Ch 37: Management of of Patients with Musculoskeletal Trauma

a) Risk for ineffective therapeutic regimen management Pg. The client without adequate support and resources is at risk for ineffective therapeutic regimen management. A total knee replacement may be used to treat avascular necrosis. While an orthopedic client is at risk for disturbed body image and situational low self-esteem, there is no evidence that these exist for this client.

1. The nurse is caring for a client who lives alone and had a total knee replacement. An appropriate nursing diagnosis for the client is: a) Risk for ineffective therapeutic regimen management b) Situational low self-esteem c) Risk for avascular necrosis of the joint d) Disturbed body image

a) Compartment syndrome Pg. 1162 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.

10. Two days after application of a cast to treat a fractured femur, the client reports severe, deep, and constant pain in the leg. What will the nurse suspect? a) Compartment syndrome b) Chronic venous insufficiency c) Phlebitis d) Infection

a) Osteomyelitis Pg. 1195 Chronic osteomyelitis may occur after persistent infection in the late postoperative period. Hematoma, hemorrhage, and infection are potential complications in the immediate postoperative period.

11. A variety of complications can occur after a leg amputation. Which is not a possibility in the immediate postoperative period? a) Osteomyelitis b) Hematoma c) Infection d) Hemorrhage

d) Never cross the affected leg when seated Pg. 1185 Crossing the affected leg may result in dislocation of the hip joint after total hip replacement. The client should be taught to keep the knees apart at all times, to put a pillow between the legs when sleeping, and to avoid bending forward when seated in a chair.

12. The nurse teaches the client which intervention to avoid hip dislocation after replacement surgery? a) Avoid placing a pillow between the legs when sleeping b) Bend forward only when seated in a chair c) Keep the knees together at all times d) Never cross the affected leg when seated

b) Subluxation Pg. 1154 A partial dislocation is referred to as a subluxation. A Volkmann's contracture is a claw like deformity that results from compartment syndrome or obstructed arterial blood flow to the forearm and hand. Compartment syndrome is a condition in which a structure such as a tendon or nerve is constricted in a confined space and affects nerve innervation, leading to subsequent palsy. A sprain is injury to the ligaments surrounding the joint.

13. A client comes to the emergency department and it is found that the client's radial head is partially dislocated. What is this partially dislocated radial head documented as? a) Volkmann's contracture b) Subluxation c) Compartment syndrome d) Sprain

c) Notify the health care provider Pg. 1185 If any clinical manifestations of dislocation of the prosthesis occur, including acute groin pain in the affected hip or shortening of the affected extremity, the nurse (or the client, if at home) must immediately notify the surgeon, because the hip must be reduced and stabilized promptly so that the leg does not sustain circulatory and nerve damage. After closed reduction, the hip may be stabilized with Buck's traction or a brace to prevent recurrent dislocation. As the muscles and joint capsule heal, the chance of dislocation diminishes. Stresses to the new hip joint should be avoided for the first 8 to 12 weeks, when the risk of dislocation is greatest.

14. The nurse assesses a client after total right hip arthroplasty and observes a shortening of the extremity. The client reports severe pain in the right side of the groin. What is the priority action of the nurse? a) Bend the knee and rotate the knee internally b) Apply Buck's traction c) Notify the health care provider d) Externally rotate the extremity

a) Discuss the complications that the client may experience if there is lack of cooperation with the care plan Pg. 1185 The nurse should discuss the care plan and its rationale with the client. Calling the health care provider to report the client's noncompliance won't alter the client's degree of participation and shouldn't be used to force the client to comply. Doing nothing isn't acceptable. Although the client does have the right to make choices, it's the nurse's responsibility to provide education to help the client make informed decisions. Although the nurse should ultimately document the client's refusal, the nurse should first discuss the care plan with the client.

15. After undergoing surgery the previous day for a total knee replacement, a client states, "I am not ready to ambulate yet." What should the nurse do? a) Discuss the complications that the client may experience if there is lack of cooperation with the care plan b) Tell the client that this noncompliance will be reported to the health care provider c) Document the client's refusal to ambulate d) Do nothing because the client has the ultimate right to determine the degree of participation

c) Splint Pg. 1167 The client would use a splint when a musculoskeletal condition does not require rigid immobilization, causes a large degree of swelling, or requires special skin treatment.

16. A client reports swelling and severe pain in the right wrist. After examination and radiographs negate a fracture, what would the physician likely prescribe as treatment? a) Cast b) Brace c) Splint d) All options are correct

d) History of diabetes Pg. 1164 Factors that inhibit fracture healing include diabetes, smoking, local malignancy, bone loss, extensive local trauma, age greater than 40, and infection. Factors that enhance fracture healing include proper nutrition, vitamin D and calcium, exercise, maximum bone fragment contact, proper alignment, and immobilization of the fracture.

17. Which factor inhibits fracture healing? a) Increased vitamin D and calcium in the diet b) Immobilization of the fracture c) Age of 35 years d) History of diabetes

b) Capillary refill Pg. 1163 Assessment for neurovascular impairment includes checking for weak pulses or delayed capillary refill (normal is <2 seconds).

18. An important nursing assessment, post fracture, is to evaluate neurovascular status. Therefore, the nurse should check for: a) Crepitus b) Capillary refill c) Swelling and discoloration d) Shortening and deformity

b) Chlorhexidine Pg. 1176-1177 Chlorhexidine solution is recommended as the most effective cleansing solution; however, water and saline are alternate choices. Hydrogen peroxide and betadine solutions have been used, but they are believed to be cytotoxic to osteoblasts and may actually damage healthy tissue.

19. Which cleansing solution is the most effective for use in completing pin site care? a) Alcohol b) Chlorhexidine c) Betadine d) Hydrogen peroxide

b) Cranial nerve assessment Pg. Cranial nerve assessment would only be carried out for head-related injuries or diseases. General nursing measures include administering analgesics, providing comfort measures, assisting with ADLs, preventing constipation, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing client for self-care.

2. Which is not one of the general nursing measures employed when caring for the client with a fracture? a) Assisting with ADLs b) Cranial nerve assessment c) Administering analgesics d) Providing comfort measures

a) Crackles in the lung bases Pg. 1162 Crackles in the lung bases can be an indicator that the client has developed pneumonia from shallow respirations. The blood pressure is high but may be due to pain. It is expected that the client will have pain in the rib area when taking deep breaths. A heart rate of 94 beats/minute is within normal range.

20. The nurse is caring for a client who sustained rib fractures in an automobile accident. What symptoms does the nurse recognize as a complication of rib fractures and should immediately be reported to the physician? a) Crackles in the lung bases b) Client complains of pain in the affected rib area when taking a deep breath c) Blood pressure of 140/90 mm Hg d) Heart rate of 94 beats/minute

c) Explain that the sensation being felt is normal and will not burn the client Pg. 1166-1167 A fiberglass cast will give off heat when applied. The reaction is a normal, temporary sensation. Heat given off during the application phase of the cast does not burn the skin. By explaining these principles to the client, the nurse can alleviate any anxiety associated with the application of the cast. Because this is a known reaction to the application of the fiberglass cast, it is not necessary to remove the cast. Holding the client may cause more harm to the injury. Antianxiety medications are generally not needed when applying a cast.

21. A client with a fractured ankle is having a fiberglass cast applied. The client starts yelling, "My leg is burning, take it off." What action by the nurse is most appropriate? a) Administer antianxiety and pain medication b) Call for assistance to hold the client in the required position until the cast has dried c) Explain that the sensation being felt is normal and will not burn the client d) Remove the cast immediately, notifying the physician

b) Sprain Pg. 1153 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.

22. A client reports pain in the right knee, stating, "My knee got twisted when I was going down the stairs." The client was diagnosed with an injury to the ligaments and tendons of the right knee. Which terminology, documented by the nurse, best reflects the injury? a) Subluxation b) Sprain c) Dislocation d) Strain

a) Crepitus Pg. 1159 Crepitus is the grating sound of bone ends moving over one another, which may be audible (this term also refers to a popping sound caused by air trapped in soft tissue). False motion is unnatural motion that occurs at the site of the fracture. Spasm is the involuntary contraction of the muscles near the fracture. Deformity describes the unusual position or bending backward assumed by the extremity due to the break.

23. A client has a fractured femur and is being seen in the emergency department. The nurse assessing the area notices there is a grating sound that is suspected to be bone ends moving over one another. This would be called: a) Crepitus b) Deformity c) False motion d) Spasm

d) Exploring factors related to the client's home environment Pg. 1186 Exploring factors related to the older adult client's home environment and determining a plan for continued rehabilitation before discharge is most important. The client should be encouraged to eat foods rich in protein, calcium, and vitamin D. Because the healing is almost complete, the client need not always keep the affected limb elevated unless prescribed to do so. Because the client is in her late 60s, she is most likely to have already undergone menopause. Therefore, educating her about the effects of menopause is not as important.

24. A 68-year-old female client who had a below-the-knee amputation is to be discharged because her healing is almost complete. Which of the following would be most important for the nurse to discuss with this client? a) Urging her to keep the affected limb in an elevated position b) Educating the client about the effects of menopause c) Advising the client to avoid red meat d) Exploring factors related to the client's home environment

a) Encourage participation in ADLs Pg. 1160 General nursing measures for a client with a fracture reduction include administering analgesics, providing comfort measures, encouraging participation with 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. Dependent positioning may increase edema because the extremity is below the level of the heart. While some pain medications may contribute to constipation, this intervention would be reserved for a client experiencing constipation and not as a preventative measure.

25. Which nursing intervention is appropriate for a client with a closed-reduction extremity fracture? a) Encourage participation in ADLs b) Use frequent dependent positioning to prevent edema c) Promote intake of omega-3 fatty acids d) Administer prescribed enema to prevent constipation

c) "I don't know if I'll be able to get off that low toilet seat at home by myself" Pg. 1185 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.

26. A client undergoes a total hip replacement. Which statement made by the client indicates to the nurse that the client requires further teaching? a) "I'll need to keep several pillows between my legs at night" b) "I need to remember not to cross my legs. It's such a habit" c) "I don't know if I'll be able to get off that low toilet seat at home by myself" d) "The occupational therapist is showing me how to use a sock puller to help me get dressed"

a) Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg Pg. 1175 The nurse should assess for pain on passive flexion of each foot, which could indicate deep vein thrombosis.

27. A patient in pelvic traction needs circulatory status assessed. How should the nurse assess for a positive Homans' sign? a) Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg b) Have the patient extend both hands while the nurse compares the volume of both radial pulses c) Have the patient squeeze the nurse's hands with his or her hands to evaluate any difference in strength d) Have the patient plantar flex both feet while the nurse performs the blanch test on all of the patient's toes

b) Infection related to effects of trauma Pg. 1157 A compound fracture involves an opening in the skin at the fracture site. Because the skin is the body's first line of defense against infection, any skin opening places the client at risk for infection. Imbalanced nutrition: Less than body requirements is rarely associated with fractures. Although Impaired physical mobility and Activity intolerance may be associated with any fracture, these nursing diagnoses don't take precedence because they aren't as life-threatening as infection.

28. Which nursing diagnosis takes highest priority for a client with a compound fracture? a) Activity intolerance related to weight-bearing limitations b) Infection related to effects of trauma c) Imbalanced nutrition: less than body requirements related to immobility d) Impaired physical mobility related to trauma

a) "CPM increases range of motion of the joint" Pg. CPM increases circulation and range of motion of the knee joint.

29. Following a total knee replacement, the surgeon orders a continuous passive motion (CPM) device. The client asks about the purpose of this treatment. What is the best response by the nurse? a) "CPM increases range of motion of the joint" b) "CPM delivers analgesic agents directly into the joint" c) "CPM strengthens the muscles of the leg" d) "CPM prevents injury by limiting flexion of the knee"

c) The client that he or she won't be cut Pg. Casts are removed with a mechanical cast cutter. Cast cutters are noisy and frightening but the blade does not penetrate deep enough to cut the client. The client needs reassurance that the machine will not cut into the skin. The other options are either irrelevant or not something the nurse knows for certain at this time.

3. A client with a right leg fracture is returning to the orthopedist to have the cast removed. During cast removal, it is important for the nurse to assure: a) That pedal pulses are present b) That the leg will be as good as new c) The client that he or she won't be cut d) That the cast cutter blade is new

c) Prevent internal rotation of the affected leg Pg. 1185 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.

30. 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? a) Keep the hip flexed by placing pillows under the client's knee b) Keep the affected leg in a position of adduction c) Prevent internal rotation of the affected leg d) Use measures other than turning to prevent pressure ulcers

b) Assessing the extremity for neurovascular integrity Pg. 1175 Although all measures are correct, assessing neurovascular integrity takes priority because a decrease in neurovascular integrity could compromise the limb. The pull of the traction must be continuous to keep the client from sliding. Sufficient countertraction must be maintained at all times by keeping the ropes over the center of the pulley. The line of pull is maintained by allowing the weights to hang free.

31. A nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority? a) Keeping the client from sliding to the foot of the bed b) Assessing the extremity for neurovascular integrity c) Keeping the ropes over the center of the pulley d) Ensuring that the weights hang free at all times

c) Joint manipulation and immobilization Pg. 1159 The physician manipulates the joint or reduces the displaced parts until they return to normal position, then immobilizes the joint with an elastic bandage, cast, or splint for several weeks.

32. A client who has injured a hip in a fall cannot place weight on the leg and is in significant pain. After radiographs indicate intact yet malpositioned bones, what repair would the physician perform? a) Analgesia and immobilization b) Ice and immobilization c) Joint manipulation and immobilization d) Heat and immobilization

c) Splint Pg. 1167 A splint may be applied to a fractured extremity initially until swelling subsides. A brace is an externally applied device to support a body part, control movement, and prevent injury. A CPM device is an instrument that moves a body part to promote healing and circulation. A trapeze is an overhead device to promote client mobility in bed.

33. Which device is designed specifically to initially support and immobilize a body part in a desired position until swelling subsides? a) Continuous passive motion (CPM) device b) Trapeze c) Splint d) Brace

d) After 2 days Pg. 1153 It is advisable to apply heat on a sprain or a contusion 2 days after a sprain or a contusion has occurred. This is because after 2 days swelling is not likely to increase and as a result heat application reduces pain and relieves local edema by improving circulation. Delaying the application of heat prolongs the pain and increased the risk of local edema.

34. When is it advisable for the nurse to apply heat to a sprain or a contusion? a) Do not apply at all b) Only after a week c) Immediately d) After 2 days

b) Incomplete Pg. 1157 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.

35. Which type of fracture involves a break through only part of the cross-section of the bone? a) Open b) Incomplete c) Oblique d) Comminuted

c) Femoral neck Pg. 1184 A fracture of the neck of the femur may damage the vascular system and the bone will become ischemic. Therefore, a vascular necrosis is common.

36. The femur fracture that commonly leads to avascular necrosis or nonunion because of an abundant supply of blood vessels in the area is a fracture of the: a) Trochanteric region b) Shaft of the femur c) Femoral neck d) Condylar area

b) Dislocation of the hip Pg. 1191 Manifestations of a dislocated hip prosthesis are increased pain at the surgical site, acute groin pain in the affected leg, shortening of the leg, abnormal external or internal rotation, and limited movement of the fractured leg. The client may report a "popping" sensation in the hip.

37. The client who had a total hip replacement was discharged home and developed acute groin pain in the affected leg, shortening of the leg, and limited movement of the fractured leg. The nurse interprets these findings as indicating which complication? a) Re-fracture of the hip b) Dislocation of the hip c) Contracture of the hip d) Avascular necrosis of the hip

a) Administer prescribed analgesics around-the-clock Pg. 1187 Pain associated with hip fracture is severe and must be carefully managed with around-the-clock dosing of pain medication to minimize energy loss in response to pain. The client may not request the medication even if they are in pain, and it should be offered at the prescribed time. Give pain medication prior to providing any type of care involved in moving the client.

4. An older adult client slipped on an area rug at home and fractured the left hip. The client is unable to have surgery immediately and is having severe pain. What interventions should the nurse provide for the patient to minimize energy loss in response to pain? a) Administer prescribed analgesics around-the-clock b) Avoid administering too much medication because the client is older c) Give pain medication to the client after providing care d) Administer prescribed pain medication only when the client requests it

a) Compound Pg. 1157 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.

5. 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? a) Compound b) Spiral c) Oblique d) Greenstick

d) "Keep your right leg elevated above heart level" Pg. 1162 The nurse should instruct the client to elevate the leg to promote venous return and prevent edema. The cast shouldn't be covered while drying. Covering the cast will cause heat buildup and prevent air circulation. The client should be instructed not to insert foreign objects into the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection.

6. A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in client cast care? a) "Cover the cast with a blanket until the cast dries" b) "A foul smell from the cast is normal" c) "Use a knitting needle to scratch itches inside the cast" d) "Keep your right leg elevated above heart level"

c) The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes Pg. 1191 Guidelines for avoiding hip dislocation after replacement surgery specify that the hip should not be flexed to put on clothing such as pants, stockings, socks, or shoes. Clients should keep the knees apart at all times, put a pillow between the legs when sleeping, and never cross the legs when seated.

7. Which is not a guideline for avoiding hip dislocation after replacement surgery. a) Keep the knees apart at all times b) Never cross the legs when seated c) The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes d) Put a pillow between the legs when sleeping

a) Immobilization Pg. 1159 Treatment of musculoskeletal trauma involves immobilization of the injured area until it has healed.

8. A client has been in a motor vehicle collision. Radiographs indicate a fractured humerus; the client is awaiting the casting of the upper extremity and admission to the orthopedic unit. What is the primary treatment for musculoskeletal trauma? a) Immobilization b) Enhancing complications c) Surgical repair d) External rotation

a) Provide feedback on the client's strengths and available resources Pg. 1181 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.

9. 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? a) Provide feedback on the client's strengths and available resources b) Request a referral to occupational therapy c) Provide wound care without discussing the amputation d) Encourage the client to perform range-of-motion (ROM) exercises to the right leg