Chapter 42 Fractures

6. In caring for a patient just admitted with a pelvic fracture, the assessment that would cause the most concern is: 1. a pain level rating of 8 on a 1 to 10 scale. 2. no urinary output for 8 hours. 3. evidence of bruising along the patient's hips and buttocks. 4. complaints of need for back care from resting in bed.

ANS: 2 The absence of urinary output could indicate a perforated bladder.

23. In dealing with the weights that are applying traction, the nurse should: 1. remove them to pull the patient up in bed. 2. hold them while the patient is changing position in bed. 3. hold them for a few minutes if the patient complains of pain. 4. allow them to hang freely.

ANS: 4 Weights always must hang freely to prevent complications.

OTHER 1. The nurse uses a diagram to show the process of a fractured bone healing. Arrange the options in the appropriate sequence. 1. Ossification 2. Hematoma 3. Fibrocartilage 4. Consolidated 5. Callus

2, 3, 5, 1, 4 The sequence of healing is hematoma, fibrocartilage, callus, ossification, and consolidation.

4. The patient with the crushed forearm cannot get pain relief with opioids. The injury is swollen, cool, and cyanotic, with weak distal pulses. The nurse assesses that this is a(n): 1. compartment syndrome. 2. overwhelming infection. 3. fat embolus. 4. osteomyelitis.

ANS: 1 A compartment syndrome may occur following massive injury or an inappropriately tight cast. The tissues become swollen to the point that they cut off their own circulation.

3. The patient who has osteomyelitis following multiple fractures inquires what the physician meant when he said that surgery would follow the antibiotic therapy. The nurse's most helpful reply is to explain that the surgery will be done to: 1. remove dead bone. 2. close the open draining wound. 3. close the area with casting material. 4. amputate.

ANS: 1 After the antibiotic has controlled the infection in the bone, surgery will be done to remove the dead bone.

22. The nurse performing a neurovascular assessment of the patient in skeletal traction assesses the abnormal sign of: 1. delayed capillary refill. 2. bilateral equal pulses. 3. absence of pain and swelling. 4. area is same color as unaffected side.

ANS: 1 Delayed capillary refill reflects possible impaired tissue perfusion.

17. The nurse who is documenting and reporting the signs and symptoms of an infection underneath a cast would include: 1. elevated temperature. 2. tingling and decreased sensation. 3. full pulses and absence of pain. 4. swelling and diminished motor function.

ANS: 1 Elevated temperature on the affected extremity may be a symptom of an infection under the cast

15. Assistive devices such as canes, crutches, and walkers are used for people who need to limit weight-bearing on joints. The statement by the nurse that best illustrates an understanding of appropriate use of these devices is: 1. "Canes provide minimal support and balance and are carried on the unaffected side." 2. "When using a cane, slide it as you go to decrease the arm strain." 3. "A three-point gait is used when walking with a walker." 4. "When using crutches, the unaffected leg goes down the steps first."

ANS: 1 Option 1 is the only true statement.

7. When an older woman falls down at church and immediately complains of severe pain in her left hip, the choir director recognizes the cardinal sign of a fractured hip when he sees: 1. the left leg is shorter than the right. 2. downward curled toes. 3. internal rotation of the left leg. 4. hematoma on the left hip.

ANS: 1 The classic sign of a fractured hip is a shortened limb on the affected side, with an externally rotated limb.

18. The nurse would choose the nursing diagnoses with the highest priority after surgery for the open reduction and external fixation of an ankle, which is: 1. risk for activity intolerance. 2. risk for infection. 3. risk for impaired physical mobility. 4. risk for constipation.

ANS: 2 All are possible diagnoses, but the one that would have the highest priority is risk for infection, because bone infections are serious complications which require much time and expense to treat.

11. A 78-year-old retired teacher with a history of osteoporosis has fallen in her bathroom and sustained a supcapital femoral fracture. She is scheduled for an ORIF (open reduction internal fixation) in the morning. The type of traction that the patient is most likely to be placed in preoperatively is: 1. Bryant's. 2. Buck's. 3. pelvic. 4. Crutchfield tongs.

ANS: 2 Buck's traction is used in this case; the other options are not applicable.

25. When the patient with a fractured pelvis says that she will not ambulate because of pain, the nurse cautions that early ambulation will prevent: 1. back injury. 2. DVT. 3. callus formation. 4. disuse syndrome.

ANS: 2 Early ambulation, although painful, avoids many of the complications of immobility such as DVT, constipation, and atrophy.

16. For which of the following patients who had a hip fracture would the acute care nurse request a home health aide on discharge? 1. The patient is married and has a laundry room on the first floor. 2. The patient is single and has a bedroom in a rooming house. 3. The patient lives in a college dormitory but is going home to stay with her parents. 4. The patient is going to stay with her daughter and son-in-law at their one-story home.

ANS: 2 The patient will need help with laundry and other ADLs (activities of daily living) needs.

1. A patient is 1 day postsurgery for a crushed pelvis. The CNA reports that the patient is complaining of being short of breath and demonstrating signs of confusion and restlessness. The nurse suspects from these signs alone that the patient has suffered: 1. impending shock. 2. a fat embolus. 3. anxiety. 4. neurovascular compromise.

ANS: 2 These are the classic symptoms of a fat embolus that has escaped from the crushed marrow.

14. Because the patient has a compound fracture, the nurse should: 1. limit narcotics for 8 hours after surgery. 2. monitor the patient's respirations every hour. 3. assess for pulses distal to the injury. 4. verify that the patient is not allergic to sulfa.

ANS: 3 Assessing for pulses distal to the injury is done to monitor for ineffective tissue perfusion.

5. The patient who sustained a simple fracture of the left fibula 7 days ago asks in what stage of bone healing he might be. The nurse replies that at 7 days, the patient would be in the stage of: 1. hematoma formation. 2. ossification. 3. callus formation. 4. fibrocartilage formation.

ANS: 3 Callus formation occurs at the end of the first week after injury.

19. When the patient who has been in a full body cast (spica) complains of nausea and abdominal distention, the LVN alerts the charge nurse about the possibility of: 1. constipation. 2. compartment syndrome. 3. cast syndrome. 4. shock.

ANS: 3 Cast syndrome is an uncommon complication for a person in a spica cast, in which there is compression of a portion of the duodenum between the mesenteric artery and the spinal column.

20. The older adult patient is at risk for constipation after sustaining a pelvic fracture. The nutritional suggestion that the nurse would make is: 1. calcium supplements to help prevent fractures in older adults. 2. vitamins B, C, and D, which are essential for bone healing. 3. while immobilized, drink at least 2 to 3 L/day. 4. overeating may cause cramping.

ANS: 3 During periods of immobilization, a daily fluid intake of 2 to 3 L is recommended to promote bowel and bladder function.

24. The nurse clarifies that in a greenstick fracture, the: 1. line of the fracture goes across the bone in right angles to the longitudinal axis. 2. periosteum is not torn away from the bone. 3. fracture is incomplete and one side is bent. 4. fracture occurred in one of the long bones of the body.

ANS: 3 Greenstick fractures are most commonly seen in children, with the bone broken on one side but only bent on the other.

21. The finding that would produce the most concern when performing pin care for the patient with an external fixator is: 1. crusts around the pin. 2. serous drainage on the dressing. 3. purulent drainage. 4. absence of pain.

ANS: 3 Purulent drainage is the only abnormal finding.

9. The nurse assisting with the application of a short arm plaster cast application would take special care to: 1. dampen the skin to make the stockinette adhere. 2. tape the arm prior to application of the stockinette. 3. smooth the stockinette to prevent a pressure ulcer. 4. roll the stockinette tightly above and below the margins of the cast.

ANS: 3 The stockinette is smoothed on the limb prior to application of the casting material to help reduce the threat of a pressure ulcer.

13. A patient with bilateral avascular necrosis of the hips is to walk with crutches using a four-point gait for 6 weeks after her bone decompression surgeries. Which statement would indicate that the patient understands this technique? 1. "The axillary bars on the crutches should support my weight when I walk." 2. "I will move both crutches and then swing my legs to the crutches—2 and 2 equals 4!" 3. "I will move my right crutch and then my left leg and then the left crutch and my right leg." 4. "I will move both crutches and then swing my legs through the crutches together."

ANS: 3 This is the correct sequence for a four-point gait, which allows bearing of weight and one foot to be placed in front of the other.

12. When the nurse is told that a patient has a compound comminuted fracture, the nurse is concerned because this type of fracture is one in which the bone is: 1. bent but not completely broken, and the bent piece protrudes through the skin. 2. compressed, and bone pieces protrude through the skin. 3. twisted, and the fragments are separated. 4. broken into two or more pieces, and bone fragments protrude through the skin.

ANS: 4 A compound comminuted fracture is a severe fracture with the bone broken in two or more pieces, with the pieces broken into small fragments and a portion of the bone protruding through the skin.

10. The older patient who sustained a fractured hip and femur in a motor vehicle accident is to be in Russell's traction for several weeks, so the nurse will focus care on: 1. offering frequent distractions. 2. encouraging nutrition. 3. pain relief. 4. prevention of DVT.

ANS: 4 Deep vein thrombosis (DVT) is a threat for the person who is going to have lengthy periods of inactivity. Certainly, nutrition concerns, pain relief, and boredom will be nursing concerns as well, but prevention of DVT is the priority.

2. The nurse would teach the older patient with a newly casted Colles' fracture to: 1. apply cool compresses to the cast. 2. let the hand and arm dangle to increase the drainage. 3. keep the hand immobile to reduce swelling. 4. move the shoulders to reduce contractures.

ANS: 4 Movement of the shoulders will help decrease the threat of contracture from immobility.

8. The patient has just had a plaster of Paris upper extremity cast placed because of a fractured radius. The statement indicating that the patient understands the discharge teaching related to cast care is: 1. "When I get home, I will remove some of the padding if it feels tight so my fingers don't swell." 2. "When I get home, I will wrap the cast in plastic so it will conserve the heat." 3. "When I get home, I will use a spoon handle to scratch inside if my arm itches." 4. "When I get home, I am going to rest in bed with my arm elevated above my head."

ANS: 4 Resting with the limb elevated above the head helps prevent swelling.