Level 2: Chapter 62

A patient fell on the right elbow and states he or she has severe pain. The nurse suspects fracture of the humerus. During neurologic examination of the patient, which nerves should the nurse assess? Select all that apply. 1. Tibial nerve 2. Ulnar nerve 3. Median nerve 4. Radial nerves 5. Peroneal nerve

2. Ulnar nerve 3. Median nerve 4. Radial nerves It is important to evaluate sensory and motor functions of the ulnar, median, and radial nerves in cases of upper extremity injury. Assess neurovascular status by abduction and adduction of the fingers, opposition of the fingers, and supination and pronation of the hand. The tibial and peroneal nerves are assessed if there is any injury to the lower limbs.

Which body part of the patient is at risk for superior mesenteric artery syndrome when sustaining a fracture? 1. Knee 2. Vertebrae 3. Lower extremity 4. Upper extremity

2. Vertebrae In stable spine injuries, a thoracic or lumbar spine body jacket brace is used for immobilization and support. Superior mesenteric artery syndrome occurs if the brace is applied too tightly, compressing the superior mesenteric artery against the duodenum. Knee injuries, lower extremity injuries, and upper extremity injuries do not require a thoracic or lumbar spine body jacket brace and, therefore, are not associated with mesenteric artery syndrome.

The nurse teaches an older adult about ways to prevent musculoskeletal problems. What instructions are appropriate for the nurse to include in the patient's education? Select all that apply. 1. "Perform tai chi exercises." 2. "Eliminate scatter rugs at home." 3. "Discuss the use of medications for pain." 4. "Do not perform weight bearing exercises on a daily basis." 5. "Do not get involved in activities such as model building and jigsaw puzzles."

1. "Perform tai chi exercises." 2. "Eliminate scatter rugs at home." 3. "Discuss the use of medications for pain." Older adults may be advised to learn tai chi because it provides range of motion exercises. Scatter rugs should be eliminated at home to decrease the risk of falling. The use of medications should be discussed for pain relief due to osteoarthritis. Weight bearing exercises are recommended to reduce musculoskeletal problems. Model building and jigsaw puzzles activities help in exercising finger joints and prevent stiffness.

When performing the physical examination of a patient, how should the nurse assess the function of the peroneal nerve? Select all that apply. 1. Assess dorsiflexion of the foot. 2. Assess plantar flexion of the foot. 3. Assess sensation in the sole of the foot between the third and fourth toes. 4. Assess sensation in the sole of the foot between the first and second toes. 5. Assess sensation in the dorsal part of the foot between the first and second toes.

1. Assess dorsiflexion of the foot. 5. Assess sensation in the dorsal part of the foot between the first and second toes. The peroneal nerve has motor and sensory functions. The motor function is assessed by looking for dorsiflexion of the foot, whereas the sensory function is assessed by looking for sensation on the dorsal aspect of the foot between the first and second toes. Plantar flexion of the foot and sensory supplies to the sole of the foot are the functions of the tibial nerve. The function of the peroneal nerve is not assessed by sensation in the sole of the foot between the third and fourth toes or by sensation in the dorsal part of the foot between the first and second toes, because the peroneal nerve does not supply these areas.

A coal miner with a history of rheumatoid arthritis reports pain, swelling, and a limited range of motion in the knee joints. What diagnosis does the nurse suspect? 1. Bursitis 2. Shin splints 3. Rotator cuff tear 4. Impingement syndrome

1. Bursitis Bursitis is the inflammation of the bursae located near the joints. Rheumatoid arthritis causes inflammation in the joints, resulting in friction between joint surfaces. The repetitive kneeling involved in occupations such as coal mining may result in bursitis. A shin splint is inflammation along the anterior aspect of the calf due to periostitis. A rotator cuff tear is a muscle tear around the shoulder joint. Impingement syndrome is also a shoulder injury.

A patient is brought to the hospital with bloodstains on clothing and active bleeding from the nose, with deformity of the right arm. Prioritize the initial interventions to be done in this case. Check for pulse rate. Check for respiratory rate. Check if there is blood in the mouth. Assess the neurovascular status of the right arm.

1. Check if there is blood in the mouth. 2. Check for respiratory rate. 3. Check for pulse rate. 4. Assess the neurovascular status of the right arm. Emergency management of any injury involves assessment of air way (A), breathing (B), and circulation (C), in that order. Therefore for this patient the attending nurse should first check for any blood in the mouth blocking the airway, then check for respiratory effort to see if the patient is breathing, then check for a pulse to see if circulation of blood is normal, and then assess the neurovascular status of the affected limb (in this case, the right arm).

A nurse is taking care of a patient with a cast on the right leg maintained in external traction. However, during the routine examination, the nurse finds that the patient has compartment syndrome. What measures should a nurse take in the management of this patient? Select all that apply. 1. Cut the cast in half. 2. Reduce external traction weight. 3. Remove or loosen any bandage. 4. Apply cold compresses to the leg. 5. Elevate the affected limb above heart level.

1. Cut the cast in half. 2. Reduce external traction weight. 3. Remove or loosen any bandage. If the patient has compartment syndrome, the cast should be split in half. If there are any bandages, they should be removed or loosened to remove the pressure. A reduction in traction weight may also decrease external circumferential pressures. Elevation of the extremity may lower venous pressure and slow arterial perfusion. Therefore the extremity should not be elevated above heart level. The application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome.

The patient had a lumbar spine arthrodesis. What should the nurse include in discharge teaching? Select all that apply. 1. Do not smoke cigarettes. 2. You should not walk for three weeks. 3. You must wear your brace at all times. 4. You may drive as soon as you feel like it. 5. Do not bend your spine until your follow-up appointment.

1. Do not smoke cigarettes. 5. Do not bend your spine until your follow-up appointment. After a spinal fusion, the patient should not smoke cigarettes, because nonunion tends to occur more often with smokers. Preventing pressure by not bending or twisting the spine or lifting more than 10 pounds will facilitate healing over time. The amount of time that is needed will be determined by the health care provider at follow-up appointments, but healing usually takes six to nine months. An important aspect of healing is progressively increasing walking, which increases circulation of nutrients and oxygen for healing. If a brace is prescribed to protect the surgical area, the health care provider will prescribe how often the patient should wear it. Driving is not done until the health care provider allows it and the patient is no longer taking opioids for pain.

A nurse is caring for a patient with a fractured femur. The health care provider finds that the patient has fat embolism syndrome. What treatment (or treatments) of fat embolism syndrome should the nurse anticipate for this patient? Select all that apply. 1. Fluid resuscitation 2. Correction of acidosis 3. Avoidance of coughing 4. Fracture immobilization 5. Frequent change in positions

1. Fluid resuscitation 2. Correction of acidosis 4. Fracture immobilization The treatment of fat embolism syndrome is directed toward the management of symptoms. This includes fluid resuscitation to prevent hypovolemic shock, correction of acidosis, and fracture immobilization. The patient should be encouraged to cough and perform deep breathing. The patient should be repositioned as little as possible to prevent dislodgment of fat droplets into the general circulation.

The nurse is caring for the patient with skeletal traction for an extremity fracture. What action(s) by the nurse are most appropriate? Select all that apply. 1. Keep the weights off of the floor. 2. Elevate the end of the bed as needed. 3. Ensure that the weights are secured to the pulleys. 4. Confirm that the forces are pulling in the same direction. 5. Make sure that the traction ranges from 5 to 45 pounds (2.3 to 20.4 kg). 6. Apply the traction intermittently as prescribed by the health care provider (HCP).

1. Keep the weights off of the floor. 2. Elevate the end of the bed as needed. 5. Make sure that the traction ranges from 5 to 45 pounds (2.3 to 20.4 kg). The weights must be kept off of the floor. The end of the bed may need to be elevated so that the weights are off the floor for traction to be applied. Traction weight ranges from 5 to 45 pounds (2.3 to 20.4 kg). Weight forces have to be in the opposite direction (counter traction). Traction must be applied continuously to be effective and the weights have to move freely through the pulleys.

The nurse reviews the test results of a patient that reports shoulder weakness with decreased range-of-motion (ROM). What activities may have contributed to the patient's condition? Select all that apply. Positive drop arm test and a tear seen in the MRI scan 1. Lifting heavy weights 2. A blow to the upper arm 3. Falling onto an outstretched arm 4. Working with vibrating power tools 5. Using a computer keyboard frequently

1. Lifting heavy weights 2. A blow to the upper arm 3. Falling onto an outstretched arm The positive results of the drop arm test and a tear seen in the MRI scan may indicate a rotator cuff injury. A tear in the rotator cuff may occur due to repeated overhead motions and can include heavy weight lifting, a blow to the upper arm, or falling onto an outstretched arm. The other activities such as working with vibrating power tools or using a computer keyboard and mouse frequently are not likely to cause a rotator cuff injury.

A patient experiences an unstable wrist fracture. Which type of cast will be most beneficial for the patient? 1. Long arm cast 2. External fixation 3. Short arm cast, restricting motion at the wrist and elbow 4. Short arm cast, providing wrist immobilization and unrestricted elbow motion

1. Long arm cast A patient who has an unstable wrist fracture needs restricted movement of the wrist and elbow that extends to the proximal humerus. This is provided by a long arm cast. Simple fractures and complex fractures with extensive soft tissue damage, nonunion or malunion, and limb lengthening can be done through external fixation, which is often used in an attempt to salvage extremities. By definition, a short arm cast facilitates unrestricted elbow motion, which is harmful for the patient with an unstable wrist fracture.

A patient is suspected of having fat emboli after a fractured hip. What assessment data gathered by the nurse are indicative of this condition? Select all that apply. 1. Increased hematocrit 2. Decreased platelet count 3. Prolonged prothrombin time 4. Pulmonary infiltration on chest radiograph 5. Increased partial pressure of arterial oxygen

2. Decreased platelet count 3. Prolonged prothrombin time 4. Pulmonary infiltration on chest radiograph This patient's signs and symptoms indicate that the patient has a condition called acute respiratory distress syndrome, caused by fat emboli. Petechiae located around the neck, the anterior chest wall, the axillae, the buccal membrane, and the conjunctivae of the eyes helps distinguish fat emboli from other problems. Results of blood tests show decreased platelet count and prolonged prothrombin time. A chest radiograph may reveal areas of pulmonary infiltrate or multiple areas of consolidation. The partial pressure of arterial oxygen (PaO2) and hematocrit are decreased.

A patient admitted with Parkinson's disease fell down the stairs in the hospital. The patient is conscious and states there is severe pain in the calf muscles. What should be the immediate course of action for the nurse? Select all that apply. 1. Apply hot compresses. 2. Elevate the affected limb. 3. Apply ice to the painful area. 4. Restrain the patient to the bed. 5. Encourage the patient to mobilize the limb.

2. Elevate the affected limb. 3. Apply ice to the painful area. If an injury occurs, the immediate care focuses on applying ice compresses to the injured area to reduce pain, muscle spasms, inflammation, and edema. The affected limb should be elevated to mobilize excess fluid from the area and prevent further edema. The nurse should instruct the patient to limit movements of the affected limb. After the acute phase (usually 24 to 48 hours) moist heat may be applied to the affected area to reduce swelling and provide comfort. Restraining the patient to the bed is not related to the management of this injury.

The nurse is caring for a patient with a fractured femur. Which nursing action(s) by the nurse is the priority? Select all that apply. 1. Resting the extremity. 2. Elevating the extremity. 3. Providing analgesia as necessary. 4. Compressing the involved extremity. 5. Applying ice compresses to the injured area. 6. Stopping the activity and limiting movement.

2. Elevating the extremity. 3. Providing analgesia as necessary. 4. Compressing the involved extremity. 5. Applying ice compresses to the injured area. 6. Stopping the activity and limiting movement. There are five interventions performed for an acute injury. Stopping the activity and limiting movement, applying ice compresses to the injured area, compressing the involved extremity, elevating the extremity, and providing analgesia as necessary. Resting the extremity is not included in the immediate care.

Which assistive device should be included in the plan of care for a patient with tendonitis who has a recurrence of symptoms? 1. Walker 2. Orthosis 3. Crutches 4. Gait belts

2. Orthosis Tendonitis may be described as the inflammation of a tendon due to overuse or incorrect use. An orthosis is a protective brace used in the treatment of recurrence of symptoms. Walkers, crutches, and gait belts can aid in walking but do not prevent recurrence of symptoms.

A patient fell from a 20-foot height onto the right elbow. The radiograph revealed a fracture in the middle third of the right humerus, with sharp edges. What are the structures that may be at risk of damage due to the sharp edges of broken bone in this patient? Select all that apply. 1. Ulnar nerve 2. Radial nerve 3. Axillary nerve 4. Brachial artery 5. Brachial plexus

2. Radial nerve 4. Brachial artery The radial nerve is present in the axillary groove of the humerus, and the brachial artery is located on the anterior aspect of the humerus. Therefore the radial nerve and brachial artery are likely to be damaged by the sharp edges of fractured bone margins of the humerus. The axillary nerve and brachial plexus are present in the axilla. Therefore they are unlikely to be damaged. The ulnar nerve is usually unaffected by bone fractures, owing to the presence of muscles and soft tissues.

What action should a nurse implement to prevent foot drop in a patient who has a full-leg cast? 1. Encourage bed rest 2. Support the foot with 90 degrees of flexion 3. Maintain the foot in a boot with 45 degrees of flexion 4. Place an antiembolic garment on the affected leg and foot.

2. Support the foot with 90 degrees of flexion As a means of preventing foot drop in a leg with a cast, the foot should be supported with 90 degrees of flexion. Encouraging bed rest for his patient is not required. Supporting the foot with 45 degrees of flexion will not prevent foot drop. Antiembolic garments will protect against thromboembolic events but not foot drop.

The nurse assists in performing annual well visits for four patients. Which patient is least likely to develop overuse syndrome? 1. A dancer 2. A musician 3. A football player 4. A grocery store cashier

3. A football player Repetitive strain injury (RSI) may result from prolonged force or repetitive movements and awkward postures. The repeated movements strain the tendons, ligaments, and muscles, causing tiny tears. It may result in inflammation, swelling, and pain in the muscles and nerves of the neck, shoulder, forearm, and hand. Persons at risk for RSI include dancers, musicians, grocery clerks, and workers who use power tools that cause vibration. The football player is least likely to develop this condition.

A patient is hospitalized with severe bleeding in the leg. An x-ray exam of the leg reveals that the periosteum is intact across the fracture and that the bone is still in alignment. What type of fracture does the patient have? 1. Oblique fracture 2. Pathologic fracture 3. Greenstick fracture 4. Comminuted fracture

3. Greenstick fracture A non-displacement fracture in which the periosteum is intact across the fracture and the bone is still in alignment is classified as a greenstick fracture. In an oblique fracture, the line of the fracture extends in an oblique direction. A pathologic fracture is a spontaneous fracture at the site of a bone disease. Displaced fractures are usually comminuted fractures in which there are more than two bone fragments with the smaller fragments floating or oblique.

A patient with an inflammation along the anterior aspect of the calf due to periostitis continues to report pain to the nurse. What is an appropriate action to be included on the patient's plan of treatment, which is specific to continued pain? 1. Apply a protective brace. 2. Consider reconstructive surgery. 3. Perform an x-ray to rule out a stress fracture of the tibia. 4. Perform a magnetic resonance imaging (MRI) to determine the need for arthroscopic surgery.

3. Perform an x-ray to rule out a stress fracture of the tibia. Shin splints may cause inflammation along the anterior aspect of calf due to periostitis. In case of persistence of pain, an x-ray test is carried out to diagnose stress fracture of the tibia. Protective braces are used if there is a recurrence of symptoms in patients with tendonitis. Reconstructive surgery is usually recommended for patients with severe acute cruciate ligament injury. In case of a meniscus injury, an MRI will confirm the diagnosis.

A nurse is completing the discharge sheet for a patient with hip fracture, who has been treated by insertion of a prosthesis using a posterior approach. What instructions should be given to this patient before discharge? Select all that apply. 1. Use low toilet seats and chairs without arms. 2. An adaptive device is not necessary for putting on shoes. 3. Place a chair inside the tub and remain seated while washing. 4. Inform the dentist about the prosthesis before any dental work. 5. Keep the hip in a neutral, straight position when sitting or lying.

3. Place a chair inside the tub and remain seated while washing. 4. Inform the dentist about the prosthesis before any dental work. 5. Keep the hip in a neutral, straight position when sitting or lying. For a patient who had a hip fracture and has been treated by insertion of a prosthesis using a posterior approach, it is important to teach him or her and the caregiver about the measures to prevent dislocation. Certain measures, such as placing a chair in the tub and remaining seated while washing and keeping the hip in a neutral and straight position when sitting, lying, or walking prevents dislocation. The patient should be advised to inform his or her dentist about the prosthesis before any dental work, so that prophylactic antibiotics can be given if indicated. Many positions and daily activities predispose the patient to the dislocation of the prosthesis. Some of these activities include putting on one's own shoes and socks without using adaptive devices; crossing the legs or feet while seated; assuming the side-lying position incorrectly; standing up or sitting down while the body is flexed more than 90 degrees relative to the chair; and sitting on low seats, especially low toilet seats. It is also important to sit in chairs with arms, because these help the patient to rise to a standing position.

The nurse suspects that a patient is experiencing a fat embolism after sustaining a femur fracture. What clinical manifestations does the nurse expect? 1. Tachypnea, tachycardia, shortness of breath, and paresthesia 2. Paresthesia, bradycardia, bradypnea, petechial rash on the chest and neck Correct3. Tachypnea, tachycardia, shortness of breath, petechial rash on the chest and neck 4. Bradypnea, bradycardia, shortness of breath, petechial rash on the chest and neck

4. Bradypnea, bradycardia, shortness of breath, petechial rash on the chest and neck A fat embolism may occur in a patient who has had a fracture of a large bone such as a femur or hip. The classic symptoms of a fat embolism include tachypnea, tachycardia, shortness of breath, and petechial rash on the chest and neck. Tachypnea, tachycardia, shortness of breath, and paresthesias; paresthesias, bradycardia, bradypnea, and petechial rash; and bradypnea, bradycardia, shortness of breath, and petechial rash are not directly characteristic of a pulmonary embolism.

A patient with a long leg cast reports pain in the toes. The nurse discovers that the toes are pale and cool to the touch with intact pulses and minimal neuropathy. The findings indicate that the patient may be experiencing what? 1. Osteomyelitis 2. A fat embolism 3. A pressure ulcer 4. Compartment syndrome

4. Compartment syndrome Compartment syndrome is the progressive compromise of neurovascular function of tissue in a confined space such as a cast. It may also result from circumferential inflammation around an extremity. The earliest sign is paresthesias, followed by pain, pressure resulting from edema, pallor, paralysis, and absence of pulse. (Absence of the peripheral pulse is a late and ominous sign.) A pressure ulcer is caused by decreased circulation due to pressure, tissue hypoxia, and destruction. Osteomyelitis is an infectious process within the bone. A fat embolism is an acute event in which fat globules released into circulation obstruct pulmonary circulation. It is seen with fractures of long bones such as the femur.

The nurse reviews the results of a magnetic resonance image (MRI) study that was performed on a patient with a severe shoulder injury. Which MRI finding has the potential risk of dislocation? 1. Tearing of the ligaments around the shoulder joint 2. Mild tears within the muscles around the shoulder joint 3. Severe tearing within the muscles around the shoulder joint 4. Deformation injury to the humerus around the shoulder joint

4. Deformation injury to the humerus around the shoulder joint The patient with a dislocation may have deformation injury to the humerus around the shoulder joint. Tearing of ligaments in the shoulder may not indicate a dislocation. Mild tears in the shoulder muscles may not indicate dislocation. Severe tearing in the shoulder muscles may not indicate dislocation.

The nurse is assessing a patient who has a traumatic leg injury. What intervention is the most important in the initial assessment? 1. Assess the patient's pain level 2. Realign the extremity in the appropriate position 3. Check for full or partial loss of feeling and sensation 4. Determine the extremity's color and temperature in the area of the injury

4. Determine the extremity's color and temperature in the area of the injury Baseline assessments are very important. It is most important to assess the extremity's color and temperature in the area of the injury to determine any venous or arterial insufficiency. If arterial or venous blood flow in the area is blocked, the area could become ischemic and die. Assessment of temperature is crucial to determine circulation and perfusion to the extremity and any change in temperature in the extremity should be reported promptly to the health care provider. Assessing the patient's pain is important but not as crucial as determining any arterial insufficiency. Realigning the injured extremity can lead to further damage or cause vascular insufficiency. Loss of sensation may be a late sign of neurovascular damage.

The patient is brought to the emergency department after a car accident and has a femur fracture. What nursing intervention should the nurse implement to prevent a fat embolus in this patient? 1. Administer enoxaparin 2. Provide range of motion exercises 3. Apply sequential compression boots 4. Immobilize the fracture preoperatively

4. Immobilize the fracture preoperatively To prevent fat emboli, the nurse immobilizes the long bone to reduce movement of the fractured bone ends and decrease the risk of a fat embolus from the bone before surgical reduction. Enoxaparin is used to prevent blood clots, not fat emboli. Range of motion and compression boots will not prevent a fat embolus in this patient.

A patient experiences a ligament injury to the ankle joint. Which instruction by the nurse would be most helpful to relieve edema? 1. Apply ice to the affected area. 2. Elevate the injured part above the heart level. 3. Immobilize the injured part for a prolonged period. 4. Wrap an elastic bandage from proximal to distal end.

4. Wrap an elastic bandage from proximal to distal end. An elastic bandage should be wrapped around the injured part to relieve edema and encourage venous return. The ice application may also help in reducing edema but may not be as beneficial as the bandage. The injured part should also be elevated above the heart level to help mobilize the excess fluid from the affected area. Immobilization of the injured part for prolonged periods increases the risk of venous stasis.