Med Surg Ch. 42 Musculoskeletal Trauma

Which of the following disorders results in widespread hemorrhage and microthrombosis with ischemia?

Disseminated intravascular coagulation (DIC) 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.

The nurses instructs the client not to cross their legs and to have someone assist with tying their shoes. Which additional instruction should the nurse provide to client?

Do not flex the hip more than 90 degrees. Proper alignment and supported abduction are encouraged for hip repairs. Flexion of the hip more than 90 degrees can cause damage to the a repaired hip fracture. By telling the patient to not to cross their legs, the leg stays in a the abducted position allowing for the hip to heal in the proper position. Having someone assist with the shoes does not allow for the hip to flex more than 90 degrees.

Which factor inhibits fracture healing?

Local malignancy 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.

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

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

Which term refers to the failure of fragments of a fractured bone to heal together?

Nonunion When nonunion occurs, the client reports persistent discomfort and movement at the fracture site. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation or dislocation of joint surfaces. Malunion refers to growth of the fragments of a fractured bone in a faulty position, forming an imperfect union.

A 19-year-old patient presents to the emergency room with an injury to her left ankle that occurred during a high school basketball game. She complains of limited motion and pain on walking, which increased over the last 2 hours. The nurse knows that her diagnosis is most likely which of the following?

Second-degree sprain A sprain is the result of an injury to ligaments that is caused by a twisting motion. A second-degree sprain is an incomplete tear of the ligament that results in painful weight bearing. A third-degree sprain involves a complete ligament tear with loss of weight-bearing function.

Two days after application of a cast to treat a fractured femur, the patient tells the orthopedic health care provider that he is experiencing severe, deep, and constant pain in his leg. The nurse suspects a diagnosis of:

Compartment syndrome. Compartment syndrome refers to the compression of nerves, blood vessels, and muscle within a closed space. This leads to tissue death from lack of oxygenation.

Which type of fracture involves a break through only part of the cross-section of the bone?

Incomplete 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.

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?

Clawlike deformity of the right hand without ability to extend fingers 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.

In a client with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which complication does the assessments help the nurse to monitor in the client?

Compartment syndrome The nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable in a client with a dislocation to assess for compartment syndrome. It is a complication associated with dislocation. A client with a dislocation does not experience an increased risk of complications such as disseminated intravascular coagulation, carpal tunnel syndrome, or fat embolism syndrome.

A client presents to the emergency department gently holding the left arm, which is slightly swollen and painful to the touch. Based on these findings, the nurse:

Elevates the arm and applies an ice pack Treatment of strains and sprains consists of resting and elevating the affected part, applying ice for the first 24 to 48 hours, and applying a compression dressing.

A client with a fracture develops compartment syndrome that requires surgical intervention. The nurse would most likely prepare the client for which of the following?

Fasciotomy 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 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 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 client with a fractured left humerus reports dyspnea and chest pain. Pulse oximetry is 88%. Temperature is 100.2 degrees Fahrenheit (38.5 degrees Centigrade); heart rate is 110 beats per minute; respiratory rate is 32 breaths per minute. The nurse suspects the client is experiencing:

Fat embolism syndrome The clinical manifestations described in the scenarion are characteristic of fat embolism syndrome.

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

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

Which of the following musculoskeletal injuries is manifested by acromioclavicular joint pain?

Rotator cuff tears Key assessment findings related to rotator cuff tears include acromioclavicular joint pain, limited range of motion, and muscle weakness. Epicondylitis (tennis elbow) is manifested by pain that usually radiates down the extensor surface of the forearm and generally is relieved with rest and avoidance of the aggravating activity. Heterotopic ossification is the abnormal formation of bone, near bones or in muscle, in response to soft tissue trauma after blunt trauma, fracture, or total joint replacement. Acute compartment syndrome involves a sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive intervention does not occur.

A patient complains of pain in the right knee, stating, "My knee got twisted when I was going down the stairs." The patient was diagnosed with an injury to the ligaments and tendons of the right knee. Which terminology, documented by the nurse, best reflects the injury?

Sprain A sprain is an injury to the ligaments and tendons surrounding a joint, usually 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 x-ray demonstrates a fracture in which a bone has splintered into several pieces. Which type of fracture is this?

Comminuted 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 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.

Which general nursing measure is used for a client with a fracture reduction?

Encourage participation in ADLs General nursing measures for a client with a fracture reduction include administering analgesics, providing comfort measures, encouraging participation in ADLs, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing the client for self-care. Omega-3 fatty acids have no implications on the diet of a client with a fracture reduction. The nurse does not need to examine the abdomen for enlarged liver or spleen because fracture reduction treatment does not affect these organs. It is unlikely that a client with a fracture reduction will be prescribed immune-enhancing tube feeding formulas.

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?

Contusion 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 an injury to ligaments and other soft tissues surrounding a joint?

Sprain 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 of the following may occur if a client experiences compartment syndrome in an upper extremity?

Volkmann's contracture Explanation: If compartment syndrome occurs in an upper extremity, it may lead to Volkmann's contracture, a clawlike 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 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." 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." 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 is being discharged from the Emergency Department after being diagnosed with a sprained ankle. Which client statement indicates the client understands the discharge teaching?

"I'll make sure to keep my ankle elevated as much as possible." Treatment consists of applying ice or a chemical cold pack to the area to reduce swelling and relieve pain for the first 24 to 48 hours. Elevation of the part and compression with an elastic bandage also may be recommended. After 2 days, when swelling no longer is likely to increase, applying heat reduces pain and relieves local edema by improving circulation. Full use of the injured joint is discouraged temporarily, not necessarily three to four weeks. Nonsteroidal anti-inflammatory drugs (NSAIDs) are typically recommended; narcotic analgesics typically are not prescribed.

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. 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.

A client is to undergo surgery to repair a ruptured Achilles tendon and application of a brace. The client demonstrates understanding of his activity limitations when he states that he will need to wear the brace for which length of time?

6 to 8 weeks Following surgical repair for a ruptured Achilles tendon, the client wears a brace or cast for 6 to 8 weeks.

When providing discharge teaching to a client with a fractured toe, the nurse should include which instruction?

Apply ice to the fracture site. Applying ice to the injury site soon after an injury causes vasoconstriction, helping to relieve or prevent swelling and bleeding. Applying heat to the fracture site may increase swelling and bleeding. Ankle dorsiflexion has no therapeutic use after a toe fracture. It's unlikely the client would need crutches after a toe fracture.

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?

Provide feedback on the client's strengths and available resources. 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.

A client is brought to the emergency department after being struck with a baseball bat on the upper arm while diving for a pitched ball. Diagnostic tests reveal that the humerus is not broken but that the client has suffered another type of injury. What type of injury would the physician likely diagnose?

contusion A contusion is a soft tissue injury resulting from a blow or blunt trauma. Sprains are injuries to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A subluxation is a partial dislocation.