Musculoskeletal Care Modalities
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." R; CPM increases circulation and range of motion of the knee joint.
A nurse is caring for a client after stabilization of a radial fracture. Which actions by the nurse would be appropriate for the client following arm casting? Select all that apply.
-Handle the cast with the palms of hands -Circulate room air with a portable fan -Petal and smooth the edges of the cast
Which would be an inappropriate initial pain relief measure for the client with a cast?
Application of a new cast R: Most pain can be relieved by elevating the casted part of the body, and by applying cold packs as prescribed and administering analgesics. Application of a new cast is usually not necessary.
Which would be an inappropriate initial pain relief measure for the client with a cast?
Application of a new cast r: Most pain can be relieved by elevating the casted part of the body, and by applying cold packs as prescribed and administering analgesics. Application of a new cast is usually not necessary.
Which action would be most important postoperatively for a client who has had a knee or hip replacement?
Assisting in early ambulation. R: 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.
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 R: 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.
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. R: 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.
A patient in pelvic traction needs circulatory status assessed. How should the nurse assess for a positive Homans' sign?
Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg.
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.
Which device is designed specifically to support and immobilize a body part in a desired position?
Splint R: 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'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. R: 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.
Which statement is accurate regarding care of a plaster cast?
The cast can be dented while it is damp. R: The cast can be dented while it is damp. A dry plaster case is white and shiny. The cast will dry in 24 to 72 hours. A freshly applied cast should be exposed to circulating air to dry and should not be covered with clothing or bed linens or placed on plastic-coated mats or bedding.
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. R: 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.
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
A hip spica cast:
encloses the trunk and a lower extremity. R: A hip spica cast encloses the trunk and a lower extremity. A double hip spica cast includes both legs. A body cast encircles the trunk. A walking cast is a short or long leg cast reinforced for strength. A long leg cast extends from the junction of the upper and middle third of the thigh to the base of the toes. The knee may be slightly flexed.
A client is in Buck's traction after fracturing his right hip. The nurse should include which action in the care plan?
Maintaining correct body alignment r: Buck's traction produces realignment by exerting a pulling force on the fractured hip. Therefore, the nurse must maintain correct body alignment. Traction should be continuous; if the weights must be removed, the nurse should apply manual traction until the weights are replaced. The nurse shouldn't use the knee gatch position because it disrupts the constant pulling force needed for alignment. Using the semi-Fowler's position would cause the client to slide in the direction of the traction, defeating the purpose of traction.
The client displays manifestations of compartment syndrome. What treatment will the nurse expect the client to be scheduled for?
A fasciotomy
A client is having a cast applied for a fractured leg that extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position. What type of cast is the client having applied?
Short leg cast R: A short leg cast extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position. A long leg cast extends from the junction of the upper and middle third of the thigh to the base of the toes. The knee may be slightly flexed. A walking cast is a short or long leg cast reinforced for strength. A hip spica cast encloses the trunk and a lower extremity.
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. r: 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.
Which is not a guideline for avoiding hip dislocation after replacement surgery.
The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes. R: Guidelines for avoiding hip dislocation after replacement surgery specify that the hip should not be flexed to put on clothing such as pants, stockings, socks, or shoes. Clients should keep the knees apart at all times, put a pillow between the legs when sleeping, and never cross the legs when seated.
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. R: 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 is a benefit of a continuous passive motion (CPM) device when applied after knee surgery?
It promotes healing by increasing circulation and movement of the knee joint. r: A CPM device applied after knee surgery promotes healing by increasing circulation and movement of the knee joint.
Which is an inaccurate principle of traction?
Skeletal traction is interrupted to turn and reposition the client. R; Skeletal traction is never interrupted. The weights are not removed unless intermittent treatment is prescribed. The weights must hang freely, with the client in good alignment in the center of the bed.
A client had a total left hip arthroplasty. What clinical manifestation would indicate to the nurse that the prosthesis is dislocated?
The left leg is internally rotated. r: The nurse must monitor the client for signs and symptoms of dislocation of the prosthesis, which include abnormal external or internal rotation of the affected extremity. The length of the leg with a dislocated prosthesis may be shorter. The client's discomfort will not indicate a dislocation. Diminished peripheral pulse of the affected extremity would be a indication of circulation issues.
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 R: 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 a cast removed after bone healing takes place. What should the nurse instruct the patient to do after removal? (Select all that apply.)
Control swelling with elastic bandages, as directed. Gradually resume activities and exercise. Apply an emollient lotion to soften the skin
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 R: 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.
The client returns to the nursing unit following an open reduction with internal fixation of the right hip. Nursing assessment findings include temperature 100.8 degrees Fahrenheit, heart rate 112 beats per minute, respiratory rate 28 breaths per minute, and blood pressure 86/58. There is no urine in the Foley catheter collection bag. The nurse interprets these findings as indicating which complication?
Hypovolemic shock R: Indicators of hypovolemic shock include a heart rate greater than 100 beats per minute, a blood pressure less than 90/60 mm Hg, and urine output less than 30 ml per hour.
The nurse is caring for a client with a spica cast. What is the nurse's priority intervention?
Keep the cast clean and dry. R: 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 has undergone an external fixation. Which actions would be the priority for this client?
Maintaining pin care R: Pin care is a priority for a client with external fixation, because pin sites are entry points for infection. The nurse should also monitor redness, drainage, and tenderness at the site. Planning the client's diet and monitoring the client's urine output and blood pressure, although necessary, are not as important as maintaining pin care.
After a traumatic back injury, a client requires skeletal traction. Which intervention takes priority?
Maintaining traction continuously to ensure its effectiveness R: 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.
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 R: 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 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." R: 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 group of students are 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 R: 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 in pelvic traction needs circulatory status assessed. How should the nurse assess for a positive Homans' sign?
Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg. R: The nurse should assess for pain on passive flexion of each foot, which could indicate deep vein thrombosis.
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."
A client had a total left hip arthroplasty. What clinical manifestation would indicate to the nurse that the prosthesis is dislocated?
The left leg is internally rotated. R: The nurse must monitor the client for signs and symptoms of dislocation of the prosthesis, which include abnormal external or internal rotation of the affected extremity. The length of the leg with a dislocated prosthesis may be shorter. The client's discomfort will not indicate a dislocation. Diminished peripheral pulse of the affected extremity would be a indication of circulation issues.
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." R: 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.
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." r: 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 nurse is caring for a client after stabilization of a radial fracture. Which actions by the nurse would be appropriate for the client following arm casting? Select all that apply.
Circulate room air with a portable fan Handle the cast with the palms of hands Petal and smooth the edges of the cast
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 R: 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 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 R: 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.
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."
A client has severe osteoarthritis in the left hip and is having surgery to replace both articular surfaces of the hip. What type of surgical procedure will the nurse prepare the client for?
Total arthroplasty R: A total arthroplasty is a replacement of both articular surfaces within one joint. An arthrodesis is a fusion of a joint for stabilization and pain relief and is usually done on a wrist or knee. A hemiarthroplasty is the replacement of one of the articular surfaces in a joint, such as the femoral head but not the acetabulum. An osteotomy is the cutting and removal of a wedge of bone to change the bone's alignment, thereby improving function and relieving pain.
A patient arrives in the emergency department with a suspected bone fracture of the right arm. How does the nurse expect the patient to describe the pain?
Sharp and piercing R: The nurse must carefully evaluate pain associated with the musculoskeletal condition, asking the patient 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
An older adult patient had a hip replacement. When should the patient begin with assisted ambulation with a walker?
24 hours R: Following hip arthroplasty (total hip replacement), patients begin ambulation with the assistance of a walker or crutches within a day after surgery.
A group of students is studying for a test on traction. The students demonstrate understanding of the types of traction when they identify which of the following as an example of skin traction?
Buck's R: An example of skin traction is Buck's traction. Crutchfield tongs, a Thomas splint, or balanced suspension traction are types of skeletal traction.
A client has just undergone a leg amputation. What will the nurse closely monitor the client for during the immediate postoperative period?
Hematoma R: 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.
