Chapter 42: Management of Patients With Musculoskeletal Trauma - ML8

An important nursing assessment, post fracture, is to evaluate neurovascular status. Therefore, the nurse should check for:

Capillary refill. R: Assessment for neurovascular impairment includes checking for weak pulses or delayed capillary refill (normal is <2 seconds).

Which of the following would lead a nurse to suspect that a client has a rotator cuff tear?

Difficulty lying on affected side R: Clients with a rotator cuff tear experience pain with movement and limited mobility of the shoulder and arm. They especially have difficulty with activities that involve stretching their arm above their head. Many clients find that the pain is worse at night and that they are unable to sleep on the affected side.

Which is not one of the general nursing measures employed when caring for the client with a fracture?

cranial nerve assessment R: Cranial nerve assessment would only be carried out for head-related injuries or diseases. General nursing measures include administering analgesics, providing comfort measures, assisting with ADLs, preventing constipation, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing client for self-care.

The nurse is caring for a client who was involved in an automobile accident and sustained multiple trauma. The client has a Volkmann's contracture to the right hand. What objective data does the nurse document related to this finding?

Claw-like deformity of the right hand without ability to extend fingers R: A Volkmann's contracture is a claw like deformity of the hand resulting from obstructed arterial blood flow to the forearm and hand. The client is unable to extend the fingers and complains of unrelenting pain, particularly if attempting to stretch the hand. Nodule on the knuckles and dislocation are not indicative of Volkmann's contracture.

A client sustains an injury to the ligaments surrounding a joint. What will the nurse identify this injury as?

Sprain R: A sprain is an injury to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A contusion is a soft tissue injury resulting from a blow or blunt trauma. A fracture is a break in the continuity of a bone.

A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction?

"Apply ice packs for the first 24 to 48 hours, then apply heat packs." R: The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing. Applying ice for only 12 to 18 hours may not keep swelling from recurring. Applying heat for the first 24 to 48 hours would worsen, not ease, swelling. Applying ice 48 hours after the injury would be less effective because swelling already has occurred by that time.

A client undergoes a total hip replacement. Which statement made by the client indicates to the nurse that the client requires further teaching?

"I don't know if I'll be able to get off that low toilet seat at home by myself." R: The client requires additional teaching if he is concerned about using a low toilet seat. To prevent hip dislocation after a total hip replacement, the client must avoid bending the hips beyond 90 degrees. The nurse should instruct the client to use assistive devices, such as a raised toilet seat, to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Teaching the client to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a client get dressed without flexing the hips beyond 90 degrees.

A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in client cast care?

"Keep your right leg elevated above heart level." R: The nurse should instruct the client to elevate the leg to promote venous return and prevent edema. The cast shouldn't be covered while drying. Covering the cast will cause heat buildup and prevent air circulation. The client should be instructed not to insert foreign objects into the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection.

An x-ray demonstrates a fracture in which a bone has splintered into several pieces. Which type of fracture is this?

Comminuted R: A comminuted fracture may require open reduction and internal fixation. A compound fracture is one in which damage also involves the skin or mucous membranes. A depressed fracture is one in which fragments are driven inward. An impacted fracture is one in which a bone fragment is driven into another bone fragment.

A client is admitted to the emergency room after being hit by a car while riding a bicycle. The client sustained a fracture of the left femur, and the bone is protruding through the skin. What type of fracture does the nurse recognize requires emergency intervention?

Compound R: A compound fracture is a fracture in which damage also involves the skin or mucous membranes with the risk of infection great. A greenstick fracture is where one side of the bone is broken and the other side is bent; it does not protrude through the skin. An oblique fracture occurs at an angle across the bone but does not protrude through the skin. A spiral fracture twists around the shaft of the bone but does not protrude through the skin.

A client comes to the emergency department and reports localized pain and swelling in the lower leg. Ecchymotic areas are noted. History reveals that the client got hit in the leg with a baseball bat. What will the nurse most likely suspect?

Contusion R: The client's description of blunt trauma by a baseball bat and localized pain in conjunction with swelling and ecchymosis would most likely suggest a contusion. A fracture would be manifested by pain, loss of function, deformity, swelling, and spasm. A sprain would be manifested by pain and swelling; ecchymosis may appear later. A strain is characterized by inflammation, local tenderness, and muscle spasms.

13s Report this Question Which of the following disorders results in widespread hemorrhage andmicrothrombosis with ischemia?

Disseminated intravascular coagulation (DIC) R: DIC is a systemic disorder that results in widespread hemorrhage and microthrombosis with ischemia. AVN of the bone occurs when the bone loses its blood supply and dies. CRPS is a painful sympathetic nervous system problem. FES occurs when the fat globules released when the bone is fractured occludes the small blood vessels that supply the lungs, brain, kidneys, and other organs.

A patient sustained an open fracture of the femur 24 hours ago. While assessing the patient, the nurse observes the patient is having difficulty breathing, and oxygen saturation decreases to 88% from a previous 99%. What does the nurse understand is likely occurring with this patient?

Fat emboli R: After fracture of long bones or pelvic bones, or crush injuries, fat emboli frequently form. Fat embolism syndrome (FES) occurs when fat emboli cause morbid clinical manifestations. The classic triad of clinical manifestations of FES include hypoxemia, neurologic compromise, and a petechial rash (NAON, 2007), although not all signs and symptoms manifest at the same time (Tzioupis & Giannoudis, 2011). The typical first manifestations are pulmonary and include hypoxia and tachypnea.

A patient sustained an open fracture of the femur 24 hours ago. While assessing the patient, the nurse observes the patient is having difficulty breathing, and oxygen saturation decreases to 88% from a previous 99%. What does the nurse understand is likely occurring with this patient?

Fat emboli R: After fracture of long bones or pelvic bones, or crush injuries, fat emboli frequently form. Fat embolism syndrome (FES) occurs when fat emboli cause morbid clinical manifestations. The classic triad of clinical manifestations of FES include hypoxemia, neurologic compromise, and a petechial rash (NAON, 2007), although not all signs and symptoms manifest at the same time (Tzioupis & Giannoudis, 2011). The typical first manifestations are pulmonary and include hypoxia and tachypnea.

Which assessment findings would the nurse expect to find in the postoperative client experiencing fat embolism syndrome?

Fat embolism syndrome is characterized by fever, tachycardia, tachypnea, and hypoxia. Arterial blood gas findings include a partial pressure of oxygen (PaO2) less than 60 mm Hg, with early respiratory alkalosis and later respiratory acidosis.

Radiographic evaluation of a client's fracture reveals that a bone fragment has been driven into another bone fragment. The nurse identifies this as which type of fracture?

Impacted R: An impacted fracture is one in which a bone fragment is driven into another bone fragment. A comminuted fracture is one in which the bone has splintered into several fragments. A compression fracture is one in which bone has been compressed. A greenstick fracture is one in which one side of the bon is broken and the other side is bent.

The nurse is caring for a patient with a pelvic fracture. What nursing assessment for a pelvic fracture should be included? (Select all that apply.)

Palpating peripheral pulses in both lower extremities Testing the stool for occult blood Checking the urine for hematuria R: In pelvic fracture, the nurse should palpate the peripheral pulses, especially the dorsalis pedis pulses of both lower extremities; absence of a pulse may indicate a tear in the iliac artery or one of its branches. To assess for urinary tract injury, the patient's urine is analyzed for blood.

A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis?

Prevent internal rotation of the affected leg. R: The nurse and other caregivers should prevent internal rotation of the affected leg. However, external rotation and abduction of the hip will help prevent dislocation of a new hip joint. Postoperative total hip replacement clients may be turned onto the unaffected side. The hip may be flexed slightly, but it shouldn't exceed 90 degrees. Maintenance of flexion isn't necessary.

Which nursing intervention is essential in caring for a client with compartment syndrome?

Removing all external sources of pressure, such as clothing and jewelry R: Nursing measures should include removing all clothing, jewelry, and external forms of pressure (such as dressings or casts) to prevent constriction and additional tissue compromise. The extremity should be maintained at heart level (further elevation may increase circulatory compromise, whereas a dependent position may increase edema). A compression wrap, which increases tissue pressure, could further damage the affected extremity. There is no indication that diagnostic studies would require I.V. access in the affected extremity.

The RICE acronym is helpful for remembering treatment interventions for musculoskeletal injuries. Which of the following are components of the RICE acronym? Select all that apply.

Rest Ice Compression Elevation

Which term refers to an injury to ligaments and other soft tissues surrounding a joint?

Sprain R: A sprain is caused by a wrenching or twisting motion. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation or dislocation of joint surfaces. Strain refers to a muscle pull or tear.

An adult is swinging a small child by the arms, and the child screams and grabs his left arm. It is determined in the emergency department that the radial head is partially dislocated. What is this partially dislocated radial head documented as?

Subluxation R: A partial dislocation is referred to as a subluxation. A Volkmann's contracture is a claw like deformity that results from compartment syndrome or obstructed arterial blood flow to the forearm and hand. Compartment syndrome is a condition in which a structure such as a tendon or nerve is constricted in a confined space and affects nerve innervation, leading to subsequent palsy. A sprain is injury to the ligaments surrounding the joint.

Which may occur if a client experiences compartment syndrome in an upper extremity?

Volkmann's contracture R: If compartment syndrome occurs in an upper extremity, it may lead to Volkmann's contracture, a claw-like deformity of the hand resulting from obstructed arterial blood flow to the forearm and hand. A whiplash injury is a cervical spine sprain. Callus refers to the healing mass that occurs with true bone formation after a fracture. Subluxation refers to a partial dislocation.

There are a variety of problems that can become complications after a fracture. Which is described as a condition that occurs from interruption of the blood supply to the fracture fragments after which the bone tissue dies, most commonly in the femoral head?

avascular necrosis R; Avascular necrosis is described as a condition that occurs from interruption of the blood supply to the fracture fragments after which the bone tissue dies, most commonly in the femoral head.

When the client who has experienced trauma to an extremity reports severe burning pain, vasomotor changes, and muscles spasms in the injured extremity, the nurse recognizes that the client is likely demonstrating signs of

complex regional pain syndrome. R:Complex regional pain syndrome is frequently chronic and occurs most often in women. Avascular necrosis is manifested by pain and limited movement. Pain and decreased function are the prime indicators of reaction to an internal fixation device. Heterotrophic ossification causes muscular pain and limited muscular contraction and movement.

A client who has fallen and injured a hip cannot place weight on the leg and is in significant pain. After radiographs indicate intact but malpositioned bones, what would the physician diagnose?

dislocation R: In joint dislocation, radiographic films show intact yet malpositioned bones. Arthrography or arthroscopy may reveal damage to other structures in the joint capsule. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. Sprains are injuries to the ligaments surrounding a joint. A fracture is a break in the continuity of a bone.

A client who has injured a hip in a fall cannot place weight on the leg and is in significant pain. After radiographs indicate intact yet malpositioned bones, what repair would the physician perform?

joint manipulation and immobilization R: The physician manipulates the joint or reduces the displaced parts until they return to normal position, then immobilizes the joint with an elastic bandage, cast, or splint for several weeks.

A teenage client is brought to the clinic by a parent and reports pain in the arm. The client is a member of a high school crew team and practices for 2 ½ hours every day after school. Which of the following would the nurse suspect?

Epicondylitis R: Epicondylitis (tennis elbow) is a painful inflammation of the elbow. The injury typically follows excessive pronation and supination of the forearm, such as that which occurs when playing tennis, pitching ball, or rowing. A ganglion is a cystic mass that develops near tendon sheaths and joints of the wrist. Carpal tunnel syndrome is a term for a group of symptoms located in the wrist where the carpal bones, carpal tendons, and median nerve pass through a narrow, inelastic canal. Tendonitis is a general term that refers to inflammation of a tendon caused by overuse.

A client has had surgical repair of a hip injury after joint manipulation was unsuccessful. After surgery, the nurse implements measures to prevent complications. Which complications is the nurse seeking to prevent? Select all that apply.

skin breakdown pneumonia wound infection R: After surgery, the nurse implements measures to prevent skin breakdown, wound infection, pneumonia, constipation, urinary retention, muscle atrophy, and contractures.

A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan?

Elevating the stump for the first 24 hours R: Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility. Heat application would be inappropriate because it promotes vasodilation, which may cause hemorrhage and increase pain. The initial pressure dressing usually remains in place for 48 to 72 hours after surgery.

Which type of fracture occurs when a bone fragment is driven into another bone fragment?

Impacted R: An impacted fracture is one in which a bone fragment is driven into another bone fragment. An oblique fracture occurs at an angle across the bone. A spiral fracture is one that twists around the shaft of the bone. A transverse fracture is one that is straight across the bone shaft.