Ch 37: Musculoskeletal Trauma PrepU

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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?

Crackles in the lung bases 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.

A client in the emergency department is being treated for a wrist fracture. The client asks why a splint is being applied instead of a cast. What is the best response by the nurse?

"A splint is applied when more swelling is expected at the site of injury." Splints are noncircumferential and will not compromise circulation when swelling is expected. A splint is applied to support and immobilize the injured joint. A fracture will swell as part of the inflammation process. The client would not have to stay longer if a fiberglass cast is applied. Fiberglass cast dry in approximately 30 minutes. An orthopedic doctor is not needed to apply the cast. Many nurses and technicians are trained in proper application of a cast. Some fractures may not be treated with a cast but it would not be appropriate to answer with this response because it does not reflect the actual reason for a splint being applied.

A client asks the nurse why his residual limb cannot be elevated on a pillow. What is the best response by the nurse?

"Elevating the leg might lead to a flexion contracture." Elevating the residual limb on a pillow may lead to a flexion contracture; this could jeopardize the client's ability to use a prosthesis. The client does need to turn to both sides but might still be able to do it with the extremity elevated. Elevating the extremity would not increase the risk for compartment syndrome. The limb should not be elevated on pillows or blankets.

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.

The nurse is admitting a client who is to undergo an open reduction with internal fixation for a fractured femur. About which comment by the client should the nurse be most concerned?

"I was worried I would have an incision and scar." An open reduction involves a surgical dissection for the visualization of the bone ends and fragments. A metal plate and screws are used to correct and stabilize the fracture through internal fixation.

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 client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in client cast care?

"Keep your right leg elevated above heart level." 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.

When discussing physical activities with the client who has just undergone a right total hip replacement, which instruction should the nurse provide?

"Limit hip flexion to 90 degrees" The client should avoid all activities that can result in dislocation of the hip. The affected leg should not cross midline or be turned inward. The hip should not bend more than 90 degrees. Ambulation begins the day following surgery, and weight bearing ambulation may not be restricted, depending on the type of prosthesis.

The nurse is providing instructions to the client who is being prepared for skeletal traction. Which statement by the client indicates teaching was effective?

"Metal pins will go through my skin to the bone." In skeletal traction, metal rods or pins are used to apply continuous traction directly to the bone. Weights are used to apply the traction. Casts, external fixators, or splints are used when the traction is discontinued.

To prepare a client who has a fractured femur for ambulation, the nurse teaches the client how to do quadriceps setting exercises. Which instruction is the most accurate?

"Press the back of your knee against the bed." Quadriceps setting exercises help the immobilized client keep the quadriceps muscles strong and ready for resuming ambulation. Pressing the back of the knee against the bed promotes tightening of the quadriceps muscle.

The client scheduled for a Syme amputation is concerned about the ability to eventually stand on the amputated extremity. How should the nurse best respond to the client's concern?

"You will eventually be able to withstand full weight-bearing after the amputation." Syme amputation (modified ankle disarticulation amputation) is performed most frequently for extensive foot trauma and produces a painless, durable extremity end that can withstand full weight-bearing. Therefore, each of the other teaching statements is incorrect.

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

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 nurse is caring for a client who has sustained ligament and a meniscal injury to the knee. Which action would be most appropriate to allow the client to progress without causing further injury? Assist with a gradual introduction of activity

A gradual introduction of activity assists the client with a knee injury to ambulate without causing any further injury. Using NSAIDs or applying ice during the first 48 hours helps ease the pain and the inflammation. The application of heat at a later stage improves the blood circulation. However, the regular use of NSAIDs, cold packs, or heat does not help the client progress without causing any further injury.

The nurse is teaching the client who will undergo surgery for a transverse fracture. Which image best depicts this type of fracture?

A transverse fracture (Option C) results in a break straight across the bone shaft. 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 fracture involving damage to the skin or mucous membranes is called an open or compound fracture (Option D).

A client is hospitalized for open reduction of a fractured femur. During the postoperative assessment, the nurse notes that the client is restless and observes petechiae on the client's chest. Which nursing action is indicated first?

Administer oxygen A client is hospitalized for open reduction of a fractured femur. During the postoperative assessment, the nurse notes that the client is restless and observes petechiae on the client's chest. Which nursing action is indicated first?

When is it advisable for the nurse to apply heat to a sprain or a contusion?

After 2 days 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.

A client with a fractured femur is placed in skeletal traction. Which intervention will increase client independence when moving in bed?

Apply a trapeze to the bed frame To encourage movement, an assistive device called a trapeze can be suspended overhead within easy reach of the client. The trapeze helps the client move about in bed and move on and off the bedpan. The client's elbows frequently become sore, and nerve injury may occur if the client repositions by pushing on the elbows. Clients frequently push on the heel of the unaffected leg when they raise themselves. This digging of the heel into the mattress may injure the tissues. It is important to instruct clients not to use their heels or elbows to push themselves up in bed. The weights should not be removed to reposition the client or for any other reason.

Which nursing action would help prevent deep vein thrombosis in a client who has had an orthopedic surgery?

Apply antiembolism stockings Applying antiembolism stockings helps prevent deep vein thrombosis (DVT) in a client who is immobilized due to orthopedic surgery. Regular administration of analgesics controls and prevents escalation of pain, while ROM exercises help maintain muscle strength and tone and prevent contractions. On the other hand, cold packs are applied to help reduce swelling; cold does not prevent deep vein thrombosis.

A nurse is caring for a client who is in skeletal traction. To prevent the complication of skin breakdown in a client with skeletal traction, what action should be included in the plan of care?

Assess the pin insertion site every 8 hours. The pin insertion site should be assessed every 8 hours for inflammation and infection. Loose cover dressings should be applied to pin sites. The client should be encouraged to use the overhead trapeze to shift weight for repositioning. Isometric exercises should be done 10 times an hour while awake.

A nurse is caring for a client who has sustained ligament and a meniscal injury to the knee. Which action would be most appropriate to allow the client to progress without causing further injury?

Assist with a gradual introduction of activity A gradual introduction of activity assists the client with a knee injury to ambulate without causing any further injury. Using NSAIDs or applying ice during the first 48 hours helps ease the pain and the inflammation. The application of heat at a later stage improves the blood circulation. However, the regular use of NSAIDs, cold packs, or heat does not help the client progress without causing any further injury.

A nurse is caring for a client who has sustained ligament and a meniscal injury to the knee. Which action would be most appropriate to allow the client to progress without causing further injury?

Assist with a gradual introduction of activity. A gradual introduction of activity assists the client with a knee injury to ambulate without causing any further injury. Using NSAIDs or applying ice during the first 48 hours helps ease the pain and the inflammation. The application of heat at a later stage improves the blood circulation. However, the regular use of NSAIDs, cold packs, or heat does not help the client progress without causing any further injury.

Which action would be most important postoperatively for a client who has had a knee or hip replacement?

Assisting in early ambulation An anticoagulant therapy and early ambulation are important for clients who undergo a knee or hip replacement. A CPM machine or crutches may be provided when prescribed. It is important to encourage clients to express their feelings of anxiety or depression. This is more crucial for clients who undergo an amputation rather than for clients who undergo a replacement surgery.

A client who has sustained a fracture reports an increase in pain and decreased function of the affected extremity. What will the nurse suspect?

Avascular necrosis Avascular necrosis refers to the death of the bone from insufficient blood supply, typically manifested by complaints of increased pain and decreased function. Fever or redness, purulent drainage, and swelling of the site would suggest infection. Respiratory distress would suggest a pulmonary embolism. Changes in vital signs, level of consciousness, and signs and symptoms of fluid loss would suggest hypovolemic shock.

An emergency department client is diagnosed with a hip dislocation. The client's family is relieved that the client has not suffered a hip fracture, but the nurse explains that this is still considered to be a medical emergency. What is the rationale for the nurse's statement?

Avascular necrosis may develop at the site if it is not promptly resolved. If a dislocation or subluxation is not reduced immediately, avascular necrosis (AVN) may develop. Bone remodeling does not take place because a fracture has not occurred. Realignment does not become more difficult with time and pain would subside with time, not become worse.

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.

The nurse advises a 36-year-old patient who suffered a severe wrist sprain subsequent to a fall that she can begin progressive passive and active exercises in:

1 to 3 weeks. Depending on the severity of the injury, exercises can begin from 2 to 5 days (mild) or 1 to 3 weeks (severe). A sprain takes weeks to months to heal because tendons and ligaments are relatively avascular.

An older adult patient had a hip replacement. When should the patient begin with assisted ambulation with a walker?

24 hours Following hip arthroplasty (total hip replacement), patients begin ambulation with the assistance of a walker or crutches within a day after surgery.

A 14-year-old client is treated in the emergency room for an acute knee sprain sustained during a soccer game. The nurse reviews discharge instructions with the client's parent. The nurse instructs the parent that the acute inflammatory stage will last how long?

24 to 48 hours Rest and ice applications during the first 24 to 48 hours produce vasoconstriction while decreasing bleeding and edema. After this time, the acute inflammatory stage decreases.

The nurse is caring for a patient after arthroscopic surgery for a rotator cuff tear. The nurse informs the patient that full activity can usually resume after what period of time?

6 to 12 months The course of rehabilitation following repair of a rotator cuff tear is lengthy (i.e., 6 to 12 months); functionality after rehabilitation depends on the patient's dedication to the rehabilitation regimen

Which is one of the most common causes of death in clients diagnosed with fat emboli syndrome?

Acute respiratory distress syndrome Acute pulmonary edema and acute respiratory distress syndrome are the most common causes of death.

A client presents at an ambulatory clinic and reports pain and aching in the lower left leg. After examining the client, a health care provider determines the client has experienced a strain related to the client's exercise regimen. The treatment plan includes analgesics, rest, and cold and heat therapies. Which guideline should be included in the care plan?

After 24 hours, apply heat for periods of 15 to 30 minutes. The injury should be managed with cold therapy for the first 24 hours, followed by heat therapy for periods of 15 to 30 minutes. Cold applications should be intermittent to avoid temperature-related injuries to the skin. Physical activities should be restricted for 2 to 5 days depending on the severity of the injury.

A young client is being treated for a femoral fracture suffered in a snowboarding accident. The nurse's most recent assessment reveals that the client is uncharacteristically confused. What diagnostic test should be performed on this client?

Arterial blood gases Subtle personality changes, restlessness, irritability, or confusion in a client who has sustained a fracture are indications for immediate arterial blood gas studies due to the possibility of fat embolism syndrome. This assessment finding does not indicate an immediate need for electrolyte levels, an ECG, or abdominal ultrasound.

Which nursing intervention is appropriate for monitoring the client for the development of Volkmann's contracture?

Assess the radial pulse. Volkmann's contracture is a type of acute compartment syndrome that occurs with a supracondylar fracture of the humerus. The nurse assesses neurovascular function of the hand and forearm.

A client who has sustained a fracture reports an increase in pain and decreased function of the affected extremity. What will the nurse suspect?

The nurse is assisting with the application of a cast. What will the nurse expect to be done first?

Cleaning the skin surface When a cast is to be applied, the skin surface of the area to be casted is cleaned and dried. Then the skin is covered with a stockinette, the limb is padded, and rolls or strips of the casting material are applied evenly. Once the cast is applied, an x-ray is done to check bone alignment.

A client sustained a stable fracture of the cervical spine and is having skeletal traction applied. What type of traction does the nurse educate the client about?

Crutchfield tongs Crutchfield tongs are cranial tongs that are used to maintain alignment for a cervical fracture. Kirschner wires and Steinmann pins are used for the skeletal traction to attach to. A Thomas splint is used to suspend a leg in traction.

Which is an inappropriate use of traction?

Decreases space between opposing structures Traction is done to increase the space between opposing surfaces. Traction is used to minimize muscle spasms, to reduce, align, and immobilize fractures, and to reduce deformity.

The primary nursing intervention that will control swelling while treating a musculoskeletal injury is:

Elevate the affected area. Elevation is used to control swelling. It is facilitated by cold, immobilization, and compression. Refer to Box 42-1 in the text.

The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a client who has sustained a fracture. The nurse suspects which complication?

Fat embolism syndrome Cerebral disturbances in the client with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion. The client with compartment syndrome reports deep, throbbing, unrelenting pain. The client with hypovolemic shock would have a decreased blood pressure and increased pulse rate. Clinical manifestations of reflex sympathetic dystrophy syndrome include severe, burning pain; local edema; hyperesthesia; muscle spasms; and vasomotor skin changes.

A nurse is performing a shift assessment on an elderly client who is recovering after surgery for a hip fracture. The client reports chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the client is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this client is likely demonstrating symptoms of what complication?

Fat embolism syndrome Fat embolism syndrome occurs most frequently in young adults and elderly clients who experience fractures of the proximal femur (i.e., hip fracture). Presenting features of fat embolism syndrome include hypoxia, tachypnea, tachycardia, and pyrexia. The respiratory distress response includes tachypnea, dyspnea, wheezes, precordial chest pain, cough, large amounts of thick, white sputum, and tachycardia. Avascular necrosis (AVN) occurs when the bone loses its blood supply and dies. This does not cause coughing. Complex regional pain syndrome does not have cardiopulmonary involvement.

A client has a cast that extends from below the elbow to the palmar crease and is secured around the base of the thumb. The thumb is also casted. The nurse identifies this as which type of cast?

Gauntlet cast A gauntlet cast is a short arm cast that extends from below the elbow to the palmar crease and is secured around the base of the thumb, with the thumb also being casted. A short arm cast extends from below the elbow to the palmar crease and is secured around the base of the thumb. A body cast is a larger form of a cylinder cast that encircles the trunk from about the nipple line to the iliac crests. A hip spica cast surrounds one or both legs and the trunk. It may be strengthened by a bar that spans a casted area between the legs.

Which factor may contribute to compartment syndrome?

Hemorrhage The normal pressure of a compartment can be altered in cases of fracture by the force of the injury itself or by development of edema or hemorrhage at the site of the injury. Venous thromboemboli are another early complication of fracture, but they are not related to compartment syndrome. Macular lesion is caused by the accumulation of blood under the skin, as occurs with trauma such as bone fracture. Disuse syndrome mostly occurs in hip fracture.

The nurse is monitoring a patient who sustained an open fracture of the left hip. What type of shock should the nurse be aware can occur with this type of injury?

Hypovolemic Hypovolemic shock resulting from hemorrhage is more frequently noted in trauma patients with pelvic fractures and in patients with a displaced or open femoral fracture in which the femoral artery is torn by bone fragments.

Radiographic evaluation of a client's fracture reveals that a bone fragment has been driven into another bone fragment. The nurse identifies this as which type of fracture?

Impacted An impacted fracture is one in which a bone fragment is driven into another bone fragment. A comminuted fracture is one in which the bone has splintered into several fragments. A compression fracture is one in which bone has been compressed. A greenstick fracture is one in which one side of the bone is broken, and the other side is bent.

Which intervention should the nurse implement with the client who has undergone a hip replacement?

Instruct the client to avoid internal rotation of the leg. The client should avoid all activities that can result in dislocation of the hip. The affected leg should not cross midline or be turned inward. A pillow is used to keep the legs in abduction. The hip should not bend more than 90 degrees when seated. The head of bed should be kept at 60 degrees or less.

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.

A client who was in a motor vehicle crash is diagnosed with a stable T7 spinal fracture with no neurologic deficits. Which nursing intervention should the nurse implement?

Maintain bed rest with the head of the bed at 20 degrees. The client should maintain limited bed rest with the head of the bed lower than 30 degrees. If the client's pain is not controlled with a lower form of pain medication, then an opioid may be used to treat the pain. The nurse should monitor for an ileus. Stable spinal fractures are treated conservatively and not with surgical repair. The client should avoid sitting until the pain eases.

A patient had a total hip replacement. What recommended leg position should the nurse ensure is maintained to prevent prosthesis dislocation?

Obduction The nurse educates the patient about protective positioning, which includes maintaining abduction and avoiding internal and external rotation, hyperextension, and acute flexion.

A client's fracture was reduced by surgically exposing the bone and realigning it. What type of treatment does the nurse identity this as?

Open reduction In an open reduction, the bone is surgically exposed and realigned. Buck's traction is a type of skin traction that provides pulling on the structures. Skeletal traction is applied directly to the bone using a wire, pin, or cranial tongs. Internal fixation involves the use of metal screws, plates, rods, nails or pins to stabilize a reduced fracture.

A variety of complications can occur after a leg amputation. Which is not a possibility in the immediate postoperative period?

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

Which is a hallmark sign of compartment syndrome?

Pain A hallmark sign of compartment syndrome is pain that occurs or intensifies with passive range of motion.

What assessment findings of the leg are consistent with a fracture of the femoral neck?

Shortened, adducted, and externally rotated With fractures of the femoral neck, the leg is shortened, adducted, and externally rotated.

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:

The client that he or she won't be cut 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.

A nurse is caring for a client in skin traction. In order to prevent bony fragments from moving against one another, the nurse should caution the client against performing what action?

Turning from side to side To prevent bony fragments from moving against one another, the client should not turn from side to side; however, the client may shift position slightly with assistance. Bearing down and coughing do not pose a threat to bone union.

The nurse is checking the traction apparatus for a client in skin traction. Which finding would require the nurse to intervene?

Weights hanging and touching the floor When checking traction equipment, the weights should be freely hanging. Weights that touch the floor require the nurse to intervene. The body should be aligned in an opposite line to the pull of the traction. The ropes should be freely moving over unobstructed pulleys.

A client sustains an injury to the left ankle in a fall. There was immediate swelling and pain from the injury, and the client was taken to the local emergency department. What initial test does the nurse anticipate the physician will order to rule out a fracture?

X-ray X-rays may show a larger-than-usual joint space and rule out or confirm an accompanying fracture. Arthrography demonstrates asymmetry in the joint as a result of the damaged ligaments, or arthroscopy may disclose trauma in the joint capsule. A CT scan is costly and not used as a first-line diagnostic tool in the initial stage of an ankle injury.

A client who plays tennis is experiencing elbow discomfort. Following assessment, the client receives a diagnosis of tendinitis, epicondylitis, or tennis elbow. What symptoms and signs did the client have? Select all that apply.

• Pain radiating down the dorsal surface of the forearm • Weak grasp Tennis elbow is characterized by pain radiating down the dorsal surface of the forearm and weak grasp. Carpal tunnel syndrome is characterized by pain or burning in one or both hands and pain more prominent at night.

The orthopedic surgeon has prescribed balanced skeletal traction for a client. What advantage is conferred by balanced traction?

Balanced traction allows for greater client movement and independence than other forms of traction. Often, skeletal traction is balanced traction, which supports the affected extremity, allows for some client movement, and facilitates client independence and nursing care while maintaining effective traction. It is not portable, however, and it cannot be removed. Bone remodeling takes longer than 6 days.

A group of students is reviewing information about cast composition in preparation for a discussion on the advantages and disadvantages of each. The students demonstrate understanding of the topic when they cite which of the following as an advantage of a plaster cast?

Better molding to the client Plaster casts require a longer time for drying but mold better to the client and are initially used until the swelling subsides. Fiberglass casts dry more quickly, are lighter in weight, longer lasting, and breathable.

A patient has stepped in a hole in the yard, causing an ankle injury. The ankle is edematous and painful to palpation. How long should the nurse inform the patient that the acute inflammatory stage will last?

Between 24 and 48 hours After the acute inflammatory stage (e.g., 24 to 48 hours after injury), intermittent heat application (for 15 to 30 minutes, four times a day) relieves muscle spasm and promotes vasodilation, absorption, and repair.

Which cleansing solution is the most effective for use in completing pin site care?

Chlorhexidine 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.

A client who has undergone a lower limb amputation is preparing to be discharged home. What outcome is necessary prior to discharge?

Client can demonstrate safe use of assistive devices A client should be able to use assistive devices appropriately and safely prior to discharge. Scar formation will not be complete at the time of hospital discharge. It is anticipated that the client will require some assistance with ADLs postdischarge. Pain should be well managed, but may or may not be wholly absent.

When the client who has experienced trauma to an extremity reports severe burning pain, vasomotor changes, and muscles spasms in the injured extremity, the nurse recognizes that the client is likely demonstrating signs of

Complex regional pain syndrome Complex regional pain syndrome is frequently chronic and occurs most often in women. Avascular necrosis is manifested by pain and limited movement. Pain and decreased function are the prime indicators of reaction to an internal fixation device. Heterotrophic ossification causes muscular pain and limited muscular contraction and movement

Which of the following type of fracture is associated with osteoporosis?

Compression Compression fractures are caused by compression of vertebrae and are associated frequently with osteoporosis. Stress fractures occur with repeated bone trauma from athletic activities, most frequently involving the tibia and metatarsals. An oblique fracture runs across the bone at a diagonal angle of 45 to 60 degrees. A simple fracture (closed fracture) is one that does not cause a break in the skin.

A client comes to the emergency department complaining of localized pain and swelling of the 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.

An x-ray demonstrates a fracture in which the fragments of bone are driven inward. This type of fracture is referred to as

Depressed. Depressed skull fractures occur as a result of blunt trauma. A compound fracture is one in which damage also involves the skin or mucous membranes. A comminuted fracture is one in which the bone has splintered into several pieces. An impacted fracture is one in which a bone fragment is driven into another bone fragment.

Colles fracture occurs in which area?

Distal radius 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 nurse is planning the care of a client with osteomyelitis that resulted from a diabetic foot ulcer. The client requires a transmetatarsal amputation. When planning the client's postoperative care, which of the following nursing diagnoses should the nurse most likely include in the plan of care?

Disturbed Body Image Amputations present a serious threat to any client's body image. None of the other listed diagnoses is specifically associated with amputation.

The primary nursing intervention that will control swelling while treating a musculoskeletal injury is:

Elevate the affected area Elevation is used to control swelling. It is facilitated by cold, immobilization, and compression. Refer to Box 42-1 in the text.

A client with a right below-the-knee amputation is being transferred from the postanesthesia care unit to a medical-surgical unit. What is the highest priority nursing intervention by the receiving nurse?

Ensure that a large tourniquet is in the room. The client with an amputation is at risk for hemorrhage. A tourniquet should be placed in plain sight for use if the client hemorrhages. Documenting the receiving report is important but is not the highest priority. The nurse may delegate to unlicensed assistive personnel (UAP) the job of gathering more pillows for positioning, but this is not the highest priority. The nurse will need to review the physician's orders for pain medication, but again, this is not the highest priority, because any hemorrhaging by the client needs to be addressed first.

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?

Explain that the sensation being felt is normal and will not burn the client. 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.

Which term describes a surgical procedure to release constricting muscle fascia so as to relieve muscle tissue pressure?

Fasciotomy A fasciotomy is a surgical procedure to release constricting muscle fascia so as to relieve muscle tissue pressure. An osteotomy is a surgical cutting of bone. An arthroplasty is a surgical repair of a joint. Arthrodesis is a surgical fusion of a joint.

An emergency department nurse is assessing a 17-year-old soccer player who presented with a knee injury. The client's description of the injury indicates that his knee was struck medially while his foot was on the ground. The nurse knows that the client likely has experienced what injury?

Lateral collateral ligament injury When the knee is struck medially, damage may occur to the lateral collateral ligament. If the knee is struck laterally, damage may occur to the medial collateral ligament. The ACL and PCL are not typically injured in this way.

After a traumatic back injury, a client requires skeletal traction. Which intervention takes priority?

Maintaining traction continuously to ensure its effectiveness The nurse must maintain skeletal traction continuously to ensure its effectiveness. The nurse should assess skin for breakdown; however, maintaining skeletal traction takes priority. Traction weights must hang freely to be effective; they should never be supported. The nurse should increase, not restrict, the client's fluid and fiber intake (unless contraindicated by a concurrent illness) to prevent constipation associated with complete bed rest.

The client with a newly applied cast reports severe unrelenting pain. What is the nurse's best response?

Make the client NPO and notify the health care provider. The client is exhibiting symptoms of compartment syndrome. The health care provider needs to be contacted as treatment options include bivalving of the cast or a possible fasciotomy, a surgical procedure. Applying ice rather than heat may provide comfort.

A nurse is admitting a client to the unit who presented with a lower extremity fracture. What signs and symptoms would suggest to the nurse that the client may have a peroneal nerve injury?

Numbness and burning of the foot

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.

Conservative treatment of a compressed nerve root is first line treatment. What conservative treatment is used to increase the distance between vertebrae and decrease severe muscle spasm?

Skin traction Skin traction, which can be applied in the home, is used to decrease severe muscle spasm as well as increase the distance between adjacent vertebrae, keep the vertebrae correctly aligned, and, in many instances, relieve pain. Treatment relieves symptoms for an extended period.

The nurse is helping to set up Buck's traction on an orthopedic client. How often should the nurse assess circulation to the affected leg?

Within 30 minutes, then every 1 to 2 hours After skin traction is applied, the nurse assesses circulation of the foot or hand within 15 to 30 minutes and then every 1 to 2 hours.

A client has been diagnosed with a muscle strain. What does the physician mean by the term "strain"?

stretched or pulled beyond its capacity A strain is an injury to a muscle when it is stretched or pulled beyond its capacity.

Which instruction should the nurse include when teaching the client following hip replacement surgery? (Select all that apply.)

• "Place pillows between your legs when you lay on your side. " • "Avoid bending forward when sitting in a chair." • "Use a raised toilet seat and high-seated chair." The client following post hip replacement should not cross the legs, even at the ankle. He or she should avoid bending forward when sitting in a chair, avoid flexing the hip when dressing, and use a raised toilet seat. A pillow should be placed between the legs when side-lying.

A client is placed in traction for a femur facture. The nurse would document which expected outcomes of traction? Select all that apply.

• Realignment of the fracture • Reduction of deformity • Minimization of muscle spasms Traction is used to minimize muscle spasms, to reduce, align, and immobilize fractures, and to reduce deformity. Traction does not allow for full range of motion or an increased ability to bear weight. The client is confined to the bed while in traction. A decreased pulse is a sign of circulatory compromise and should be investigated and reported.

Two days after surgery to amputate the left lower leg, a client reports pain in the missing extremity. Which action by the nurse is most appropriate?

Administer medication, as ordered, for the reported discomfort. The sensation of pain and discomfort in an amputated extremity is known as phantom pain. Phantom pain is a normal occurrence after an amputation. It should be treated with medication. The nurse doesn't need to contact the health care provider at this time. Consultation with the psychologist isn't indicated, and the nurse shouldn't take this action without consulting the health care provider.

A client who is undergoing skeletal traction reports pressure on bony areas. Which action would be most appropriate to provide comfort for the client?

Changing the client's position within prescribed limits. Changing the position of a client within prescribed limits helps relieve pressure on bony areas and promotes comfort. Analgesics help to relive pain but may not help relieve pressure on bony areas. Warm compresses aid blood circulation. The client should not exercise while on traction unless prescribed to regain strength in the affected limb.

A client has had surgical repair of a hip injury after joint manipulation was unsuccessful. During postoperative recovery, what specific complication might develop in this client's case?

Compartment syndrome The nurse monitors the client for signs and symptoms of compartment syndrome such as unrelenting pain unrelieved by analgesics. Also, neurovascular checks are performed to help prevent this complication.

A client was climbing a ladder, slipped on a rung, and fell on the right side of the chest. X-ray studies reveal three rib fractures, and the client reports pain with inspiration. What is the anticipated treatment for this client?

Coughing and deep breathing with pillow splinting Because these fractures cause pain with respiratory effort, the client tends to decrease respiratory excursions and refrains from coughing. As a result, tracheobronchial secretions are not mobilized, aeration of the lung is diminished, and a predisposition to atelectasis and pneumonia results. To help the client cough and take deep breaths and use an incentive spirometer, the nurse may splint the chest with his or her hands, or may educate the client on using a pillow to temporarily splint the affected site.

Meniscectomy refers to the

Excision of damaged joint fibrocartilage. The most common site for meniscectomy is the knee; the procedure refers to the excision of damaged joint fibrocartilage. Fasciotomy refers to the incision and diversion of the muscle fascia to relieve muscle constriction. Hemiarthroplasty refers to the replacement of one of the articular surfaces of a joint. Amputation refers to the removal of a body part.

A patient sustains an open fracture with extensive soft tissue damage. The nurse determines that this fracture would be classified as what grade?

III Open fractures are graded according to the following criteria (Schaller, 2012): Grade I is a clean wound less than 1 cm long. Grade II is a larger wound without extensive soft tissue damage or avulsions. Grade III is highly contaminated and has extensive soft tissue damage. It may be accompanied by traumatic amputation and is the most severe.

A nurse is preparing to discharge a client from the emergency department after receiving treatment for an ankle sprain. While providing discharge education, the nurse should encourage what action?

Keep an elastic compression bandage on the ankle Treatment of a sprain consists of resting and elevating the affected part, applying cold, and using a compression bandage. After the acute inflammatory stage (usually 24 to 48 hours after injury), heat may be applied intermittently. Rotation exercises would likely be painful.

The client presents with nausea and vomiting, sluggish bowel sounds, and abdominal distention. How does the nurse interpret these findings?

Physiologic cast syndrome Physiological cast syndrome is characterized by impaired gastrointestinal function, such as nausea and vomiting, sluggish bowel sounds, and abdominal distention.

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 nursing diagnosis is a priority for a client with a traumatically amputated lower extremity?

Risk for injury related to amputation The priority diagnosis for this client is Risk for injury related to amputation. Patient safety takes priority. Amputation typically causes an unsteady gait until the client receives physical therapy and learns to ambulate safely. Impaired skin integrity, Anticipatory grieving, and Disturbed body image are also appropriate for a client presenting with a traumatic amputation of an extremity, but Risk for injury is the priority nursing diagnosis.

A client is being discharged home with a long arm cast. What education should the nurse include to prevent disuse syndrome in the arm?

Use of isometric exercises Isometric exercises allow for use of the muscle without moving the bone. Doing isometric exercises every hour while the client is awake will help prevent disuse syndrome. Proper use of a sling does not prevent disuse syndrome. The client should not attempt to reposition the arm in the cast. Abduction and adduction of the shoulder will help the shoulder joint but does not require the use of muscles in the lower arm.

After surgery to treat a hip fracture, a client returns from the postanesthesia care unit to the medical-surgical unit. Postoperatively, how should the nurse position the client?

With the leg on the affected side abducted The nurse must keep the leg on the affected side abducted at all times after hip surgery to prevent accidental dislodgment of the affected hip joint. Placing a pillow or an A-frame between the legs helps maintain abduction and reminds the client not to cross the legs. The nurse should avoid acutely flexing the client's affected hip (for example, by elevating the head of the bed excessively), adducting the leg on the affected side (such as by moving it toward the midline), or externally rotating the affected hip (such as by removing support along the outer side of the leg) because these positions may cause dislocation of the injured hip joint.

Which evaluation finding requires follow up by the nurse caring for a client with a total knee replacement? Select all that apply.

• 650 mL bloody drainage in drain wound • Knee flexion at 30 degrees A suction drain removes fluid accumulating in the wound. Typical drainage ranges from 200 to 400 ml the first 24 hours after surgery and declines to fewer then 25 ml by 48 hours. Knee mobility is increased with a continuous passive motion (CPM) device. Initial settings of the CPM are usually 10 degrees of extension and 50 degrees of flexion with an ultimate goal of full extension (0 degrees) and 90 degrees of flexion by discharge. A pain rating of 2 is an indicator of effective pain management. Strong and equal pedal pulses are an expected finding. Progressive ambulation begins on the day after surgery; ambulating 10 feet on postoperative day would be expected.

A client arrives in the emergency room complaining of severe pain in her left hip after falling out of the bed. What indication upon assessment does the nurse recognize as a dislocated left hip? Select all that apply.

• The left leg is shorter than the right • Limited range of motion of the left hip • The skin of the lower left left is pale The leg may be shorter than its unaffected counterpart as a result of the displacement of one of the articulating ones. ROM is limited. Evidence of soft tissue injury includes swelling, coolness (not heat), numbness, tingling, and pale or dusky color of the distal tissue. The client will not be able to bend the knee but will be able to move the toes.

A continuous passive motion (CPM) machine is used to promote healing and flexibility in the knee and hip joint and increase circulation to the operative area. What is true about the use of CPM? Select all that apply.

• The physician orders the amount of extension and flexion produced by the machine. • The physician orders the frequency of use of the machine. • The amount of flexion for clients with hip replacement should never exceed 30 degrees in the CPM machine . The physician orders the amount of extension and flexion produced by the machine. The physician orders the frequency of use of the machine. The amount of flexion for clients with hip replacements should never exceed 30 degrees in the CPM machine.

Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education?

"The client is receiving physical therapy twice per day, so the client doesn't need a continuous passive motion device." Further staff education is needed when the nurse states that the continuous passive motion device isn't needed because the client receives physical therapy twice per day. The continuous passive motion device should be used in conjunction with physical therapy because the device helps prevent adhesions. Bleeding is a complication associated with the continuous passive motion device; skin integrity should be monitored while the device is in use.

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?

Claw-like 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

A client was playing softball and dislocated four fingers when diving for a ball. The physician manipulated the fingers into alignment and applied a splint to maintain alignment. What type of procedure does the nurse document this as?

Closed reduction In a closed reduction, the bone is restored to its normal position by external manipulation. A bandage, cast, or traction then immobilizes the area. In an open reduction, the bone is surgically exposed in the operating room and realigned. If internal fixation is needed to stabilize a reduced fracture, the surgeon secures the bone with metal screws, plates, rods, nails, or pins. In external fixation, the surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pin.

A client reports to the emergency department after experiencing pain in the left arm. The client reports having extended both arms in an attempt to prevent a fall. Which fracture type does the nurse anticipate?

Colles fracture A Colles fracture occurs in the distal radius. Falling with outstretched arms and hands may increase the risk of this type of fracture. A spiral fracture results from a twisting movement. A greenstick fracture is a bent and incomplete fracture commonly seen in children. A compound fracture results in the bone extending through the skin.

Which type of fracture is one in which the skin or mucous membrane wound extends to the fractured bone?

Compound A compound fracture is one in which the skin or mucous membrane wound extends to the fractured bone. A complete fracture involves a break across the entire cross section of the bone and is frequently displaced. An incomplete fracture involves a break through only part of the cross section of the bone. A simple fracture is one that does not cause a break in the skin.

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?

Dislocation of the hip 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.

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 nurse is caring for a client who had a total knee replacement 3 days ago. Which nursing assessment finding requires immediate attention by the nurse?

Drainage from wound suction device = 100 ml Drainage from a wound suction device should be less than 25 ml 48 hours after surgery; 100 ml is an excessive amount and may necessitate opening of the wound to remove the blood.

A client has delayed bone healing in a fractured right humerus. What should the nurse prepare the client for that promotes bone growth?

Electrical stimulation Delayed union may require surgical interventions to promote bone growth and correct the incorrect union. If necessary, prepare the client for use of electrical stimulation measures that promote bone growth, or for a bone graft. Administration of low-dose heparin would be used to prevent pulmonary embolism. Joint fusion may be used in the case of avascular necrosis. Administration of antibiotics would be used for the potential of infection or to treat an actual infection.

After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis?

Fat embolism Fat embolism is a relatively rare but life-threatening complication of pelvis and long-bone fractures, arising 24 to 48 hours after the injury. It occurs when fat droplets released at the fracture site enter the circulation, become lodged in pulmonary capillaries, and break down into fatty acids. Because these acids are toxic to the lung parenchyma, capillary endothelium, and surfactant, the client may develop pulmonary hypertension. Signs and symptoms of fat embolism include an altered mental status, fever, tachypnea, tachycardia, hypoxemia, and petechiae. Compartment syndrome and infection may complicate any fracture and aren't specific to a pelvis fracture. Volkmann's ischemic contracture is a potential complication of a hand or forearm fracture.

A client broke his arm in a sports accident and required the application of a cast. Shortly following application, the client reported an inability to straighten his fingers and was subsequently diagnosed with Volkmann contracture. What pathophysiologic process caused this complication?

Obstructed arterial blood flow to the forearm and hand Volkmann contracture occurs when arterial blood flow is restricted to the forearm and hand and results in contractures of the fingers and wrist. It does not result from nerve pressure, skin irritation, or spasms.

A fracture is considered pathologic when it

Occurs through an area of diseased bone Pathologic fractures can occur without the trauma of a fall. An avulsion fracture results in a fragment of bone being pulled away by a ligament or tendon and its attachment. A greenstick fracture presents as one side of the bone being broken and the other side being bent. A compound fracture involves damage to the skin or mucous membranes

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.'

The nurse is caring for a patient with a pelvic fracture. What nursing assessment for a pelvic fracture should be included? (Select all that apply.)

• Checking the urine for hematuria • Palpating peripheral pulses in both lower extremities • Testing the stool for occult blood In pelvic fracture, the nurse should palpate the peripheral pulses, especially the dorsalis pedis pulses of both lower extremities; absence of a pulse may indicate a tear in the iliac artery or one of its branches. To assess for urinary tract injury, the patient's urine is analyzed for blood.

A client has had a brace prescribed to facilitate recovery from a knee injury. What are the potential therapeutic benefits of a brace? Select all that apply.

• Preventing additional injury • Providing support • Controlling movement Braces (i.e., orthoses) are used to provide support, control movement, and prevent additional injury. They are not used to immobilize body parts or to facilitate bone remodeling.

A client who was in a motor vehicle crash is diagnosed with a stable T7 spinal fracture with no neurologic deficits. Which nursing intervention should the nurse implement?

Which is not one of the general nursing measures employed when caring for the client with a fracture?

Cranial nerve assessment 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.

Which would be consistent as a component of self-care activities for the client with a cast?

Cushion rough edges of the cast with tape The client can cushion rough edges with tape to prevent skin irritation. The cast should be kept dry, but do not cover it with plastic or rubber because this causes condensation, which dampens the cast and skin. The casted extremity is to be elevated to heart level frequently; a dependent position will increase swelling. A client should not use any object to scratch under the cast.

Which nursing intervention is appropriate for a client with a closed-reduction extremity fracture?

Encourage participation in ADLs 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.

The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this client is likely demonstrating symptoms of what complication?

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:

Femoral neck 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.

A client has just undergone a leg amputation. What will the nurse closely monitor the client for during the immediate postoperative period?

Hematoma Hematoma, hemorrhage, and infection are potential complications in the immediate postoperative period. Sleeplessness, nausea, and vomiting may occur but are adverse reactions, not complications. Chronic osteomyelitis and causalgia are potential complications that are likely to arise in the late postoperative period. A neuroma occurs when the cut ends of the nerves become entangled in the healing scar. This would occur later in the postoperative course.

While riding a bicycle on a narrow road, the patient was hit from behind and thrown into a ditch, sustaining a pelvic fracture. What complications does the nurse know to monitor for that are common to pelvic fractures?

Hemorrhage and shock Hemorrhage and shock are two of the most serious consequences that may occur in a pelvic fracture.

Which type of cast encloses the trunk and a lower extremity?

Hip Spica A hip spica cast encloses the trunk and a lower extremity. A body cast encloses the trunk. A long-leg cast extends from the junction of the upper and middle third of the thigh to the base of the toes. A short-leg cast extends from below the knee to the base of the toes.

A nurse is caring for a client who is recovering in the hospital following orthopedic surgery. The nurse is performing frequent assessments for signs and symptoms of infection in the knowledge that the client faces a high risk of what infectious complication?

Osteomyelitis Infection is a risk after any surgery, but it is of particular concern for the postoperative orthopedic client because of the risk of osteomyelitis. Orthopedic clients do not have an exaggerated risk of cellulitis, sepsis, or septic arthritis when compared to other surgical clients.

A patient has a long leg cast applied. Where does the nurse understand a common pressure problem may occur?

Peroneal nerve The nurse assesses circulation by observing the color, temperature, and capillary refill of the exposed toes. Nerve function is assessed by observing the patient's ability to move the toes and by asking about the sensations in the foot. Numbness, tingling, and burning may indicate peroneal nerve injury resulting from pressure at the head of the fibula.

A patient has a cast removed after bone healing takes place. What should the nurse instruct the patient to do after removal? (Select all that apply.)

• Apply an emollient lotion to soften the skin • Control swelling with elastic bandages as directed. • Gradually resume activities and exercise. The skin needs to be washed gently and lubricated with an emollient lotion. The patient should be instructed to avoid rubbing and scratching the skin, because doing so can cause damage to newly exposed skin. The nurse and physical therapist educate the patient to resume activities gradually within the prescribed therapeutic regimen. Exercises prescribed to help the patient regain joint motion are explained and demonstrated. Because the muscles are weak from disuse, the body part that has been immobilized cannot withstand normal stresses immediately. In addition, the patient should be instructed to control swelling by elevating the formerly immobilized body part, no higher than the heart, until normal muscle tone and use are reestablished.

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.

The client is admitted to the hospital with a diagnosis of left femoral neck fracture. Which treatment modality would the nurse expect the health care provider to order?

Buck's traction Fractures of the proximal femur are immobilized with Buck's traction prior to surgical fixation.

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.

The nurse is very concerned about the potential debilitating complication of peroneal nerve injury. What symptom does the nurse recognize as a result of that complication?

Foot drop Injury to the peroneal nerve as a result of pressure is a cause of foot drop (the inability to maintain the foot in a normally flexed position). Consequently, the patient drags the foot when ambulating

Peroneal nerve injury may result in numbness, tingling, and burning in the feet. Cyanosis, pallor, and decreased capillary refill are signs of inadequate circulationWhich term refers to a fracture in which one side of a bone is broken and the other side is bent?

Greenstick 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.

A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan?

Teach the client how to prevent problems caused by immobility By teaching the client about prevention measures, the nurse can help prevent problems caused by immobility, such as hypostatic pneumonia, muscle contracture, and atrophy. The nurse applies traction straps for skin traction — not skeletal traction. For a client in skeletal traction, the nurse should assess the affected limb, rather than assess the level of consciousness. Removing skeletal traction is the physician's responsibility — not the nurse's

A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan?

Teach the client how to prevent problems caused by immobility. By teaching the client about prevention measures, the nurse can help prevent problems caused by immobility, such as hypostatic pneumonia, muscle contracture, and atrophy. The nurse applies traction straps for skin traction — not skeletal traction. For a client in skeletal traction, the nurse should assess the affected limb, rather than assess the level of consciousness. Removing skeletal traction is the physician's responsibility — not the nurse's.

A rehabilitation nurse is working with a client who has had a below-the-knee amputation. In order to determine the client's ability to be an active participant in self-care, the nurse should prioritize assessment of what variable?

The client's attitude Amputation of an extremity affects the client's ability to provide adequate self-care. The client is encouraged to be an active participant in self-care. The client and the nurse need to maintain positive attitudes and to minimize fatigue and frustration during the learning process. Balanced nutrition and the client's learning style are important variables in the rehabilitation process but the client's attitude is among the most salient variables. The client's presurgical level of function may or may not affect participation in rehabilitation.

A client is having traction applied to a fractured left lower extremity prior to surgery. What outcomes does the nurse expect from the application of the traction for the client? Select all that apply.

• Muscle spasms will be relieved • The bones of the leg will be aligned • Immobilization of the leg will be maintained Traction is used to relieve muscle spasm, align bones, and maintain immobilization when used properly. It will not replace surgery to correct the fracture. The client will still require pain medication prior to surgical correction.

For which of the following immobility-related complications is the client in traction at risk? Select all that apply.

• Thromboemboli • Urinary stasis Immobility-related complications may include pressure ulcers, atelectasis, pneumonia, constipation, loss of appetite, urinary stasis, urinary tract infections, and venous thromboemboli formation.

A client comes to the clinic 2 days after sustaining a sprain to the left ankle. What intervention can the nurse encourage the client to perform that will help improve circulation?

Applying heat After 2 days, when swelling is no longer likely to increase, applying heat reduces pain and relieves local edema by improving circulation. Full use of the injured joint is discouraged temporarily. Nonsteroidal anti-inflammatory drugs will ease discomfort but not improve circulation. Applying cold compresses is only used in the first 24 to 48 hours after an injury to reduce swelling and relieve pain.

A patient sustains a fracture of the arm. When does the nurse anticipate pendulum exercise should begin?

As soon as tolerated, after a reasonable period of immobilization Many impacted fractures of the surgical neck of the humerus are not displaced and do not require reduction. The arm is supported and immobilized by a sling and swathe that secure the supported arm to the trunk (Fig. 43-10). Limitation of motion and stiffness of the shoulder occur with disuse. Therefore, pendulum exercises begin as soon as tolerated by the patient. In pendulum or circumduction exercises, the physical therapist instructs the patient to lean forward and allow the affected arm to hang in abduction and rotate. These fractures require approximately 4 to 10 weeks to heal, and the patient should avoid vigorous arm activity for an additional 4 weeks. Residual stiffness, aching, and some limitation of ROM may persist for 6 months or longer (NAON, 2007).

A client is transported to the emergency department for a femur fracture following a motor vehicle crash. What action by the nurse is the highest priority?

Assess vital signs and level of consciousness Femur fractures can lead to hypovolemic shock due to blood loss in the tissue. By assessing the vital signs and level of consciousness, the nurse can assess for shock. Assessing the pedal pulses and measuring the diameter of the thigh are appropriate interventions for someone with a femur fracture, but assessing for hypovolemic shock would be a priority. Pain medication should be safely administered per orders to help control pain. Many pain medications lower blood pressure (BP). If the client is in shock, BP may be too low to administer the pain medication safely.

A client sustains a fractured right humerus in an automobile accident. The arm is edematous, the client states not being able to move or feel the fingers, and the nurse does not feel a pulse. What condition should the nurse be concerned about that requires emergency measures?

Compartment Syndrome Separation of adjacent bones from their articulating joint interferes with normal use and produces a distorted appearance. The injury may disrupt local blood supply to structures such as the joint cartilage, causing degeneration, chronic pain, and restricted movement. Compartment syndrome is a condition in which a structure such as a tendon or nerve is constricted in a confined space. The fractured humerus may also be dislocated but is not the result of the impaired circulatory status. Muscle spasms may occur around the fracture site but are not the cause of circulatory impairment. Subluxation is a partial dislocation.

A client who has extremity right wrist fracture complains of severe burning pain, frequent changes in the skin from hot and dry to cold, and feeling clammy skin that is shiny and growing more hair in the injured extremity. The nurse should anticipate providing care for what complication?

Complex regional pain syndrome The symptoms reported by the client are consistent with complex regional pain syndrome. Avascular necrosis is manifested by pain and limited movement. Pain and decreased function are the prime indicators of reaction to an internal fixation device. Heterotrophic ossification causes muscular pain and limited muscular contraction and movement.

A client has a cast applied to the leg for treatment of a tibia fracture and also has a wound on the leg that requires dressing changes due to drainage. For what should the nurse prepare the client?

Cutting a cast window After the cast dries, a cast window, or opening, may be cut. This usually is done when the client reports discomfort under the cast or has a wound that requires a dressing change. The window permits direct inspection of the skin, a means to check the pulse in a casted arm or leg, or a way to change a dressing. A bivalve cast is when the cast is cut in two if the leg swells or if the client is being weaned from a cast, when a sharp x-ray is needed, or as a splint for immobilizing painful joints when a client has arthritis. The cast should not be removed due to the instability of a fracture. The client's condition does not indicate an external fixator is required.

A client with a tibia fracture was placed in an external fixator 24 hours ago. The nurse is completing pin care and notices redness at the pin site and a small amount of serous drainage. What action by the nurse is appropriate?

Document the findings Serous drainage and redness at the pin site is an expected finding for 48 to 72 hours after insertion. The nurse should document the findings and continue to monitor the site. The physician does not need to be notified unless other signs and symptoms are present. The fixator does not need to be removed at this time. The greatest concern is infection; assessing the hemoglobin and hematocrit are not relevant to assessing for infection.

What is the best action by the nurse to achieve optimal outcomes when caring for a client with a musculoskeletal disorder who is using a cast?

Educate the client on cast care and complications Educating the client is essential to achieve optimal outcomes. Although the nurse should prepare the client for cast applications, assess for neurovascular compromise, and provide effective pain control, these interventions are centered on care provided by the nurse. The client is more likely to be in the home setting while a cast is in place, requiring the client to have the education to properly care for the cast and have knowledge of the complications so that early interventions can happen.

The health care provider is preparing to bivalve the client's cast. Which supplies should the nurse assemble?

Elastic compression bandages Bivalving of a cast involves splitting the cast longitudinally and spreading the cast apart to relieve pressure. The fractured extremity is immobilized by securing the two parts of the cast together with an elastic compression bandage.

A client comes to the orthopedic clinic and reports having pain that radiates down the forearm and being unable to grasp objects firmly. What does the nurse suspect is occurring with the client?

Epicondylitis Epicondylitis (tennis elbow) is a painful inflammation of the elbow that is caused by injury following excessive pronation and supination of the forearm, such as that which occurs when playing tennis, pitching a ball, or rowing. Client reports pain radiating down the dorsal surface of the forearm and a weak grasp. Carpal tunnel syndrome is compression of the median nerve and affects the hand with burning. Pain is more prominent in the early morning or at night. The pain of a ganglion cyst is more localized in the area of the cyst. The symptoms the client describes do not correlate with a diagnosis of shoulder rotation.

The client is scheduled for a meniscectomy of the right knee. The nurse would plan postoperative care based on what surgical procedure?

Excision of damaged joint fibrocartilage The most common site for meniscectomy is the knee; the procedure refers to the excision of damaged joint fibrocartilage. Fasciotomy refers to the incision and diversion of the muscle fascia to relieve muscle constriction. Hemiarthroplasty refers to the replacement of one of the articular surfaces of a joint. Total joint arthroscopy is the replacement of a joint with synthetic material.

A nurse is caring for a client with a cast on the left arm after sustaining a fracture. Which assessment finding is most significant for this client?

Fingers on the left hand are swollen and cool Swollen and cool fingers on the left hand are the most significant assessment findings. They represent altered circulation to the hand caused by the cast. A normal radial, not popliteal, pulse should be present in the left arm; the popliteal pulse is found on the leg. Skin irritation is an abnormal assessment finding but it isn't as significant as altered circulation. Minimal pain in the left arm is expected.

A variety of complications can occur after a leg amputation. Which is not a possibility in the immediate postoperative period?

A nurse is providing discharge education to a client who is going home with a cast on his leg. What topic should the nurse emphasize in the teaching session?

Reporting signs of impaired circulation Reporting signs of impaired circulation is critical; signs of impaired circulation must be reported to the physician immediately to prevent permanent damage. For this reason, this education is a priority over exercise and crutch use. The client does not independently remove the cast.

Which of the following is an inappropriate nursing diagnosis for the client following casting?

Risk for deficient knowledge: procedure The client needs adequate information before experiencing the procedure. Information about its purpose, the actual steps of the procedure, and the client's role during and after the procedure is essential. Appropriate nursing diagnoses following the procedure would include risk for disuse syndrome, risk for impaired skin integrity, and risk for impaired tissue perfusion.

A nurse is developing a teaching plan for a client who must undergo an above-the-knee amputation of the left leg. After a leg amputation, exercise of the remaining limb:

Should begin the day after surgery. Exercise of the remaining limb should begin the day after surgery. Exercise is necessary to maintain the muscle tone of the remaining limb. Immediately after surgery, the client usually isn't alert enough to participate and may be in too much pain. Exercise needs to begin before discharge to a rehabilitation center.

An elderly client's hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse's priority assessment?

Signs of neurovascular compromise Because impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment. Leg shortening and internal or external rotation are common findings with a fractured hip. Pain, especially on movement, is also common after a hip fracture.

Which device is designed specifically to initially support and immobilize a body part in a desired position until swelling subsides?

Splint 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.

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?

Splint 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.

Which device is designed specifically to support and immobilize a body part in a desired position?

Splint A splint may be applied to a fractured extremity initially until swelling subsides. Splints are designed to provide stability for fractures that are unstable and to immobilize and support the body part in a functional position. A brace is an externally applied device to support a body part, control movement, and prevent injury; braces are used to enhance movement while preventing injury. A sling is a bandage used to support an arm temporarily while the client ambulates; it is not designed to immobilize the body part. Traction is the use of a pulling force on a body part and thus it is not designed to immobilize; the goal of traction is to achieve or maintain alignment, decrease muscle spasms and pain, or correct or prevent deformities.

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?

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.

• Capillary refill less than 3 seconds • Repositions self with trapeze • Peripheral pulses +2 bilaterally • Elbows are free of skin breakdown A capillary refill time of less than 3 seconds, the ability to reposition using a trapeze, peripheral pulses +2 bilaterally, and elbows free of skin breakdown are normal assessments for the nurse to find with a client in skeletal leg traction. An abnormal finding of a deep vein thrombosis include calf tenderness, warmth, redness, and swelling of the affected extremity.

A patient sustains an open fracture of the left arm after an accident at the roller skating rink. What does emergency management of this fracture involve? (Select all that apply.)

• Covering the area with a clean dressing if the fracture is open • Immobilizing the affected site • Splinting the injured limb Immediately after injury, if a fracture is suspected, the body part must be immobilized before the patient is moved. Adequate splinting is essential. Joints proximal and distal to the fracture also must be immobilized to prevent movement of fracture fragments. In an upper extremity injury, the arm may be bandaged to the chest, or an injured forearm may be placed in a sling. The neurovascular status distal to the injury should be assessed both before and after splinting to determine the adequacy of peripheral tissue perfusion and nerve function. With an open fracture, the wound is covered with a sterile dressing to prevent contamination of deeper tissues.

The nurse suspects "compartment syndrome" for a casted extremity. What characteristic symptoms would the nurse assess that would confirm these suspicions? (Select all that apply.)

• Decreased sensory function • Excruciating pain • Loss of motion Clinical manifestations include dusky, pale appearance of the exposed extremity; cool skin temperature; delayed capillary refill; paresthesia; and unrelenting pain not relieved by position changes, ice, or analgesia. A hallmark sign is pain that occurs or intensifies with passive range of motion (Johnston-Walker & Hardcastle, 2011). The patient may complain that the cast, brace, or splint is too tight. The primary provider must be notified immediately.

The nurse teaching the client with a cast about home care includes which instruction?

• Dry a wet fiberglass cast thoroughly to avoid skin problems Instruct the client to keep the cast dry, to dry a wet fiberglass cast thoroughly to avoid skin problems, and not to cover it with plastic or rubber. A cast should be kept dry, but do not cover it with plastic or rubber because this causes condensation, which dampens the cast and skin. A casted extremity should be elevated frequently to heart level to prevent swelling. A broken cast should be reported to the physician and the client should not attempt to fix it.

A nurse is caring for a client who has had an amputation. What interventions can the nurse provide to foster a positive self-image? (Select all that apply.)

• Encouraging the client to care for the residual limp. • Allowing the client to express grief. • Introducing the client to local amputee support groups. The nurse helps the client set realistic rehabilitation goals and encourages the client to be an active participant in self-care. The nurse creates an accepting and supportive atmosphere in which the patient and family are encouraged to express and share their feelings and work through the grieving process; support from family and friends promotes the patient's acceptance of the loss. Mental health and support group referrals may be appropriate. Although the nurse supports the client in coming to terms with the appearance and function of the residual limb, and in sharing feelings about the amputation with family and friends, viewing of the residual limb by family and friends is not a priority and may not be helpful for the client's well-being.

A client with a fractured femur is admitted to the nursing unit. Which assessment finding requires follow up by the nurse? Select all that apply.

• I cannot seem to catch my breath • I have pins and needles sensation in my toes. • Dorsoplantar weak and unequally bilaterally • T 101.2 degrees F; HR 110; RR 28; pulse oximetry 90% Fat embolism syndrome and compartment syndrome are complications of a fracture, especially of the long bones. Dyspnea, tachycardia, tachypnea, fever, and low pulse oximetry would be indicators of fat embolism syndrome. Paresthesia (pins-and-needles sensation), limited motion, and motor weakness would be indicators of compartment syndrome. Capillary refill less than 3 seconds is a normal finding

A client returns to the nursing unit following an open reduction with internal fixation of the right hip. Which nursing interventions would be appropriate for the prophylactic treatment of deep vein thrombosis? Select all that apply.

• Increased fluid intake • Maintaining antiembolic stockings • Administering enoxaparin Increasing fluid intake decreases stasis by lessening hemoconcentration. Antiembolic stockings and administering enoxaparin are standards of care associated with decreasing deep vein thrombosis. Encouraging coughing exercises helps to reduce respiratory complications. Increased fiber intake increases bulk in stool, but does not prevent deep vein thrombosis.

Which intervention should the nurse implement with the client who has an external fixator? Select all that apply.

• Perform pin care as ordered • Supervise the client during transfers • Perform neurovascular assessments • Inspect pin sites for signs of infection Nursing care of the client with an external fixator includes pin care, inspection of pin sites for signs of infection, neurovascular assessment, and supervision of the client during transfers. The nurse does not adjust the clamps on the external fixator frame; this is the responsibility of the physician.

Which actions by the nurse demonstrate an understanding of caring for a client in traction? Select all that apply.

• Placing a trapeze on the hand • Ensuring that the weights are hanging freely • Assessing the client's alignment in the bed • Frequently assessing pain level The weights must hang freely, with the client in good alignment in the center of the bed. The nurse should frequently monitor pain, as uncontrolled pain may be a sign of a complication. The client will be able to assist with alignment and bed mobility if a trapeze is placed on the bed. Skeletal traction should never be interrupted.

A 75-year-old client had surgery for a left hip fracture yesterday. When completing the plan of care, the nurse should include assessment for which complications? Select all that apply.

• Pneumonia • Skin breakdown • Sepsis • Delirium Complications in clients with hip fractures are often related to the client's age. During the first 24 to 48 hours following surgery for hip fracture, atelectasis or pneumonia can develop as a result of the anesthesia. Thromboemboli are possible, as is sepsis. Elderly clients are also at risk for delirium in hospital settings because of the stress of the trauma, unfamiliar surroundings, sleep deprivation, and medications. An elderly client with decreased mobility is at risk for skin breakdown. Necrosis is a potential complication of the surgery, but the complication would be with the femur, not the humerus.

Which client(s) is most likely to have compartment syndrome after sustaining a fracture? Select all that apply.

• The client with elevated pressure within the muscles • The client with hemorrhage in the site of injury • The client with a plaster cast applied immediately after injury Compartment syndrome occurs in cases of fracture when the normal pressure of a compartment is altered by the force of the injury itself, by development of edema, or by hemorrhaging at the site of the injury, which increases the contents of the compartment, or from outside pressure caused by constriction from a dressing or cast. A client with elevated muscle pressure is at risk for compartment syndrome. The application of a plaster cast immediately after the injury places the client at risk for compartment syndrome because the cast will not allow for edema and therefore will compress the tissue. Clavicle fractures are not a risk factor for compartment syndrome because of the location of the fracture. Ice will assist in decreasing edema and may help prevent compartment syndrome.

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?

"Antibiotic therapy has been prescribed as a precaution because your bone was exposed to the environment at the time of your injury." 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.

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?

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

A client has returned to the postsurgical unit from the PACU after an above-the-knee amputation of the right leg. Results of the nurse's initial postsurgical assessment were unremarkable but the client has called out. The nurse enters the room and observes copious quantities of blood at the surgical site. What should be the nurse's initial action?

Apply a tourniquet A client has returned to the postsurgical unit from the PACU after an above-the-knee amputation of the right leg. Results of the nurse's initial postsurgical assessment were unremarkable but the client has called out. The nurse enters the room and observes copious quantities of blood at the surgical site. What should be the nurse's initial action?

A nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?

Assessing the extremity for neurovascular integrity 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.

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?

Avascular necrosis 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.

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

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?

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.

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 comes to the emergency department and reports localized pain and swelling in the lower leg. Ecchymotic areas are noted. History reveals that the client got hit in the leg with a baseball bat. What will the nurse most likely suspect?

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.

Which would be contraindicated as a component of self-care activities for the client with a cast?

Cover the cast with plastic to insulate it The cast should be kept dry, but do not cover it with plastic or rubber because this causes condensation, which dampens the cast and skin. The other activities are consistent with cast care.

A client with a recent left above-the-knee amputation states, "I can feel pain in my left toes." Which is the best response by the nurse?

Describe the pain and rate it on the pain scale The nurse should recognize phantom pain as real and complete a pain assessment as if the limb were attached. The client's pain should be address and treated appropriately. By telling the client that the toes have been amputated or the pain is really from the nerves in the upper leg, the nurse is negating the client's pain. Opioid pain medication can be effective with phantom pain.

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

Difficulty lying on affected side 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.

The nurse caring for a client, who has been treated for a hip fracture, 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 hips 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 fractureA nurse is performing a shift assessment on an elderly client who is recovering after surgery for a hip fracture. The client reports chest pain has an increased heart rate, and increased respiratory rate. The nurse further notes that the client is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum.

A client is reporting pain following orthopedic surgery. Which intervention will help relieve pain?

Elevate the affected extremity and use cold application Elevating the affected extremity and using cold applications reduce swelling. Deep breathing and coughing helps with maintenance of effective respiratory rate and depth. ROM exercises maintain full ROM of unaffected joints. Antiembolism stockings help prevent deep vein thrombosis (DVT).

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 scenario are characteristic of fat embolism syndrome.

Which factor inhibits fracture healing?

History of diabetes 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.

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.

Impaired physical mobility Ankle strains result in pain and damage to the ligaments as well as Impaired physical mobility. Although the traumatic event that caused the strain may disrupt the skin, the manifestations of a strain don't warrant a nursing diagnosis of Impaired skin integrity. Risk for deficient fluid volume is an appropriate nursing diagnosis for a process that results in the loss of a large volume of fluid or blood; it isn't appropriate for a client with a strained ankle. Disturbed body image would be appropriate if the client's livelihood alters because of the strain.

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.

To reduce the incidence of complications in a client in traction, which intervention should be included in the care plan?

Increase fiber intake Immobility increases the incidence of constipation. Increasing fiber intake will reduce GI complications. The weights in traction should never be removed. Inactivity results in fewer calories being burned. Increasing calories would be counterproductive. Reducing fluids will increase the likelihood of constipation.

Which nursing diagnosis takes highest priority for a client with a compound fracture?

Infection related to effects of trauma 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.

The nurse is caring for a client with a spica cast. What is the nurse's priority intervention?

Keep the cast clean and dry Keeping the cast clean and dry around the perineal opening is a priority. A spica cast has a built-in abduction bar. The client should be positioned on the unaffected side every 2 hours and prone twice a day. A fracture bedpan is easier to use for the client with a spica cast.

A client is seen in the orthopedic clinic for complaints of severe pain in the left hip. After a series of diagnostic tests, the client is diagnosed with severe degenerative joint disease of the left hip and suggested to have the hip reconstructed. What procedure will the nurse schedule the client for?

Left hip arthroplasty Clients with arthritis, trauma, hip fracture, or a congenital deformity may have an arthroplasty, or reconstruction of the joint. This procedure uses an artificial joint that restores previously lost function and relieves pain. An arthroscopy is not used to reconstruct a diseased hip. A closed reduction is not an invasive surgical procedure and would not be used to reconstruct the hip. An open reduction and internal fixation is not the treatment for reconstruction of the hip related to a diseased hip.

A client has sustained a long bone fracture and the nurse is preparing the client's care plan. Which of the following should the nurse include in the care plan?

Monitor temperature and pulses of the affected extremity. The nurse should include monitoring for sufficient blood supply by assessing the color, temperature, and pulses of the affected extremity. Weight-bearing exercises are encouraged, but passive ROM exercises have the potential to cause pain and inhibit healing. Corticosteroids, vitamin D, and calcium are not normally given.

The nurse teaches the client which intervention to avoid hip dislocation after replacement surgery?

Never cross the affected leg when seated 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..

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 client arrives in the emergency department with a suspected bone fracture of the right arm. How does the nurse expect the client to describe the pain?

Sharp and piercing The nurse must carefully evaluate pain associated with the musculoskeletal condition, asking the client to indicate the exact site and to describe the character and intensity of the pain using a pain rating scale. Most pain can be relieved by elevating the involved part, applying ice or cold packs, and administering analgesic agents as prescribed. Pain associated with the underlying condition (e.g., fracture, which is sharp and piercing) is frequently controlled by immobilization. Pain due to edema that is associated with trauma, surgery, or bleeding into the tissues can frequently be controlled by elevation and, if prescribed, intermittent application of ice or cold packs. Ice bags (one third to one half full) or cold application devices are placed on each side of the cast, if prescribed, making sure not to indent or wet the cast. Unrelieved or disproportionate pain may indicate complications. Pain associated with compartment syndrome is relentless and is not controlled by modalities such as elevation, application of ice or cold, and usual dosages of analgesic agents. Severe burning pain over bony prominences, especially the heels, anterior ankles, and elbows, warns of an impending pressure ulcer. This may also occur from too-tight elastic wraps used to hold splints in place.

Which statement describes external fixation?

The surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. In external fixation, the surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. In internal fixation, the surgeon secures the bone with metal screws, plates, rods, nails, or pins. A cast or other mode of immobilization is applied. In closed reduction, the bone is restored to its normal position by external manipulation. In open reduction, the bone is surgically exposed and realigned.

Arthrodesis is:

fusion of a joint (most often the wrist or knee) for stabilization and pain relief. Arthrodesis is fusion of a joint (most often the wrist or knee) for stabilization and pain relief. Arthroplasty is total reconstruction or replacement of a joint (most often the knee or hip) with an artificial joint to restore function and relieve pain. Hemiarthroplasty is the replacement of one of the articular surfaces in a joint, such as the femoral head but not the acetabulum. Osteotomy is the cutting and removal of a wedge of bone (most often the tibia or femur) to change the bone's alignment, thereby improving function and relieving pain.

A client is diagnosed with several fractured ribs after a motor vehicle crash. Which actions will the nurse take when caring for this client? Select all that apply.

• Provide analgesics as prescribed • Instruct on the use of an incentive spirometer • Demonstrated the use of a pillow to a splint the area • Remind to take deep breaths and cough every hour. Rib fractures are some of the most common thoracic injuries; they occur frequently in adults of all ages, typically from blunt trauma such as motor vehicle crashes or falls, and usually result in no impairment of function. The mainstay of treatment is pain control to decrease chest wall splinting and subsequent atelectasis. Therefore, analgesics should be provided as prescribed. An incentive spirometer should be used to prevent pooling of secretions. A pillow should be used to splint the area prior to deep breathing and coughing. Chest binders to immobilize the rib fracture are not used, because decreased chest expansion may result in atelectasis and pneumonia.

A nurse is caring for a construction worker who fell from the second story of a building site and fractured the femoral neck. Which nursing diagnosis is a priority for the client? Select all that apply.

• Risk for infection • Impaired physical mobility • Risk for injury The usual surgical management for a femoral neck fracture is an open reduction and internal fixation with nails or screws, placing the client at risk for infection from a surgical incision. The client's physical mobility is impaired, increasing the risk for injury. Disturbed body image and urinary incontinence are not expected problems for the client with a femoral neck fracture.

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.

• Skin breakdown • Wound infection • Pneumonia After surgery, the nurse implements measures to prevent skin breakdown, wound infection, pneumonia, constipation, urinary retention, muscle atrophy, and contractures.

Ch 37: Musculoskeletal Trauma PrepU

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