Chapter 44: Fractures

30. Arrange the process of stair climbing with crutches in the correct sequence: (Separate letters by a comma and space as follows: A, B, C, D.) A. Body weight is supported with crutches. B. Crutches are moved to the next step. C. The affected leg moves to the next step. D. The unaffected leg is moved to the next step. E. Body weight is transferred to the unaffected leg.

ANS: A, D, E, B, C When climbing steps on crutches, the body weight is supported with the crutches. While the unaffected leg is moved to the next step, the body weight is transferred to the unaffected leg; while the crutches are moved up, the affected leg moves up. DIF: Cognitive Level: Comprehension REF: p. 982 OBJ: 5 TOP: Stair Climbing with Crutches KEY: Nursing Process Step:

29. A nurse uses a diagram to show the process of a fractured bone healing. (Arrange the options in the appropriate sequence. Separate letters by a comma and space as follows: A, B, C, D.) A. Ossification B. Hematoma C. Fibrocartilage D. Consolidation E. Callus

ANS: B, C, E, A, D The sequence of healing is hematoma, fibrocartilage, callus, ossification, and consolidation. DIF: Cognitive Level: Comprehension REF: p. 972 OBJ: 2 TOP: Bone Healing KEY: Nursing Process Step: Implementation MSC:

28. A fracture that occurs because of osteoporosis is classified as a(n) _____ fracture.

ANS: pathological A fracture that occurs as a result of a tumor of an pathologic condition is classified as a pathologic fracture. DIF: Cognitive Level: Knowledge REF: p. 971 OBJ: 3 TOP: Pathological Fracture KEY: Nursing Process Step:

15. Assistive devices such as canes, crutches, and walkers are used for people who need to limit weight-bearing activities on joints. Which statement by a nurse best illustrates an understanding of the appropriate use of these devices? a. "Canes provide minimal support and balance and are carried on the unaffected side." b. "When using a cane, slide it as you go to decrease the arm strain." c. "A three-point gait is used when walking with a walker." d. "When using crutches, the unaffected leg goes down the steps first."

ANS: A "Canes provide minimal support and balance and are carried on the unaffected side" is the only true statement. DIF: Cognitive Level: Comprehension REF: p. 982-983 OBJ: 5 TOP: Assistive Devices KEY: Nursing Process Step: Evaluation MSC:

3. A patient who has osteomyelitis after multiple fractures inquires what the physician meant when he said that surgery would follow the antibiotic therapy. What is the nurse's most helpful reply to explain why this surgery will be performed? a. To remove dead bone b. To close the open draining wound c. To close the area with casting material d. To amputate

ANS: A After the antibiotic has controlled the infection in the bone, surgery will be performed to remove the dead bone. DIF: Cognitive Level: Comprehension REF: p. 973 OBJ: 4 TOP: Osteomyelitis KEY: Nursing Process Step: Implementation MSC:

4. A patient with a crushed forearm cannot get pain relief with opioid medications. The injury is swollen, cool, and cyanotic, with weak distal pulses. What should the nurse suspect? a. Compartment syndrome b. Overwhelming infection c. Fat embolus d. Osteomyelitis

ANS: A Compartment syndrome may occur after a massive injury or an inappropriately tight cast. The tissues become swollen to the point that they cut off their own circulation. DIF: Cognitive Level: Analysis REF: p. 974 OBJ: 3 TOP: Compartment Syndrome KEY: Nursing Process Step: Assessment MSC:

22. Which assessment is considered abnormal when a nurse performs a neurovascular assessment on a patient in skeletal traction? a. Delayed capillary refill b. Bilateral equal pulses c. Absence of pain and swelling d. Limb is the same color as the unaffected side

ANS: A Delayed capillary refill reflects possible impaired tissue perfusion. DIF: Cognitive Level: Comprehension REF: p. 979-980 OBJ: 5 | 6 TOP: Traction KEY: Nursing Process Step: Assessment MSC:

17. What should a nurse who is documenting and reporting the signs and symptoms of an infection underneath a cast include in the medical record? a. Elevated temperature b. Tingling and decreased sensation c. Full pulses and absence of pain d. Swelling and diminished motor function

ANS: A Elevated temperature on the affected extremity may be a symptom of an infection under the cast. DIF: Cognitive Level: Application REF: p. 973 OBJ: 3 TOP: Complications of a Fracture KEY: Nursing Process Step: Assessment MSC:

7. An older woman falls down at church and immediately complains of severe pain in her left hip. Which observation is recognized as the cardinal sign of a fractured hip? a. Shortened left leg compared with the right b. Downward curled toes c. Internal rotation of the left leg d. Hematoma on the left hip

ANS: A The classic sign of a fractured hip is a shortened limb on the affected side, with an externally rotated limb. DIF: Cognitive Level: Comprehension REF: p. 985 OBJ: 1 TOP: Fractured Hip KEY: Nursing Process Step: Assessment MSC:

27. Which characteristics are present when crutches are properly fitted? (Select all that apply.) a. The axilla piece is 3 to 4 fingerbreadths below the axilla. b. They fit close to the axilla for secure support. c. They are measured and adjusted when the patient is in the tripod position. d. Adjusted handgrips allow for a 45-degree flexion of the elbow. e. They are padded so patient can bear weight on the axilla piece when ambulating.

ANS: A, C Crutches should allow for 3 to 4 fingerbreadths between the axilla and the axilla piece, the crutches should be adjusted when the patient is in the tripod position, the elbow flexion should be adjusted for a 30-degree flexion, and the weight should not be borne on the axilla because of the possibility of nerve damage. DIF: Cognitive Level: Comprehension REF: p. 980 OBJ: 5 TOP: Crutch Adjustment KEY: Nursing Process Step:

26. To what can delayed union of a fracture be attributed? (Select all that apply.) a. Inadequate immobilization b. Hormone replacement therapy c. Long-term use of corticosteroids d. Infection e. Poor nutrition

ANS: A, D, E Delayed union can be caused by inadequate immobilization, infection, poor nutrition, and poor alignment of the bone fragments. DIF: Cognitive Level: Knowledge REF: p. 974 OBJ: 3 TOP: Delayed Union KEY: Nursing Process Step:

18. Which nursing diagnosis has the highest priority after surgery for the open reduction and external fixation of an ankle? a. Risk for activity intolerance b. Risk for infection c. Risk for impaired physical mobility d. Risk for constipation

ANS: B All are possible diagnoses, but risk for infection would have the highest priority because bone infections are serious complications. DIF: Cognitive Level: Analysis REF: p. 983-984 OBJ: 6 TOP: Nursing Diagnosis KEY: Nursing Process Step: Nursing Diagnosis MSC:

11. A 78-year-old retired teacher with a history of osteoporosis has fallen in her bathroom and sustained a subcapital femoral fracture. She is scheduled for an open reduction and internal fixation (ORIF) procedure in the morning. Which type of traction will most likely be implemented? a. Bryant b. Buck c. Pelvic d. Crutchfield tongs

ANS: B Buck traction is used to stabilize the fracture. The options are not applicable. DIF: Cognitive Level: Application REF: p. 979-980 OBJ: 5 TOP: Traction KEY: Nursing Process Step: Evaluation MSC:

25. A patient with a fractured pelvis says that she will not ambulate because of pain. What should a nurse inform the patient can be prevented with early ambulation? a. Back injury b. DVT c. Callus formation d. Disuse syndrome

ANS: B Early ambulation, although painful, avoids many of the complications of immobility such as DVT, constipation, and atrophy. DIF: Cognitive Level: Comprehension REF: p. 974 OBJ: 3 | 5 TOP: Early Ambulation with Fractured Pelvis KEY: Nursing Process Step: Implementation MSC:

6. Which assessment is of the greatest concern to a nurse when caring for a patient just admitted with a pelvic fracture? a. Pain level rating of 8 on a scale of 1 to 10 b. No urinary output for 8 hours c. Evidence of bruising along the patient's hips and buttocks d. Complaints of the need for back care from resting in bed

ANS: B The absence of urinary output could indicate a perforated bladder. DIF: Cognitive Level: Analysis REF: p. 987 OBJ: 3 TOP: Pelvic Fracture KEY: Nursing Process Step: Assessment MSC:

9. What special precaution should a nurse implement when assisting with the application of a short arm plaster cast? a. Dampen the skin to make the stockinette adhere. b. Tape the arm before applying the stockinette. c. Smooth the stockinette to prevent a pressure ulcer. d. Roll the stockinette tightly above and below the margins of the cast.

ANS: C The stockinette is smoothed on the limb before applying the casting material to help reduce the threat of a pressure ulcer. DIF: Cognitive Level: Application REF: p. 977 OBJ: 5 TOP: Cast Care KEY: Nursing Process Step: Implementation MSC:

16. Which patient is most appropriate for a nurse to refer to home health care? a. A married man with a laundry room on the first floor b. A single woman with a bedroom in a rooming house c. A student living in a college dormitory but going home to stay with parents d. A woman staying with her daughter and son-in-law at their one-story home

ANS: B The patient will need help with laundry and activities of daily living. DIF: Cognitive Level: Analysis REF: p. 984 OBJ: 6 TOP: Nursing Assessment of a Patient with a Fracture KEY: Nursing Process Step: Assessment MSC:

1. Two days after surgery for a crushed pelvis, a certified nursing assistant (CNA) reports that the patient is complaining of a shortness of breath and is demonstrating signs of confusion and restlessness. What should a nurse suspect, from these signs alone, that the patient has developed? a. Impending shock b. Fat embolus c. Anxiety d. Neurovascular compromise

ANS: B These are the classic symptoms of a fat embolus that has escaped from the crushed marrow. DIF: Cognitive Level: Analysis REF: p. 974 OBJ: 3 | 6 TOP: Complications: Fat Embolism KEY: Nursing Process Step: Assessment| Nursing Process Step: Evaluation MSC:

14. What action should a nurse implement when caring for a patient diagnosed with a compound fracture? a. Limit narcotics for 8 hours after surgery. b. Monitor the patient's respirations every hour. c. Assess for pulses distal to the injury. d. Verify that the patient is not allergic to sulfa.

ANS: C Assessing for pulses distal to the injury is performed to monitor for ineffective tissue perfusion. DIF: Cognitive Level: Application REF: p. 982-983 OBJ: 6 TOP: Care of the Patient after Surgery for a Fracture KEY: Nursing Process Step: Implementation MSC:

5. A patient who sustained a simple fracture of the left fibula 7 days earlier asks in what stage of bone healing he might be. What stage of healing should the nurse relay to the patient? a. Hematoma formation b. Ossification c. Callus formation d. Fibrocartilage formation

ANS: C Callus formation occurs at the end of the first week after injury. DIF: Cognitive Level: Comprehension REF: p. 972 OBJ: 2 TOP: Healing Process of Fractures KEY: Nursing Process Step: Implementation MSC:

19. A patient in a full body cast (spica) complains of nausea and abdominal distention. What potential complication should a licensed vocational nurse (LVN) suspect? a. Constipation b. Compartment syndrome c. Cast syndrome d. Shock

ANS: C Cast syndrome is an uncommon complication for a person in a spica cast, in which compression of a portion of the duodenum occurs between the mesenteric artery and the spinal column. DIF: Cognitive Level: Analysis REF: p. 977-979 OBJ: 6 TOP: Cast Syndrome KEY: Nursing Process Step: Assessment MSC:

20. An older adult patient is at risk for constipation after sustaining a pelvic fracture. Which nutritional suggestion by the nurse is most appropriate? a. Select food with high sodium content. b. Avoid foods high in dietary fiber. c. While immobilized, drink at least 2 to 3 L of fluids daily. d. Include milk products at every meal.

ANS: C During periods of immobilization, a daily fluid intake of 2 to 3 L is recommended to promote bowel and bladder function. Food with sodium causes fluid retention. Dietary fiber helps diminish constipation. DIF: Cognitive Level: Application REF: p. 983 OBJ: 6 TOP: Nutrition Concepts with Fractures KEY: Nursing Process Step: Planning MSC:

24. Which is true about a greenstick fracture? a. Line of the fracture goes across the bone in right angles to the longitudinal axis. b. Periosteum is not torn away from the bone. c. Fracture is incomplete, and one side is bent. d. Fracture occurred in one of the long bones of the body.

ANS: C Greenstick fractures are most commonly seen in children, with the bone broken on one side but only bent on the . DIF: Cognitive Level: Knowledge REF: p. 971 OBJ: 1 TOP: Fracture Healing KEY: Nursing Process Step: Implementation MSC:

21. Which finding should produce the most concern when performing pin care for a patient with an external fixator? a. Crusts around the pin b. Serous drainage on the dressing c. Purulent drainage d. Absence of pain

ANS: C Purulent drainage is the only abnormal finding. DIF: Cognitive Level: Comprehension REF: p. 976 OBJ: 5 | 6 TOP: Pin Care KEY: Nursing Process Step: Assessment MSC:

13. A patient with bilateral avascular necrosis of the hips is to walk with crutches using a four-point gait for 6 weeks after her bone decompression surgeries. Which statement would indicate that the patient understands this technique? a. "The axillary bars on the crutches should support my weight when I walk." b. "I will move both crutches and then swing my legs to the crutches—2 and 2 equals 4!" c. "I will move my right crutch and then my left leg and then the left crutch and my right leg." d. "I will move both crutches and then swing my legs through the crutches together."

ANS: C This option describes the correct sequence for a four-point gait, which allows bearing of weight and one foot to be placed in front of the . DIF: Cognitive Level: Comprehension REF: p. 981 OBJ: 5 TOP: Crutch Walking KEY: Nursing Process Step: Evaluation MSC:

12. A nurse is told that a patient has a compound comminuted fracture. What characteristic of the bone in this type of fracture causes the nurse to be concerned? a. It is bent but not completely broken, and the bent piece protrudes through the skin. b. It is compressed, and bone pieces protrude through the skin. c. It is twisted, and the fragments are separated. d. It is broken into two or more pieces, and bone fragments protrude through the skin.

ANS: D A compound comminuted fracture is a severe fracture with the bone broken in two or more pieces, with the pieces broken into small fragments and a portion of the bone protruding through the skin. DIF: Cognitive Level: Comprehension REF: p. 971-972 OBJ: 1 TOP: Fracture Types KEY: Nursing Process Step: Assessment MSC:

10. An older patient who sustained a fractured hip and femur in a motor vehicle accident is to be in Russell traction for several weeks. What should be the focus of care for the nurse? a. Offering frequent distractions b. Encouraging nutrition c. Offering pain relief d. Preventing deep vein thrombosis (DVT)

ANS: D DVT is a threat for the person who is going to experience lengthy periods of inactivity. Although nutrition, pain relief, and boredom will be nursing concerns as well, the prevention of DVT is the priority. DIF: Cognitive Level: Application REF: p. 974 OBJ: 3 | 5 TOP: Long-Term Complications of Fractures KEY: Nursing Process Step: Evaluation MSC:

2. What should a nurse teach an older patient with a newly casted Colles fracture? a. Apply cool compresses to the cast. b. Let the hand and arm dangle to increase the drainage. c. Keep the hand immobile to reduce swelling. d. Move the shoulders to reduce contractures.

ANS: D Movement of the shoulders will help decrease the threat of contracture from immobility. DIF: Cognitive Level: Comprehension REF: p. 987 OBJ: 7 TOP: Colles Fracture KEY: Nursing Process Step: Implementation MSC:

8. A patient has just had a plaster of Paris upper extremity cast placed because of a fractured radius. Which statement indicates that the patient understands the discharge teaching related to cast care? a. "When I get home, I will remove some of the padding if it feels tight so my fingers don't swell." b. "When I get home, I will wrap the cast in plastic so it will conserve the heat." c. "When I get home, I will use a spoon handle to scratch inside if my arm itches." d. "When I get home, I am going to rest in bed with my arm elevated above my heart."

ANS: D Resting with the limb elevated above the heart helps prevent swelling. DIF: Cognitive Level: Comprehension REF: p. 984 OBJ: 5 TOP: Cast Care KEY: Nursing Process Step: Evaluation MSC:

23. What action should a nurse implement when dealing with the weights that are applying traction to a patient? a. Remove them to pull the patient up in bed. b. Hold them while the patient is changing positions in bed. c. Hold them for a few minutes if the patient complains of pain. d. Allow them to hang freely.

ANS: D Weights must always hang freely to prevent complications. DIF: Cognitive Level: Application REF: p. 979 OBJ: 5 | 6 TOP: Traction KEY: Nursing Process Step: Implementation MSC: