness, boot, or belt to secure the extremity while 5 to 10 lbs of weight is applied to relieve muscle spasms and maintain the length of the bone. Test Taking Tips: Do not confuse traction types.

The nurse is caring for a client in the emergency department with a severe sprain to the left ankle. The nurse should include which information in the discharge teaching? Select all that apply. Rest the injury. Use a compression wrap to the injury. Apply heat for 20 minutes every hour for the first 24 hours. Decrease oral intake. Elevate the extremity.

Rest the injury. Use a compression wrap to the injury. Elevate the extremity.

The nurse is caring for a client who was involved in a crush injury of the lower extremity and experiencing severe flank pain and the presence of dark, tea-colored urine. The nurse is aware of the potential for which serious complication? Pulmonary embolism Rhabdomyolysis Compartment syndrome Fat embolism

Rhabdomyolysis

The nurse is caring for a client experiencing osteomyelitis secondary to an open fracture. Which complications should the nurse monitor for? Select all that apply. Tetanus Gas gangrene Thrombocytopenia Hypokalemia Disseminated intravascular coagulopathy

Thrombocytopenia Hypokalemia

The nurse is caring for a client with a femoral shaft fracture. Which types of fracture may the client have? Select all that apply. Transverse Greenstick Comminuted Compound Displaced

Transverse Comminuted Compound

Identify the postoperative nursing processes for a client who has had an orthopedic surgical revision for a fracture (open reduction internal fixation - ORIF) and has developed compartment syndrome. Fasciotomy: Treatment for compartment syndrome Recommended when there is a strong pulse in the affected limb Urgent procedure Helps to pressure from internal edema Includes the placement of three incisions Incision made into the dermal layer of the skin

Treatment for compartment syndrome Urgent procedure Helps to pressure from internal edema CORRECT. When compartment syndrome is present, an immediate fasciotomy is indicated to relieve internal pressure from edema. The surgical procedure includes incisions on both the medial and lateral aspects of the extremity down through the fascia, relieving the compartment pressure.