Musculoskeletal Trauma & Orthopedic Surgery

What assessment finding indicates an acute meniscus injury in a football player? A. Localized edema B. Decreased pedal pulse C. Pinpoint tenderness D. Muscle weakness of 2/5

Answer: C Rationale: An acutely torn meniscus may be suspected when localized tenderness, pain, and effusion are identified. Pain is elicited by flexion, internal rotation, and then extension of the knee (McMurray's test). Edema usually is not significant because most of the cartilage is avascular. The meniscus injury is a local knee injury rather than affecting the entire limb.

What modifications should be made for the patient going home after hip replacement? A. Elevate the toilet seat. B. Pad side rails. C. Use a bathmat when taking baths. D. Do not drive for 2 weeks.

Answer: A Rationale: An elevated toilet seat is required to prevent the hip from more than 90 degrees of flexion. Padded side rails are used for patients with seizures. Showers, not baths, should be used the first 4 to 6 weeks. No driving is allowed for at least 4 to 6 weeks.

You explain to a patient with a distal tibial fracture who is returning for a 3-week checkup that healing is indicated by A. formation of callus. B. complete bony union. C. hematoma at fracture site. D. presence of granulation tissue.

Answer: A Rationale: Bone goes through a remarkable reparative process of self-healing (called union) that occurs in stages. The third stage is callus formation. As minerals (calcium, phosphorus, and magnesium) and new bone matrix are deposited in the osteoid, an unorganized network of bone is formed that is woven around the fractured parts. Callus is primarily composed of cartilage, osteoblasts, calcium, and phosphorus. It usually appears by the end of the second week after injury. Evidence of callus formation can be verified by x-ray.

What co-morbidity can cause bursitis? A. Increased serum uric acid B. Increased eosinophils C. Sickle cell anemia D. Joint effusion

Answer: A Rationale: Bursitis results from repeated or excessive trauma or friction, gout, rheumatoid arthritis, or infection. Gout has high levels of uric acid that result in the formation of urate crystals. Increased eosinophils are related to an allergic response. Sickle cell anemia has joint pain related to hemorrhage into the joint. Joint effusion is a symptom of bursitis, not a cause.

What should the patient be taught after a hip arthroplasty? A. Setting gluteal muscles exercises B. Swinging the leg side-to-side to strengthen quadriceps C. Flexion exercises to prevent joint "freezing" D. Elevating the foot to heart level to minimize edema

Answer: A Rationale: Exercises are done to restore strength and muscle tone in the quadriceps and other muscles to improve function and range of motion. They include quadriceps setting (e.g., tightening the kneecap) and gluteal muscle setting (e.g., tightening the buttocks). The leg is raised and swung, but never crosses the midline. There should not be 90-degree flexion of the hip for 4 to 6 weeks. Flexion exercises and raising the leg are not done because they cause more than 90 degrees of flexion.

During the postoperative period, you instruct the patient with an above-the-knee amputation that the residual limb should not be routinely elevated because this position promotes A. hip flexion contractures. B. skin irritation and breakdown. C. clot formation at the incision site. D. increased risk of wound dehiscence.

Answer: A Rationale: Flexion contractures may delay the rehabilitation process after amputations. The most common and debilitating contracture is hip flexion. To prevent flexion contractures, have patients avoid sitting in a chair for more than 1 hour with hips flexed or having pillows under the surgical extremity. Unless specifically contraindicated, patients should lie on their abdomen for 30 minutes three or four times each day and position the hip in extension while prone.

The patient has a long cast applied to the right leg. You are uncertain if the right foot feels cool to touch. What is the best method to make this determination? A. Compare the right foot with the left foot. B. Ask the patient if the foot feels cold to him. C. Apply a sock and recheck it in 1 hour. D. Have the patient dorsiflex the ankle, and reassess the situation.

Answer: A Rationale: Neurovascular assessment includes a peripheral vascular assessment (color, temperature, capillary refill, peripheral pulses, and edema) and a peripheral neurologic assessment (sensation, motor function, and pain). Through the assessment, compare both extremities to obtain an accurate assessment. The patient may not be aware of a change, especially in the presence of co-morbidities such as diabetes. If the patient is experiencing neurovascular changes, they must be dealt with now, not later. The issue is not to attempt other measures to improve circulation but to determine if the neurovascular compromise or compartment syndrome exists.

A patient with a fracture of the pelvis should be monitored for A. changes in urinary output. B. petechiae on the abdomen. C. a palpable lump in the buttock. D. sudden decrease in blood pressure.

Answer: A Rationale: Pelvic fractures may cause serious intraabdominal injury such as paralytic ileus, hemorrhage, and laceration of the urethra, bladder, or colon. Patients may survive the initial pelvic injury, only to die from sepsis, fat embolism syndrome, or thromboembolism. Because a pelvic fracture can damage other organs, assess bowel and urinary elimination and distal neurovascular status.

The computer operator has tingling in his hands when he dangles it. What interventions should you expect? A. Immobilize with splints B. Acetaminophen (Tylenol) C. Alternate hot and cold applications D. Wrap the wrist with ACE wrap

Answer: A Rationale: Phalen's sign is diagnostic of carpal tunnel syndrome (CTS). It is elicited by allowing the wrists to fall freely into maximum flexion and maintain that position for more than 60 seconds. A positive response is a sensation of tingling in the distribution of the median nerve over the hand. Treatment involves stopping the aggravating movement and resting the hand and wrist by immobilization in a hand splint. Hot and cold applications are not used because of the risk of thermal injury.

What is proper management of skeletal traction? A. Assess pin sites for purulent drainage. B. Remove weights intermittently to promote circulation. C. Place weights on the floor at the foot of the bed. D. Keep the maximum weight at 10 pounds (4.5 kg).

Answer: A Rationale: Skeletal traction requires a pin in the bone, and pin sites need assessment for infection. Weights should not be removed and should be free hanging. Skin traction uses only 5 to 10 pounds, but skeletal traction uses 5 to 45 pounds (2.3 to 20.4 kg).

What is the difference between a sprain and strain? A. Sprain is ligamentous injury made by twisting; strain is excessive muscle stretching. B. A sprain is initially treated with ice; strain is treated with heat. C. Sprains may require surgery, but strains are self-limiting. D. Sprains symptoms are pain and edema; strains symptoms are ecchymosis and striae

Answer: A Rationale: Sprain is an injury to ligamentous structures surrounding a joint, usually caused by twisting motion. A strain is excessive stretching of a muscle and its fascial sheath, often involving a tendon. Both are treated with RICE (rest, ice, compression, elevation). Both are usually self-limiting, although severe strains may require surgical repair. Both have similar symptoms of pain, edema, and decreased function.

What symptoms reported by a grocery store clerk and bagger are most indicative of repetitive strain injury? A. Numbness and pain in the shoulder B. Shoulder bump and inability to raise the same-side arm C. Weakness in the thumb and clumsiness with fine hand movements D. Point tenderness and unilateral forearm swelling

Answer: A Rationale: Symptoms include pain, weakness, numbness, and impairment of motor function. The shoulder bump and lack of function indicate a dislocation. Thumb weakness and clumsiness indicate carpal tunnel syndrome. Point tenderness and unilateral forearm swelling likely indicate a fracture

What is the classic presentation of a hip fracture? A. Shortened external rotation of the limb B. Decreased pedal pulse in the affected limb C. Point tenderness at the iliac crest D. Abnormal pelvic movement and bruising

Answer: A Rationale: The clinical manifestations of hip fractures are shortened external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness in the region of the fracture site.

It is most important that you monitor for what complication in a fracture of the humerus? A. Growing pulsatile hematoma B. Abnormal mobility in extremity C. Muscle spasm D. Shortened extremity

Answer: A Rationale: The major complications associated with fracture of the humerus are radial nerve injury and vascular injury to the brachial artery as a result of laceration, transaction, or muscle spasm. A sign of a brachial artery injury is a growing pulsatile hematoma. The other options are expected findings in a patient with a fractured humerus.

You are caring for a 76-year-old man who has undergone left knee arthroplasty and prosthetic replacement of the knee joint to relieve the pain of severe osteoarthritis. What should be included in the postoperative care of the affected leg? A. Progressive leg exercises to obtain 90-degree flexion B. Early ambulation with full weight bearing on the left leg C. Bed rest for 3 days with the left leg immobilized in extension D. Immobilization of the left knee in 30-degree flexion for 2 weeks to prevent dislocation

Answer: A Rationale: The patient is encouraged to engage in progressive leg exercises until 90-degree flexion is possible. Because this is painful after surgery, the patient requires good pain management and often the use of a continuous passive motion (CPM) machine.

The patient has a suspected facial fracture. During an ocular assessment, you notice brown tissue on the surface of the globe. What action should you take? A. Place a protective shield over the eye. B. Assess CNs III, IV, and VI. C. Check for pupil constriction. D. Press gently on the globe to feel for hardness.

Answer: A Rationale: When eye globe rupture is suspected, the examination is stopped, and a protective shield is placed over the eye. Signs of globe rupture include the extrusion of vitreous humor or brown tissue (iris or ciliary body) on the surface of the globe or penetrating through a laceration with an eccentric or teardrop-shaped pupil.

What should you teach the patient related to cast care? A. Apply ice directly over the fracture site for the first 24 hours. B. Do not get the cast wet. C. Elevate the extremity above the level of the heart at night. D. Move joints above and below the cast regularly. E. Fiberglass casts tolerate weight bearing.

Answer: A, B, D Rationale: Cast care includes applying ice directly over the fracture site for the first 24 hours. Casts should not become wet, and the joints are moved. The extremity should be elevated above the level of the heart for the first 48 hours. No new cast, regardless of material, should be used for weight bearing for the first 48 hours. Not all casts are made for weight bearing, and the health care provider should make the determination.

Which are ergonomic recommendations to prevent repetitive strain injury when working at a computer (select all that apply)? A. Keep hips and knees flexed to 90 degrees. B. Keep the wrist straight while typing. C. Take a stretch break every 4 hours. D. Elevate the feet to a level even with the heart. E. Have the top of the computer monitor even with the forehead.

Answer: A, B, E Rationale: Ergonomic considerations include keeping the hips and knees flexed to 90 degrees with the feet flat, keeping the wrist straight while typing, and having the top of computer monitor even with forehead. Hourly stretch breaks should be taken.

What would be the most distinct sign that the patient had dislocated his shoulder after the bike accident? A. Localized bruising B. Tingling at night C. Deformity D. Weakness in the thumb

Answer: C Rationale: The most obvious sign of a dislocation is deformity. Other manifestation can include local pain, local tenderness, loss of function of the injured part, and swelling of soft tissue in the joint region. Tingling at night and weakness in the thumb are seen in carpal tunnel syndrome.

The patient with a fractured pelvis is treated with a hip spica cast. What is an appropriate nursing action? A. Position the patient by using gentle pressure on the support bar. B. Monitor the patient for abdominal pain and pressure. C. Cover the plaster cast to aid curing. D. Do not allow weight bearing on the cast for 1 hour

Answer: B Rationale: A hip spica cast is two casts joined together: a trunk or body cast and a long leg cast. A body jacket cast extends from the nipple line to the pubis. After application, it is possible to develop cast syndrome, which occurs if it is too tight. The cast compresses the superior mesenteric artery against the duodenum. Symptoms include abdominal pain, abdominal pressure, nausea, and vomiting. The support bar should not be pulled on. A plaster cast should not be covered because air cannot circulate, heat builds up in the cast, and drying can be delayed. A cast can dry in 15 minutes but is not strong enough for weight bearing until about 24 to 72 hours later.

The patient had a dislocated joint that was treated by realignment and splinting until healed. What teaching should you provide? A. Watch for signs of avascular necrosis. B. Restrict activity to prevent repeated dislocation. C. Wear an elastic support continuously. D. There is a lifelong risk for development of tophi at the site.

Answer: B Rationale: A person who has dislocated a joint may be at a greater risk for repeated dislocations because of loose ligaments. Activity restrictions may be imposed on the use of the affected joint to decrease the risk of repeatedly dislocating the joint. Avascular necrosis (bone cell death as a result of inadequate blood supply) is a risk initially with dislocated joint that is not promptly or correctly treated.

The patient had a right below-the-knee amputation yesterday and reports feeling pain and heaviness in the right lower leg today. What action should you take? A. Reassure the patient that the pain is not real. B. Administer an analgesic. C. Use distraction techniques. D. Apply ice around the upper leg.

Answer: B Rationale: Approximately 90% of amputees have phantom limb sensation. The patient feels pain, coldness, heaviness, cramping, shooting, burning, or crushing pain in the limb that has been amputated. It should be treated with an analgesic, just as if the limb was there. The sensation usually subsides over time.

What instruction is most effective in helping to prevent carpal tunnel syndrome? A. Avoid lifting more than 20 pounds. B. Keep wrists even with the keyboard when typing. C. Wear gloves when going outside in winter. D. Limit overhand throwing by grade school children.

Answer: B Rationale: Carpal tunnel syndrome is caused by compression of the median nerve from continuous wrist movement. Keep wrists even with the keyboard or use adaptive keyboards to prevent injury. The condition is not related to heavy lifting. Wearing gloves outside in the winter is taught to patients with Raynaud's syndrome. Limiting overhand throwing is related to rotator cuff injury.

An 18-year-old male twisted his ankle while playing soccer. What treatment should be done? A. Elevate the foot 6 inches. B. Put ice on for 20 minutes at a time. C. Apply bandage from proximal to distal site. D. Provide aspirin for analgesia.

Answer: B Rationale: Cold should be applied immediately but should not exceed 20 to 30 minutes per application and should not be applied directly to skin. Elevation should be above the level of the heart and done even at night. After 48 hours, heat may be used. Compression bandages should be applied from the distal to the proximal point to aid fluid return. Aspirin is not used because it can promote bleeding; instead, use a nonsteroidal antiinflammatory drug (NSAID).

What is most important in the first 24 hours after a below-the-knee amputation? A. Observe for serosanguineous drainage. B. Elevate the stump to decrease edema. C. Complete passive range-of-motion (ROM) exercise for the unaffected limb. D. Measure the stump for the prosthesis size

Answer: B Rationale: For the first 24 hours only, the stump is elevated to minimize edema and optimize venous return. It is not done for a longer period to prevent development of contracture. Some serosanguineous drainage is expected. Excessive bleeding is the concern. Passive ROM exercises are not done immediately postoperatively, and the stump must heal before prosthesis fitting.

What is the appropriate nursing action for a patient with CTS? A. Put the patient's wrist in a hyperextended position. B. Remind the patient not to lift heavy objects. C. Assess the hands for discoloration and brittle nails. D. Inform the patient that surgery is a cure for CTS.

Answer: B Rationale: It is correct to remind the patient not to lift heavy objects for 4 to 6 weeks. The splint should be in a neutral or slightly extended position. Assessment for discoloration and brittle nails is not important for this diagnosis. CTS can recur; paraesthesia and pain can last for an extended time after surgery.

The patient has a fractured humerus. What is most important for you to communicate to the nursing assistant that he or she should report immediately? A. Reports of pain B. Patient appears newly confused C. Blood pressure of 150/90 mm Hg D. Voided 900 mL/8-hour shift

Answer: B Rationale: New-onset confusion requires immediate assessment for major complications, including a fat embolism.

The orthopedic patient is in skeletal traction. The patient's urine pH rose. What action should you take? A. Notify primary provider for antibiotic order. B. Provide cranberry juice to acidify the urine. C. Assess for coexisting vaginal discharge. D. Strain all urine.

Answer: B Rationale: Renal calculi can develop as a result of bone demineralization. The hypercalcemia from demineralization causes a rise in urine pH and stone formation resulting from the precipitation of calculi. Unless contraindicated, fluid intake should be 2500 mL/day, and cranberry juice is provided to acidify the urine and prevent precipitation of minerals into stones.

While completing an admission history for a 73-year-old man with osteoarthritis who was admitted for knee arthroplasty, you ask about his perception of the reason for admission. What response do you expect? A. Recent knee trauma B. Debilitating joint pain C. Repeated knee infections D. Onset of "frozen" knee joint

Answer: B Rationale: The most common reason for knee arthroplasty is debilitating joint pain despite attempts to manage it with exercise and drug therapy.

A patient with rheumatoid arthritis is scheduled for a total hip arthroplasty (THA). You explain that the purpose of this procedure is to (select all that apply) A. fuse the joint. B. replace the joint. C. prevent further damage. D. improve or maintain range of motion. E. decrease the amount of destruction in the joint.

Answer: B, D Rationale: Arthroplasty is the reconstruction or replacement of a joint. This surgical procedure is performed to relieve pain, improve or maintain range of motion, and correct deformity. THA provides significant relief of pain and improvement of function for a patient with rheumatoid arthritis.

What should the patient understand about knee arthroplasty? A. Avoid weight bearing for 6 weeks. B. It is common in patients with osteoporosis. C. A continuous passive motion (CPM) machine provides flexion. D. Alignment is changed, and weight bearing is shifted as a result.

Answer: C Rationale: Active flexion exercises or passive flexion exercises through the use of a CPM machine postoperatively may promote joint mobility. Full weight bearing is begun before discharge. Patients with osteoporosis have difficulties and may require grafting before the surgery. It is the treatment for patients with unremitting pain and instability as a result of severe destructive deterioration of the knee joint. An osteotomy is performed to remove a wedge or slide of bone to change alignment and to shift weight bearing. It is common in patients with ankylosing spondylitis.

The patient fractured his foot, and you are providing crutch-walking instructions. The patient puts his weight on the axilla. You tell the patient to put his weight on his hands, but the patient continues to put the weight on the axilla. What action should you take? A. Encourage weight lifting to build patient's upper body strength. B. Teach the patient two-point crutch walking technique instead. C. Initiate changing the patient to a walker. D. Obtain a wheelchair for the patient instead of crutches.

Answer: C Rationale: Bearing weight on the axilla rather than the hands endangers the neurovascular bundle that passes across the axilla. A common reason is inadequate upper limb strength. If the patient cannot correct the problem with verbal coaching, another form of ambulation should be provided until the strength is adequate. It is preferable to keep the patient ambulating in some form, rather than a wheelchair.

Thirty-six hours after a major trauma with pelvic and femur fractures, what finding is most important for you to monitor? A. Pulse of 100 beats/minute and blood pressure of 140/90 mm Hg B. Pain rated at 8 C. Restlessness and petechiae D. Bilateral leg edema

Answer: C Rationale: Fat embolism syndrome is characterized by the presence of systemic fat globules, and it is seen most often in fractures in the long bones, ribs, tibia, and pelvis. Clinical manifestations usually occur within 24 to 48 hours after injury, causing hemorrhagic interstitial pneumonitis and acute respiratory distress syndrome (ARDS). The change in level of consciousness and petechiae distinguish it from other problems. Bilateral leg edema can be a generalized symptom resulting from immobility and fluid resuscitation; deep vein thrombosis manifests as unilateral leg swelling

The patient had surgery for a hip fracture using a posterior approach. You must intervene when you notice the patient doing which activity? A. Sitting up at a 45-degree angle B. Putting on a sock using an extension aid C. Crossing legs at the knee D. Sitting on a raised toilet seat

Answer: C Rationale: Fractures treated with a posterior approach are at greater risk for dislocation of the femoral head prosthesis. Activities that predispose the patient to dislocation are more than 90 degrees of flexion, abduction, or internal rotation. This can occur when crossing the legs or feet when seated. The other options are acceptable actions.

You formulate a nursing diagnosis of impaired physical mobility related to decreased muscle strength for a 78-year-old patient after a left total knee replacement. What would be an appropriate nursing intervention for this patient? A. Promote vitamin D and calcium intake in the diet. B. Provide passive range of motion to all of the joints every 4 hours. C. Encourage isometric quadriceps-setting exercises at least four times daily. D. Keep the left leg in extension and abduction to prevent contractures.

Answer: C Rationale: Great emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the first day after surgery.

What is an indication of a neurovascular problem noticed during assessment of a patient with a fracture? A. Exaggeration of strength with movement B. Increased redness and heat below the injury C. Decreased sensation distal to the fracture site D. Purulent drainage at the site of an open fracture

Answer: C Rationale: Musculoskeletal injuries can cause changes in the neurovascular status of the injured extremity. With musculoskeletal trauma, application of a cast or constrictive dressing, poor positioning, and the physiologic responses to the traumatic injury can cause nerve or vascular damage, usually distal to the injury. The neurovascular assessment consists of a peripheral vascular assessment (color, temperature, capillary refill, peripheral pulses, and edema) and a peripheral neurologic assessment (sensation, motor function, and pain).

The patient with rotator cuff injury has been treated with rest, ice, and nonsteroidal antiinflammatory drugs (NSAIDs), and surgery is now required. What is most important to teach the patient before surgery? A. Wound care instructions B. Need for physical therapy immediately after surgery C. Stop NSAIDs for 2 weeks before surgery D. Keep the leg elevated after surgery

Answer: C Rationale: NSAIDs affect clotting and should be stopped before surgery.

What nonoperative treatment can be provided for a fractured humerus? A. Immobilize the affected limb for 6 weeks. B. Elevate the arm and apply ice. C. Allow the affected arm to hang freely. D. Wrap the arm in an adducted position.

Answer: C Rationale: Nonoperative treatment can include a hanging arm cast and allowing the arm to hang freely when the patient is sitting and standing. These actions assist gravity in reducing the fracture. An exercise program is required to improve strength and mobility. It includes assisted motion of the hands and fingers.

The patient has been in a significant motor vehicle crash. You notice unusual pelvic movement and ecchymosis on the abdomen. What is most important for you to do? A. Place an ice pack on the abdominal area. B. Apply continuous manual traction to the lower extremities. C. Look for lacerations of the urethra before catheter insertion. D. Use a folded sheet across abdomen to immobilize the pelvis.

Answer: C Rationale: Signs of a pelvic fracture include local swelling, tenderness, deformity, unusual pelvic movement, and ecchymosis of the abdomen. Pelvic fractures may cause serious intraabdominal injury, including laceration of the urethra or bladder. A catheter should not be inserted if there are lacerations of the urethra or blood in the urine.

The patient had a pelvis fracture and open reduction surgery. What is a chief disadvantage of this form of fracture management? A. Increased pain B. Decreased mobility C. Infection D. Deformity

Answer: C Rationale: The chief disadvantages of open reduction (e.g. bone alignment through surgical incision) are infection, anesthesia complications, and effects of preexisting medical conditions.

You are assessing the patient who had a cast applied 12 hours earlier. The affected foot is cooler and cyanotic compared with the unaffected foot. You notify the doctor, who states it has always been like that. What action should you take next? A. Document the physician's statements. B. Continue to monitor the patient. C. Notify the charge nurse. D. Contact the hospital medical director.

Answer: C Rationale: The patient has symptoms of neurovascular compromise (alteration in the Ps: pallor, pain, pulselessness, paresthesia, and paralysis). This requires an urgent response and cannot be delayed. It is necessary for you to activate the chain of command to get the patient adequate care. Documentation is important, but patient care is first. The patient must be monitored, but there is already evidence that the patient is in need of intervention. The medical director is eventually notified, but having the patient receive adequate care is more important than letting senior administration know.

You are caring for a patient with osteoarthritis who is about to undergo total left knee arthroplasty. You assess the patient carefully to be sure that there is no evidence of which of the following in the preoperative period? A. Pain B. Left knee stiffness C. Left knee infection D. Left knee instability

Answer: C Rationale: The patient must be free of infection before a total knee arthroplasty. Joint infection can cause even greater pain and joint instability, requiring extensive surgery. You monitor the patient for signs of infection, such as redness, swelling, fever, and elevated white blood cell count.

A patient with a stable, closed fracture of the humerus caused by trauma to the arm has a temporary splint with bulky padding and an elastic bandage applied. You suspect compartment syndrome and notify the physician when the patient experiences A. increasing edema of the limb. B. muscle spasms of the lower arm. C. rebounding pulse at the fracture site. D. pain when passively extending the fingers

Answer: D Rationale: One or more of the following are characteristic of compartment syndrome: (1) paresthesia (numbness and tingling); (2) pain distal to the injury that is not relieved by opioid analgesics and pain on passive stretch of muscle traveling through the compartment; (3) pressure increasing in the compartment; (4) pallor, coolness, and loss of normal color of the extremity; (5) paralysis or loss of function; and (6) pulselessness or diminished or absent peripheral pulses. Also assess peripheral edema; pitting edema may occur with severe injury.

he patient had a knee bursectomy. Which finding is most concerning the first postoperative day? A. White blood cell (WBC) count of 11,000/μL B. Decreased breath sounds C. Hypoactive bowel sounds D. Leg pain that worsens with passive stretch

Answer: D Rationale: Pain on passive stretch is a sign of compartment syndrome. The other options are expected findings.

A patient with a comminuted fracture of the femur is scheduled to have an open reduction with internal fixation (ORIF) of the fracture. When is ORIF indicated? A. The patient is unable to tolerate prolonged immobilization. B. The patient cannot tolerate the surgery of a closed reduction. C. A temporary cast would be too unstable to provide normal mobility. D. Adequate alignment cannot be obtained by other nonsurgical methods.

Answer: D Rationale: A comminuted fracture has more than two bone fragments. ORIF is indicated for a comminuted fracture and is used to realign and maintain bony fragments. ORIF has become the preferred method to manage a femoral fracture. Other nonsurgical methods would fail to obtain satisfactory reduction. Internal fixation reduces the hospital stay and the complications associated with prolonged bed rest.

You suspect an ankle sprain when a patient at the urgent care center relates A. being hit by another soccer player during a game. B. having ankle pain after sprinting around the track. C. dropping a 10-lb weight on his lower leg at the health club. D. twisting his ankle while running bases during a baseball game.

Answer: D Rationale: A sprain is an injury to the ligamentous structures surrounding a joint, usually caused by a wrenching or twisting motion. Most sprains occur in the ankle and knee joints.

Why is a sugar-tong splint cast used for a fracture? A. Better immobilization B. Improved comfort C. Cost-effectiveness D. Allows for swelling

Answer: D Rationale: A sugar-tong splint is typically used for acute wrist injuries or injuries that may result in significant swelling.

What assessment would most likely indicate poor venous return (versus arterial insufficiency) in an affected extremity? A. Pallor B. Coldness C. Lack of pulse D. Cyanosis

Answer: D Rationale: A warm cyanotic extremity may indicate poor venous return. Pallor, coldness, and lack of pulse are indications of arterial insufficiency.

In teaching a patient scheduled for total ankle arthroplasty (TAA), it is important that you tell him to avoid what after surgery? A. Lifting heavy objects B. Sleeping on the back C. Abduction exercises of the affected ankle D. Bearing weight on affected leg for 6 weeks

Answer: D Rationale: After TAA, the patient may not bear weight for 6 weeks and must elevate the extremity to reduce and prevent edema, be extremely careful to prevent postoperative infection, and maintain immobilization as directed by the physician.

The teenager is scheduled for a below-the-knee amputation as a result of a motorcycle accident. What is most important to include in the preoperative period? A. Explain that walking with prosthesis will be possible afterward. B. Arrange for a continuation of school work. C. Encourage exercise to build upper body strength. D. Address feelings and fear related to the surgery.

Answer: D Rationale: Before surgery, dealing with feelings and fear related to body image and function is the highest priority, especially for a teenager. The other options can be done after surgery.

What is the pathophysiology of bursitis? A. Chronic inflammation that affects small joints B. Tear in fibrocartilage C. Overstretching of muscle D. Inflammation of sacs near joints

Answer: D Rationale: Bursitis is an inflammation of the bursa, a closed sac that contains a small amount of the synovial fluid located at sites of friction. Chronic inflammation that affects small joints describes rheumatoid arthritis. A fibrocartilage tear is a meniscus injury. Overstretching of muscle is strain.

The patient was not wearing a seatbelt when he drove the car into a tree. The windshield is shattered from the force of his face hitting it, and facial fracture is suspected. What other potential injury is a primary concern? A. Hypovolemic shock B. Ruptured tympanic membrane C. Cranial nerve (CN) IX and X injury D. Cervical spine injury

Answer: D Rationale: Cervical spine injuries are common when there is a facial fracture. All patients with facial injuries should be treated as if they have a cervical injury until proved otherwise. Although there is bleeding because the face is vascular, pressure packing controls hemorrhage, and loss from a facial fracture usually is not profuse. Ruptured tympanic membrane is not a primary injury. The ocular nerve and CNs III, IV, and VI are primary concerns.

What is a key etiologic factor in hip fractures? A. Immobility B. Menopause C. Diabetes D. Osteoporosis

Answer: D Rationale: Falls account for 90% of hip fractures, which occurs more commonly in women with osteoporosis.

Which precipitating activity is typically associated with bursitis? A. Planting the foot and twisting of the knee B. Falling with blunt traumatic force C. Movement causing narrowing of nerve channel D. Repetitive kneeling

Answer: D Rationale: Improper body mechanics, repetitive kneeling (carpet layers, coal miners, and gardeners), jogging in worn-out shoes, and prolonged sitting with crossed legs are common precipitating activities. Twisting of the knee is a meniscus injury. Blunt traumatic force can cause fracture. Narrowing of the nerve channel is carpal tunnel syndrome.

What is correct information about synovectomy? A. It is used for osteoarthritis. B. A slice of bone is removed to change alignment. C. Debridement removes degenerative debris. D. It is done prophylactically to prevent joint damage progression.

Answer: D Rationale: Is used as a prophylactic measure and as a palliative treatment for rheumatoid arthritis. It helps to prevent further progression of joint damage. In osteotomy, a slice of bone is removed to change alignment Debridement is a separate procedure.

The patient had facial fractures and had surgery for a mandibular fracture. What is essential postoperatively? A. Place ice packs on cheek bone areas to minimize ecchymosis. B. Place the patient in a semi-Fowler's position to minimize edema. C. Keep the patient NPO for the first 5 days. D. Tape wire cutters at the head of the bed.

Answer: D Rationale: Postoperative care after surgery for a mandibular fracture should focus on the airway. The jaw is wired shut. Wire cutters (or scissors if rubber bands are used) are taped to the head of the bed and always sent with the patient if the patient leaves the area. They are used to cut the wires (or elastic bands) in case of emergency.

The carpet installer reports that his knee "clicks and pops" and sometimes gives way. You should evaluate for what type of pathology? A. Joint subluxation B. Strain C. Sprain D. Meniscus injury

Answer: D Rationale: Signs of a meniscus injury are localized tenderness, pain, and effusion. Pain is elicited by flexion, internal rotation, and then extension of the knee (McMurray's test). The patient may feel that the knee is unstable and often reports that the knee may "click, pop, lock, or give way."

Which assessment is most helpful to determine a rotator cuff injury in a competitive swimmer? A. Pain when tapping over the median nerve in the wrist B. Shoulder radiograph C. Shoulder deformity D. Arm that suddenly drops when abducted 90 degrees and slowly lowered

Answer: D Rationale: The drop arm test, in which the arm falls suddenly after the patient is asked to slowly lower the arm to the side and abduct it to 90 degrees. Tinel's sign can be elicited by tapping over the median nerve as it passes through the carpal tunnel in the wrist. A positive response is a sensation of tingling in the distribution of the median nerve over the hand. This is a positive finding for carpal tunnel syndrome. A radiograph alone is usually not beneficial. Shoulder deformity is typically seen with a shoulder dislocation.

You are completing discharge teaching for an 80-year-old man who underwent right total hip arthroplasty. You identify a need for further instruction if the patient states the need to do which of the following? A. Avoid crossing his legs B. Use a toilet elevator on toilet seat C. Notify future caregivers about the prosthesis D. Maintain hip in adduction and internal rotation

Answer: D Rationale: The patient should not cross his legs, force the hip into adduction, or force the hip into internal rotation.

What nursing action should be done to prevent hip flexion contractions? A. Dangle the residual limb over the edge of the bed. B. Wear a limb shrinker at all times. C. Position the patient with pillows under the surgical extremity. D. Position the patient prone several times each day

Answer: D Rationale: Unless specifically contraindicated, the patient should lie on his abdomen for 30 minutes three or four times each day and position the hip in extension while prone. The residual limb should not dangle, because it contributes to edema. A limb shrinker is worn to shape the limb for eventual prosthesis fitting, not to prevent flexion contractures. The patient should not sit in a chair for more than 1 hour with the hips flexed or have pillows under the surgical extremity.

You are caring for a 75-year-old woman who underwent left total knee arthroplasty and has a new physician order to be "up in a chair today before noon." Which action would you take to protect the knee joint while carrying out the order? A. Administer a dose of prescribed analgesic before completing the order. B. Ask the physical therapist for a walker to limit weight bearing while getting out of bed. C. Keep the CPM machine in place while lifting the patient from bed to chair. D. Put on a knee immobilizer before moving the patient out of bed, and keep the surgical leg elevated while sitting.

Answer: D Rationale: You should apply a knee immobilizer for stability before assisting the patient to get out of bed. This is a standard measure to protect the knee during movement after surgery.