Ch 42: Management of Patients with Musculoskeletal Trauma (2)

Which factor inhibits fracture healing? pg. 1193

Local malignancy Explanation: Factors that inhibit fracture healing include local malignancy, bone loss, and extensive local trauma. Factors that enhance fracture healing include proper nutrition, vitamin D, exercise, and maximum bone fragment contact.

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. pg. 1203

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

Which assessment findings would the nurse expect to find in the postoperative client experiencing fat embolism syndrome? pg. 1193

Column B [Heart rate: 116 bpm, Respiratory rate: 32/min; pH: 7.50; CO2: 30 mm Hg; HCO2: 24 mEq/L; PaO2: 55 mm Hg] Explanation: Fat embolism syndrome is characterized by fever, tachycardia, tachypnea, and hypoxia and other manifestations of respiratory failure. Arterial blood gas findings include a partial pressure of oxygen (PaO2) less than 60 mm Hg, with early respiratory alkalosis and later respiratory acidosis.

Colles fracture occurs in which area? pg. 1200

Distal radius Explanation: A Colles fracture is a fracture of the distal radius (wrist). It is usually the result of a fall on an open, dorsiflexed hand.

A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan? pg. 1216

Elevating the stump for the first 24 hours Explanation: 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.

A client with a fracture develops compartment syndrome that requires surgical intervention. What treatment will the nurse would most likely prepare the client for? pg. 1194

Fasciotomy Explanation: Surgical treatment of compartment syndrome is achieved with a fasciotomy, a surgical incision of the fascia and separation of the muscle to relieve pressure and restore tissue perfusion. Bone graft, joint replacement or amputation may be done for a client who experiences avascular necrosis.

A client with a traumatic amputation of the right lower leg is refusing to look at the leg. Which action by the nurse is most appropriate? pg. 1217

Provide feedback on the client's strengths and available resources. Explanation: The nurse should encourage the client to look at, and assist with, care of the residual limb. Providing feedback on the client's strengths and resources may allow the client to start to adapt to the body image and lifestyle change. The nurse should also allow time for the client to discuss their feelings related to the amputation. Requesting a referral to occupational therapy and encouraging the client to perform ROM exercises are appropriate but do not address the emotional aspect of losing an extremity.

Which term refers to an injury to ligaments and other soft tissues surrounding a joint? pg. 1186

Sprain Explanation: 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.

Which may occur if a client experiences compartment syndrome in an upper extremity? pg. 1199

Volkmann's contracture Explanation: 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.

A client who has suffered a compound fracture is preparing for discharge to home. During the teaching session, the client asks why he needs antibiotics for a broken bone. Which response by the nurse is most appropriate? pg. 1192

"Antibiotic therapy has been prescribed as a precaution because your bone was exposed to the environment at the time of your injury." Explanation: The nurse should tell the client that antibiotics are prescribed as a preventive measure for a client with a compound fracture because such fractures expose the bone to the environment and possible infection. Telling the client to discuss his medications with the physician at his follow-up appointment doesn't address the client's questions or immediate needs. The client needs this medication regardless of his body temperature. Antibiotics don't help a bone fracture to heal.

The client has suffered a comminuted fracture. Which image best depicts this type of fracture? pg. 1190

Image - Option A: Shaft broken completely across with small bone fragments along break Explanation: A comminuted fracture (Option A) is a bone that has splintered into several fragments. A fracture in which a bone fragment is driven into another bone fragment is called an impacted fracture (Option B). A transverse fracture (Option C) results in a break straight across the bone shaft. A fracture involving damage to the skin or mucous membranes is called an open or compound fracture (Option D).

A client undergoes open reduction with internal fixation to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan? pg. 1204

Keeping a pillow between the client's legs at all times Explanation: After open reduction with internal fixation, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period, because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After open reduction with internal fixation, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.

A client comes to the emergency department complaining of localized pain and swelling of his lower leg. Ecchymotic areas are noted. History reveals that the client got hit in the leg with a baseball bat. Which of the following would the nurse suspect as most likely? pg. 1185

Contusion Explanation: 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.

Which term refers to a fracture in which one side of a bone is broken and the other side is bent? pg. 1190

Greenstick Explanation: A greenstick fracture is a fracture in which one side of a bone is broken and the other side is bent. A spiral fracture is a fracture twisting around the shaft of the bone. An avulsion is when a fragment of bone has been pulled away by a ligament or tendon and its attachment. An oblique is a fracture occurring at an angle across the bone.

Which of the following would lead a nurse to suspect that a client has a rotator cuff tear? pg. 1187

Difficulty lying on affected side Explanation: 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.

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? pg. 1193

Fat emboli Explanation: 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.

The nurse is monitoring a patient who sustained a fracture of the left hip. The nurse should be aware that which kind of shock can be a complication of this type of injury? pg. 1193

Hypovolemic Explanation: In a client with a pelvic fracture, the nurse should be aware of the potential for hypovolemic shock resulting from hemorrhage. Cardiogenic shock, in which the heart cannot pump enough blood to meet the body's needs, often arises from severe myocardial infarction. Neurogenic shock is often a consequence of spinal cord injury and resulting loss of sympathetic nervous system function. Septic shock results from body-wide infection.

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? pg. 1186

avascular necrosis Explanation: 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.

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? pg. 1199

Claw-like deformity of the right hand without ability to extend fingers Explanation: 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 is brought to the emergency department after injuring the right arm in a bicycle accident. The orthopedic surgeon tells the nurse that the client has a greenstick fracture of the arm. What does this mean? pg. 1190

One side of the bone is broken and the other side is bent. Explanation: In a greenstick fracture, one side of the bone is broken and the other side is bent. A greenstick fracture also may refer to an incomplete fracture in which the fracture line extends only partially through the bone substance and doesn't disrupt bone continuity completely. (Other terms for greenstick fracture are willow fracture and hickory-stick fracture.) The fracture line extends through the entire bone substance in a complete fracture. A fracture that results from an underlying bone disorder, such as osteoporosis or a tumor, is a pathologic fracture, which typically occurs with minimal trauma. Bone fragments are separated at the fracture line in a displaced fracture.