(Iggy Study Guide) Chapter 47: Concepts of Care for Patients with Musculoskeletal Trauma

Which client will the nurse assess most frequently for indications of venous thromboembolism (VTE)? A. 25-year-old weightlifter with a fracture of the right femur B. 45-year-old with metastatic cancer and a spinal compression fracture C. 55-year-old car crash victim with multiple facial fractures D. 65-year-old with a broken elbow and hypertension

A VTE is the most common complication of lower extremity fracture resulting from trauma. Immobilization of the limb also contributes to the risk.

Which clients with fractures will the nurse recognize as being at increased risk for delayed or slow bone healing? Select all that apply. A. 28-year-old male with multiple long-bone fractures B. 35-year-old female with diet-induced osteopenia C. 45-year-old female semiprofessional tennis player D. 58-year-old female taking corticosteroids daily for an autoimmune disorder E. 65-year-old male with arteriosclerosis F. 75-year-old male chronic obstructive pulmonary disease

B,D,E,F Risk factors for delayed or slow bone healing after a fracture include age older than 70 years, presence of bone density loss, such as with osteopenia or chronic use of corticosteroids, and poor circulation, such as would be present with arteriosclerosis. Unless there are complications, multiple fractures do not increase delayed healing risk.

What is the nurse's best response when a client who had a long-leg plaster cast applied an hour ago reports that the casts feels "hot"? A. "Plaster gives off heat as it dries, and the heat does not mean anything is wrong." B. "It is likely that you have an infection and will need to be started on antibiotics immediately." C. "This means you are having an allergic reaction and this cast will have to be removed immediately." D. "Don't worry. This heat is normal and I will apply a cooling blanket over it for your comfort."

A Plaster is applied as a wet and easily deformed substance. As plaster dries, it gives off heat as part of this normal chemical reaction. The client is reassured that the heat is normal. Because plaster is easily deformed until it dries completely, it cannot be covered with a cooling blanket.

A client who had a plaster splint applied to the ankle at 7 a.m. and received pain medication at 9 a.m. now at 11 a.m. reports that the pain is getting worse, not better. What is the nurse's best first action to prevent harm? A. Assessing the pulses and skin temperature distal to the splint B. Loosening the splint and reassessing the client's pain in 15 minutes C. Requesting a prescription to administer the pain medication IV D. Repositioning the extremity on a pillow and placing an ice pack

A The ankle could be swelling under the cast and impinging on circulation, leading to increased pain from tissue hypoxia or anoxia. The nurse's best first action is performing neuromuscular assessments to determine if a circulatory problem is present. If circulation is compromised, the nurse would then loosen the splint and notify the primary health care provider.

Which points and actions will the nurse include when teaching a client and family after a below-the-knee amputation about care of the residual limb? Select all that apply. A. Demonstrating how to apply a figure-eight elastic wrap B. Reviewing the signs and symptoms of wound infection C. Reminding the client and family to rewrap the limb several times each day D. Obtaining a return demonstration of the elastic wrap application E. Reviewing positioning and exercises for prevention of flexion contractures F. Informing the client that after the incision is healed, it can be cleaned during bathing or showering with soap and water

A,B,C,D,E,F All of the listed points and actions are appropriate for the nurse to include when teaching a client and family about care of the residual limb at home.

Which actions are appropriate for the nurse to perform when caring for a client who is placed in Buck's traction after a hip fracture? Select all that apply. A. Ensuring that the weight never rest on the floor. B. Removing the boot or belt every 8 hours to assess skin integrity. C. Comparing the amount of weights applied with the amount prescribed. D. Removing the weights every 8 hours for 30 minutes to prevent muscle spasms. E. Assessing circulation distal to the traction device every hour for the first 24 hours. F. Instructing all personnel and visitors to not touch or change the position of the weights.

A,B,C,E,F Traction weights are prescribed at a specific weight and are not removed without an order. They are not to be lifted manually, allowed to rest on the floor, and must hang freely at all times. The belt or boot used for skin traction is removed every 8 hours to inspect the skin under the device. The client's circulation is monitored every hour for the first 24 hours after traction is applied and at least every 4 hours thereafter.

Clients with which problems or factors will the nurse assess most frequently for development of acute compartment syndrome? Select all that apply. A. Lower legs caught between the bumpers of two cars B. Massive infiltration of IV fluid into the forearm C. Bivalve cast on the lower leg D. Multiple insect bites to lower legs E. Daily use of oral corticosteroids F. Severe burns to the upper extremities

A,B,D,F Acute compartment syndrome is a serious limb-threatening condition in which increased pressure within one or more compartments (that contain muscle, blood vessels, and nerves) reduces circulation to a lower leg or forearm. Common health problems leading to this condition include crush injuries to the extremities, extravasation and infiltration of IV fluids, and severe inflammatory response with excessive swelling in an extremity, such as with burn injuries or release of toxins from multiple insect stings or bites.

Which assessments are a priority for the nurse to perform to prevent harm on a client who was hit by a motorcycle and has a suspected pelvic fracture? Select all that apply. A. Checking vital signs B. Asking about opioid use C. Examining urine for presence of blood D. Asking the client to rate his or her pain E. Determining the level of consciousness F. Performing neurovascular checks of the lower limbs

A,C,E Injuries that cause pelvic fractures often also cause significant damage to the abdomen and can cause internal hemorrhage, as well as damage to the bladder. Assessing vital signs and level of consciousness have the highest priority to rule out whether hemorrhage and shock are present. Assessing for bladder injury is also a priority. Although the other assessments are important, they are not the immediate priority.

Which assessment findings on a client being prepared for a vertebroplasty for a compression fracture of the lumbar vertebrae will the nurse report immediately to the orthopedic surgeon? Select all that apply. A. Platelet count is 40,000/mm3. B. White blood cell count is 9000/mm3. C. Client reports taking the prescribed dose of an antihypertensive this morning. D. Client reports taking the prescribed dose of rivaroxaban this morning. E. Pain rating is an 8 on a 0 to 10 scale. F. Sensation to pinprick stimulation is reduced on the right leg.

A,D Although a vertebroplasty is considered a type of minimally invasive surgery, there is a gander of bleeding into the spinal area. Contraindications to the procedure are a platelet count lower than 100,000/mm3 and/or having taken an anticoagulant drug, such as rivaroxaban, within 48 hours. The other assessment findings are either normal or expected as a response to spinal compression fractures.

Which client will the nurse determine requires the most assistance with performance of ADLs? A. 28-year-old with bilateral below-the-knee amputations B. 40-year-old with amputation of the dominant hand C. 50-year-old with an above-the-knee amputation of the dominant leg D. 70-year-old with amputation of all the toes on the left foot

B Clients who have any part of an upper extremity amputated, especially of the dominant hand are much more likely to become less independent in ADLs. A 70-year-old client who has been independent in ADLs is likely to remain independent after amputation of all toes on the left foot although balance and mobility may be changed.

Which assessment finding on a client who has a closed fracture of the lower femur with extensive swelling and bruising best indicates to the nurse that perfusion in the affected limb is adequate? A. Pulse oximetry on the right forefinger is 98%. B. Pedal pulse of the affected limb is easily palpated and strong. C. Femoral pulse of the affected limb is easily palpated and strong. D. Capillary refill on great toe of the affected limb is about 4 seconds.

B Measures of perfusion adequacy in the affected limb must be made on the affected limb, distal to the injury. Although capillary refill can provide an indication of perfusion adequacy, it is not as reliable as a pedal pulse.

Which assessment finding in a client who has a fracture of the right wrist alerts the nurse to a possible early indication of a complication? A. Wiggling fingers causes pain. B. Client reports numbness and tingling. C. Fingers are cold and pale; pulses are impalpable. D. Pain is severe and seems out of proportion to injury.

B Numbness and tingling are early indications of nerve entrapment or impingement. Moving the fingers below a wrist injury is expected to cause some pain. Cold, pale fingers in which pulses cannot be palpated is a late indication of a complication, as is pain that grows worse out of proportion to the injury.

What is the nurse's best response to a client with lower limb amputation who says "I think I am going crazy. I know my foot is gone but I still feel my big toe burning and itching."? A. "Are you sure you were awake? Sometimes people dream this pain was part of hoping that the missing body part will grow back." B. "You are not crazy; many people continue to feel pain and other sensations in a limb that was amputated. How severe is this pain?" C. "This complication is usually seen in a person who has not accepted the fact that the limb is gone. A psychologist can help you cope with this." D. "This problem is very common and although nothing can be done about it, we can give you pain medication for the pain you feel at the surgical site."

B Phantom limb pain (PLP) is a real physiologic problem for many people after amputation. The pain is real and requires appropriate management. Telling the client that the limb cannot be hurting because it is missing is not therapeutic and will not reduce the client's expressed concern that he may be "crazy". Drug therapy for PLP varies with the type of sensation felt as well as the intensity. Although some clients may need a mental health care professional to assist with coping, immediate pain management is the priority for this client, along with allaying his anxiety.

What is the nurse's best response to a young adult client who says "How will I ever walk on that?" on seeing his pale and thin leg after removal of a long-leg cast that has been in place for 7 weeks? A. "Fractures can heal but the bones are never as strong as they were before the break." B. "The leg will be weak at first, but will regain muscle strength and size as you exercise." C. "The bone will thicken as healing continues and make this leg as large as your other one." D. "The color changed because the plaster in the cast rubbed off on it and will improve when you are able to shower."

B With immobilization in a cast, leg muscles atrophy and become thin. Skin becomes pale, dry, and flaky from lack of exposure to air and water. Both of these conditions improve when the cast is off. How much strength returns to the leg depends on the degree of exercise and use it gets, not on the thickness of the bone.

Which client assessment findings or factors indicate to the nurse the possible presence of carpal tunnel syndrome (CTS)? Select all that apply. A. Client has been taking calcium and vitamin D supplements for osteopenia. B. Numbness and pain are reported on performance of the Phalen maneuver. C. Muscle pad below the thumb is flat and atrophied. D. Client's favorite hobby is knitting and crocheting. E. Wrist and hand pain awaken the client at night. F. Lifestyle is very sedentary.

B,C,D,E CTS is most commonly caused by repetitive motions of the hand and wrist, such as would occur with knitting and crocheting. Muscle atrophy of hand muscles often results from CTS. Pain and numbers with the Phalen maneuver are strong indicators of CTS as is the increased presence of these symptoms at night. Neither osteopenia nor a sedentary lifestyle predispose a person to CTS.

A client expresses concern over the presence of external pins and external devices used to manage her fracture and says she wishes it all could have been placed internally so it wound't be visible. What advantages will the nurse tell the client that external fixation has over internal fixation of fractures? Select all that apply. A. The risk for infection is reduced. B. You lost less blood than you would have with an internal fixation. C. This device allows you to move and walk earlier than an internal device. D. You will not need surgery to remove these devices after healing is complete. E. Most people have less pain with the external devices than with internal devices. F. This device replaces the need for the use of any other device such as a cast or a boot, later.

B,C,D,E The use of external fixation devices results in less blood loss and less pain than internal fixation devices. Moving, walking, and exercising can occur much earlier. The infection risk for external fixation devices is greater than with internal devices because there is a continuing disruption of skin integrity with the presence of pins. Other devices may still be needed after fractures are stabilized with external fixation devices.

Which assessment findings in a client with a complete and displaced fracture of the femur indicates to the nurse possible fat embolism syndrome (FES)? Select all that apply. A. Increased swelling over the fracture site .B. Petechiae on the neck and chest C. Decreased platelet count D. Dry mucous membranes E. Sudden-onset confusion E. PaO2=72 mm Hg

B,C,E,F Decreased arterial oxygen level, acute confusion, and a decreased platelet count are common indicators of FES. Although the presence of a petechial rash is a late manifestation, it is a classic finding of FES. Swelling over the fracture site and dry mucous membranes are not symptoms associated with FES.

Which action will the nurse perform first when a client in a body cast reports a painful "hot spot" underneath the cast and an unpleasant odor? A. Requesting a cast change B. Offering the client a PRN pain medication C. Assessing the client's temperature and other vital signs D. Elevating the extremity and applying an ice pack over the sport

C A hot spot coupled with an unpleasant odor are indications of a possible infection under the cast. Before notifying the primary health care provider or taking any other actions, the nurse will assess the client's temperature and other vital signs for other indications of infection.

Which client with a non healing fracture of the humerus will the nurse recognize as having a contraindication for use of electrical bone stimulation? A. 30-year-old with a seizure disorder B. 40-year-old smoker with hypertension C. 50-year-old with an implanted cardiac pacemaker D. 60-year-old with reduced immunity from corticosteroid use

C Any type of electrical bone stimulation on an arm is contraindicated for clients who have implanted pacemakers.

Which suggestion will the nurse make to help a client who has complex regional pain syndrome (CRPS) in the right arm weeks after an open reduction was required to repair a broken elbow and fractured radius to reduce the discomfort? A. Take pain medications around the clock even when the pain is not present. B. When the sensations occur, immobilize and ice the limb until they pass. C. Use a dry wash cloth and rub the skin on the arm several times daily. D. Wrap the arm in warm, wet compresses as soon as the pain starts.

C CRPS is a dysfunction of the central and peripheral nervous systems in areas of bone fractures with soft-tissue damage that leads to severe, persistent burning pain, muscle spasms, and changes in skin color, temperature, and sensitivity among other symptoms. To facilitate soft-tissue healing and prevent CRPS, clients are told to frequently apply a variety of objects with varying surface types directly to the skin to desensitize it. These objects can be rough, smooth, hard, soft, sharp (but not enough to damage the skin), or dull.

Which instructions for handling the amputated digit will the nurse provide to a caller to the emergency department who reports that a friend just sustained an amputation of a finger while cleaning his lawn mower? A. "Place the finger in a glass of milk and keep in cold while transporting it." B. "Seal the finger in a plastic bag and pack with the cut side up in a cup of ice." C. "Wrap the finger in a clean cloth, seal it in a plastic bag, and place the bag in ice water." D. "Place the finger back on your friend's hand and wrap it tightly with an elastic bandage."

C Current recommended guidelines for maintaining viability of an amputated finger (or other digit) are to wrap the completely severed finger in a dry clean cloth, place the finger in a water-tight, sealed plastic bag, and then put the bag in ice water, never directly on ice.

What is the most appropriate action for the nurse to take when assessment on a client with external fixation reveals crusts have formed around the pin sites? A. Assessing the client's temperature B. Notifying the surgeon immediately C. Documenting the finding as the only action D. Removing the crusts and culturing the drainage

C Drainage of clear fluid (weeping) is expected in the first 72 hours around pin sites. The drainage forms crusts that are believed to protect the site from infection and are not removed.

Which assessment is the priority for the nurse to perform on a client admitted to the emergency department with multiple rib fractures? A. Pulses in all four extremities B. Pulse rate and rhythm C. Oxygen saturation D. Pain intensity

C Rib fractures are painful and the client may be breathing too shallowly to maintain gas exchange. In addition, if there are shard edges on the ribs, the lungs can be punctured. After respiratory assessment, cardiac assessment would be the next priority.

Which assessment finding on an older client who fell while getting out of bed indicates to the nurse a possible fracture? A. The client is extremely confused and trying to get up. B. The client cries out when the nurse attempts to examine him. C. One leg is shorter than the other and has a protruding bump on the side. D. The skin of both legs is cooler and darker than that of the upper extremities.

C Strong indicators of lower limb fracture or joint dislocation is a change in the length (usually shorter) of the affected limb and abnormal protrusions or obvious deformities. In an older client, the skin of the legs is cooler and darker than that of the arms. Confusion may be a cause or a consequence of the fall but does not indicate a fracture of bone injury. Pain is nonspecific.

Which actions will the nurse take to prevent a flexion contracture in a client who is postoperative from an above-the-knee amputation low on the femur? Select all that apply. A. Applying the elastic wraps on the stump distal to proximal in a figure-eight pattern B. Using aseptic technique when irrigating the wound or changing the dressing C. Instructing the client to perform gluteal muscle contraction exercise hourly while awake D. Assisting the client to a prone position for 20 to 30 minutes every 3 to 4 hours E. Keeping the remaining part of the extremity positioned above the level of the heart F. Encouraging the client to spend as much time as possible in a chair while awake

C,D Gluteal muscles are extensors of the hip joint. Contraction exercises of these buttocks muscles straighten the leg and make the extensor muscles stronger to help prevent flexion contractures. Having the client assume a prone position for 20 to 30 minutes every 3 to 4 hours also helps keep the upper leg in an extended position and prevents flexion contractures. Sitting in a chair requires flexion and promotes flexion contractures.

Which precautions or care information are appropriate for the nurse to include when teaching a client going home with a synthetic forearm cast? A. "Be sure to change the stockinette at least once a week." B. "Limit movement of the fingers and wrist joints to prevent pain." C. "Keep your hands and arm elevated above the level of your heart to reduce swelling." D. "Use an ice pack on the cast for the first 6-8 hours, and cover the pack with a towel." E. "When upright, wear the sling so that it distributes over your shoulders and not just your neck" F. "Call your primary health care provider immediately if numbness and tingling occur in your hand or fingers."

C,D,E,F A synthetic cast dries quickly and is not deformed by handling. A fresh fracture is likely to swell and applying ice to the cast, as well as keeping the hands and arms elevated above the level of the heart can help limit the swelling. The swelling can still cause impingement of a nerve, and the client is instructed to report numbness and tingling as soon as possible to prevent harm. Slings, although partially supported by the neck, should have the greater support resting on the shoulders and trunk to prevent damage to the neck. The stockinette is not changed separately from the cast. The client is instructed to move the wrist and fingers to maintain range of motion and prevent muscle atrophy or contractures.

After ensuring airway, breathing, and circulation along with a head-to-toe assessment, which action will the nurse take next in the emergency care of a client with an extremity fracture? A. Checking the neuromuscular status of the area distal to the injury: temperature, color, sensation, movement, and distal pulses by comparing the affected and unaffected limbs B. Elevating the affected area on pillows, applying an ice pack that is wrapped to protect the skin, and obtaining a prescription for pain medication C. Immobilizing the extremity by splinting; including joints above and below the fracture site, followed by rechecking the circulation D. Removing or cutting the client's clothing to inspect the affected area while supporting the injured area above and below the injury

D Before any appropriate intervention action can be taken, the nurse must first visually inspect the area to adequately assess the trauma. This entails removing or cutting away clothing in the affected area without causing more harm.

Which question is most appropriate for the nurse to ask a client who has been receiving scheduled and PRN opioids for severe pain with multiple fractures who now has a distended abdomen and hypoactive bowel sounds? A. "Did you use opioids or other recreational drugs before your injury?" B. "What specific foods have you eaten in the past 2 days?" C. "How would you rate your pain on a 0 to 10 scale?" D. "When was your last bowel movement?"

D Severe fractures are very painful and usually require opioid pain medications for some time regardless of whether the client has ever used opioids in the past. A major side effect of opioids is decreased peristalsis and constipation (opioid-induced constipation [OIC]). The first question to ask is when did the client last have a bowel movement. The client usually requires a bowel regimen to relieve constipation and prevent a possible paralytic ileus.

Which precaution or care information will the nurse teach a client prescribed low-intensity pulsed ultrasound treatments for a very slow-healing fracture of the lower leg specific for this treatment? A. Use a reliable form of birth control until treatment is complete. B. The treatment cannot be used if you have any type of diabetes mellitus. C. The device should not be used in the same room with a microwave oven. D. Expect to dedicate approximately 20 minutes each day for the treatment.

D There are no specific adverse effects or contraindications for the use of this therapy.

Which client will the nurse consider to be at highest risk for nonunion after a fracture? A. 40-year-old who is 20 lb overweight and has a Colles fracture of the wrist B. 50-year-old female with comminuted fracture of the humerus C. 60-year-old male with multiple fractured ribs D. 70-year-old female with a "sib-fib" fracture

D This client has three major risk factors for nonunion: older age, female, and lower limb fracture.