Honan-Chapter 42: Nursing Management: Patients With Musculoskeletal Trauma

A 75-year-old client had surgery for a left hip fracture yesterday. When completing the plan of care, the nurse should include assessment for which complications? Select all that apply. A. Pneumonia B. Necrosis of the humerus C. Skin breakdown D. Sepsis E. Delirium

A. Pneumonia C. Skin breakdown D. Sepsis E. Delirium

Which of the following would lead a nurse to suspect that a client has a rotator cuff tear? A. Ability to stretch arm over the head B. Difficulty lying on affected side C. Pain worse in the morning D. Minimal pain with movement

B. Difficulty lying on affected side RATIONALE 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 type of fracture involves a break through only part of the cross-section of the bone? A. Incomplete B. Comminuted C. Open D. Oblique

A. Incomplete RATIONALE An incomplete fracture involves a break through only part of the cross-section of the bone. A comminuted fracture is one that produces several bone fragments. An open fracture is one in which the skin or mucous membrane wound extends to the fractured bone. An oblique fracture runs across the bone at a diagonal angle of 45 to 60 degrees.

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? A. avascular necrosis B. fat embolism C. pulmonary embolism D. shock

A. avascular necrosis RATIONALE 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.

An x-ray demonstrates a fracture in which the fragments of bone are driven inward. This type of fracture is referred to as A. depressed. B. compound. C. comminuted. D. impacted.

A. depressed. RATIONALE Depressed skull fractures occur as a result of blunt trauma. A compound fracture is one in which damage also involves the skin or mucous membranes. A comminuted fracture is one in which the bone has splintered into several pieces. An impacted fracture is one in which a bone fragment is driven into another bone fragment.

In the immediate postoperative period, which measure would best prevent a DVT? A. Adding a multivitamin to the patient's medication B. Early ambulation C. Measuring intake and output D. Lowering the legs below the level of the heart

B. Early ambulation RATIONALE Early ambulation enhances venous return and is an appropriate intervention to prevent problems related to inactivity such as a DVT.

A 22-year-old man is admitted to the emergency department with a crush injury to both lower legs. He was pinned under a car for 3 hours. On admission, his vital signs are stable; he is alert and oriented and complaining of extreme pain in his legs. Popliteal pulses are strong; pedal and posterior tibial pulses are weak. The ankle and feet appear dusky; the skin is tense, but the skin envelope is not broken. X-rays show no broken bones. Based upon these data, what interventions are most appropriate? A. Notify the provider and anticipate that a stat V˙/Q˙ scan will be performed to rule out fat emboli. B. Notify the provider and prepare to set up skin traction to decrease the pressure on the calf muscle. C. Notify the provider and anticipate that the provider will measure the pressure in the compartment and possibly perform a fasciotomy if elevated pressure is noted. D. Notify the provider and prepare to give IV antibiotics stat to decrease the risk of osteomyelitis.

C. Notify the provider and anticipate that the provider will measure the pressure in the compartment and possibly perform a fasciotomy if elevated pressure is noted. RATIONALE Fat emboli would present with signs and symptoms of pulmonary distress, mental status changes, and a petechial rash that develops from 6 to 72 hours after injury. Skin traction is not appropriate in this situation; skin traction is used to treat fractures, dislocations, and long-duration muscle spasms. Compartment syndrome is defined as increasing pressure between bone and fascia of the limb and often presents with complaints of extreme pain unrelieved by pain medication, pain on passive extension, paresthesis and pulselessness. However, pulselessness presents late in this disorder. The patient symptoms suggest compartment syndrome. The provider should be notified immediately as a delay in diagnosis and treatment of compartment syndrome can lead to permanent nerve and muscle damage. Compartment pressure monitoring is useful in diagnosing this complication. Osteomyelitis presents with fever, pain, swelling, redness, drainage, and leukocytosis and typically occurs after several days or weeks.

A 73-year-old patient is placed in skeletal traction prior to surgery for an ORIF of fractured femur. She develops chest pain, tachypnea, and tachycardia the second day in traction. What additional symptom would indicate her symptoms are related to a fat emboli rather than a pulmonary thromboembolic event? A. Hypotension B. Restlessness C. Petechiae of the anterior chest wall D. Warm, reddened areas in her leg

C. Petechiae of the anterior chest wall RATIONALE Specific symptoms associated with fat emboli are pulmonary distress, mental status changes, and a petechial rash that develops from 6 to 72 hours after injury. Common symptoms of pulmonary emboli (PE) are shortness of breath, chest pain, increased respiratory rate, cough, apprehension and tachycardia.

A 23-year-old patient, experienced an open fracture of the left tibia with major soft tissue damage of his lower leg in a bicycle accident. Surgical reduction and fixation of the tibia were performed with debridement of nonviable tissue and drain placement in the damaged soft tissue. Which finding by the nurse would most likely indicate the development of the osteomyelitis? A. Tachycardia B. Elevated ESR C. Numbness in the left leg and toes D. Muscle spasms around the affected bone

B. Elevated ESR RATIONALE The erythrocyte sedimentation rate (ESR), is over 90% for patients who have confirmed osteomyelitis. However, a normal or slightly elevated ESR does not eliminate the diagnosis. In addition, the nurse assesses for pain over the affected bone.

During assessment of a patient admitted to the emergency room after a motor vehicle collision, he becomes semiconscious and continues moaning with pain. His blood pressure has now decreased to 100/42, and his pulse has increased to 122. What is the most immediate life-threatening problem for this patient? A. Arrhythmias due to hypokalemia B. Hypovolemia C. Respiratory depression from pain medication D. Fat embolus to the lung

B. Hypovolemia RATIONALE Tachycardia and hypotension are associated with hypovolemia. Any patient with multitrauma is at risk for hypovolemia. Refer to Box 42-2 in the text for signs and symptoms of hypovolemic shock.

Which nursing intervention is essential in caring for a client with compartment syndrome? A. Keeping the affected extremity below the level of the heart B. Wrapping the affected extremity with a compression dressing to help decrease the swelling C. Removing all external sources of pressure, such as clothing and jewelry D. Starting an I.V. line in the affected extremity in anticipation of venogram studies

C. Removing all external sources of pressure, such as clothing and jewelry RATIONALE 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.